By Stan Deresinski, MD, FACP, FIDSA
Clinical Professor of Medicine, Stanford University
SYNOPSIS: Six cases of Bartonella quintana infection were detected in New York City in individuals experiencing homelessness; four required cardiac valve replacement for endocarditis.
SOURCE: Rich SN, Beeson A, Seifu L, et al. Notes from the Field: Severe Bartonella quintana infections among persons experiencing unsheltered homelessness — New York City, January 2020-December 2022. MMWR Morb Mortal Wkly Rep 2023;72:1147-1148.
After being alerted in early 2023 to two cases of Bartonella quintana infection that had occurred in the previous year, the New York City Department of Health initiated retrospective active surveillance of clinical laboratories of five New York City hospital networks. This activity identified an additional four cases in 2020-2022, bringing the total to six.
Five of the six were hospitalized for a median of 14 days (range 8-78 days). Four underwent valve replacement for culture-negative left-sided endocarditis. Three patients experienced renal failure. Two died from complications related to their endocarditis and one died as the result of complications of traumatic injury not related to the infection.
All six had a history of unsheltered homelessness, and five had documented mental health or substance use disorders; there was no epidemiological linkage among them.
COMMENTARY
B. quintana, the cause of trench fever in World War I, is transmitted by body lice. Shepard and colleagues previously retrospectively collected 14 cases of B. quintana infection in homeless individuals at two academic medical centers in the Denver metropolitan area in 2016-2021.1 Of note is that in September 2020, they had instituted a policy of extending the blood culture duration of incubation to 14 days for specimens obtained for patients experiencing homelessness, and this has proven to be quite successful. Blood cultures were positive in 10/13 cases, and the average time to blood culture positivity was 12.1 days (standard deviation, 6.2 days) in their labs. Thus, strictly speaking, Bartonella cannot be considered as causing only culture-negative endocarditis.
Bartonella may be detected in blood by polymerase chain reaction in patients with endocarditis. In addition, the recent update of infective endocarditis guidelines added indirect immunofluorescence assays (IFA) for detection of immunoglobulin M (IgM) and immunoglobulin G (IgG) antibodies to Bartonella henselae or Bartonella quintana with IgG titer ≥ 1:800 as a major diagnostic criterion.2
A recent European guideline recommends that patients with Bartonella endocarditis be treated with doxycycline for four weeks together with gentamicin for the first two weeks and state that the success rate for this regimen is ≥ 90%.3
REFERENCES
- Shepard Z, Vargas Barahona L, Montalbano G, et al. Bartonella quintana infection in people experiencing homelessness in the Denver metropolitan area. J Infect Dis 2022;226(Suppl 3):S315-S321.
- Fowler VG, Durack DT, Selton-Suty C, et al. The 2023 Duke-International Society for Cardiovascular Infectious Diseases Criteria for Infective Endocarditis: Updating the Modified Duke Criteria. Clin Infect Dis 2023;77:518-526. Erratum in: Clin Infect Dis 2023;77:1222.
- Delgado V, Ajmone Marsan N, de Waha S, et al; ESC Scientific Document Group. 2023 ESC Guidelines for the management of endocarditis. Eur Heart J 2023;44:3948-4042. Erratum in: Eur Heart J 2023 Sep 20:ehad625. [Online ahead of print].
