Infectious endocarditis
Endocarditis infecciosa
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CHU Sainte-Justine. Université de Montréal. Montréal. Canada." "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Endocarditis infecciosa" ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Why the Tenth Symphony of Gustav Mahler was Unfinished?</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Gustav Mahler <span class="elsevierStyleSup">1,2</span> was born on July 7, 1860, in Kalista (Bohemia) near Moravia. His first musical work was a polka composed at the age of 6 years. Mahler studied music at the Vienna Conservatory. He was a composer much criticized by the press. In 1902, Mahler married Alma Schindler, with whom he had 2 daughters, Anna and Maria. The latter died of scarlet fever at the age of only 5. The death of his younger daughter left him depressed; that same year, he discovered he had a heart disease. Forced by a largely anti-Semitic press, he accepted an offer to conduct the Metropolitan Opera in New York in 1907. In 1911, he fell seriously ill with endocarditis. He was attended by Dr. E. Libman who demonstrated the presence of</span> Streptococcus viridans <span class="elsevierStyleItalic">in a large volume (200 ml) of his blood. Mahler was taken to Paris and treated with</span> "Metchnikoff's Bulgarian milk" (Lactobacillus bulgaricus), <span class="elsevierStyleItalic">the probiotics of that era. However, septic abscesses began to appear in other parts of his body. He was taken back to Vienna, and died on May 18, 1911, leaving his Tenth Symphony incomplete.</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction</span></p><p class="elsevierStylePara">Infectious endocarditis is a major infection involving the endocardium, particularly the cardiac valves. For a long time, it was called bacterial endocarditis. Actually, in addition to bacteria, infectious endocarditis can be caused by other microbiological agents. Changes in the presentation of this disease are explained by modifications in susceptible populations, predisposing factors, and the evolution of microorganisms. Despite a great deal of progress made in recent decades, the diagnosis and treatment of endocarditis continue to be difficult.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Historical aspects</span></p><p class="elsevierStylePara">Fernel's <span class="elsevierStyleItalic">Medicini</span> in 1554 was the first book to introduce the term of endocarditis <span class="elsevierStyleSup">3</span>. During the 17<span class="elsevierStyleSup">th</span> and 18<span class="elsevierStyleSup">th</span> centuries, anomalies of the cardiac valves were described during autopsies of these patients <span class="elsevierStyleSup">2</span>. In 1669, Richard Lower in England was the first to diagnose endocarditis of the tricuspid valve. In 1806, Jean Nicolas Corvisart (1755-1821) was probably the first to use the term "vegetations" <span class="elsevierStyleSup">2</span>. In 1816, Théophile Laënnec <span class="elsevierStyleSup">1</span> invented the cylindrical stethoscope, improving cardiac auscultation. In 1835, Jean-Baptiste Bouillaud <span class="elsevierStyleSup">2</span> defined the endocardium in his "<span class="elsevierStyleItalic">Traité clinique des maladies du coeur</span>". In France, routine blood cultures were introduced by Pasteur in the late 19<span class="elsevierStyleSup">th</span> century <span class="elsevierStyleSup">1</span>. Penicillin was discovered by Sir Alexander Fleming in 1929 and it has being administered for the treatment of this disease since 1940 <span class="elsevierStyleSup"> 2</span>.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Epidemiology</span></p><p class="elsevierStylePara">Currently, the incidence of endocarditis is 1-4 cases/100,000 or 1/1,300 annual paediatric admissions <span class="elsevierStyleSup">4,5</span>. The increased occurrence of endocarditis is related to improved survival of children with congenital heart disease, newborns or other very ill children. Vascular conduits, patches or valvuloplasty in children with congenital heart disease are risk factors for endocarditis <span class="elsevierStyleSup"> 6</span>. Other risks are: catheter use in critically ill children, children with immunodeficiency, and the neonatology and the paediatric intensive care units <span class="elsevierStyleSup">7</span>. Eight to 10 percent of paediatric infectious endocarditis cases occur in healthy hearts. Endocarditis caused by intravenous drug use is rare in paediatrics. In the past, rheumatic fever was a risk factor, but it has disappeared in the western world. The epidemiology of endocarditis also has changed, thanks to the development and evolution of paediatric cardiology.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Pathogenesis</span></p><p class="elsevierStylePara">An injury in the endotelium is the first inducer of thrombogenesis <span class="elsevierStyleSup">4</span>, allowing bacteria to adhere and form vegetation. In children with cardiac malformations and turbulent or abnormal blood flow, injuries to the endothelium can easily arise. Catheters traumatize the endocardium <span class="elsevierStyleSup">8</span>. Cutaneous or mucosal injuries from tracheal suction, parenteral feeding and umbilical or peripheral catheters are at the origins of bacteraemia in newborns <span class="elsevierStyleSup"> 4</span>. Neonatal endocarditis frequently affects the right heart of newborns. If there is a critical mass of bacteria in the blood during bacteraemia, they can propagate and adhere to the endocardium. During thrombogenesis, blood platelets, sanguinous fibrin and blood cells collect as deposits, and an aseptic thrombus is formed. Bacteria colonize the aseptic thrombus, and blood platelets, fibrin and blood cells are deposited over these organisms, creating vegetation. Microorganisms trapped in the vegetation are protected from phagocytes and other defence mechanisms <span class="elsevierStyleSup">4</span>.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Clinical manifestations</span></p><p class="elsevierStylePara">The presentation can be insidious with prolonged fever and non-specific symptoms: fatigue, weakness, anorexia, weight loss, and sweating. At other times, it can be sudden, and these children are terribly ill. Endocarditis presents 4 phenomena:</p><p class="elsevierStylePara"><span class="elsevierStyleItalic"> 1.</span>Bacteraemia or fungemia.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic"> 2.</span>Valvulitis: new heart murmur or cardiac insufficiency.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic"> 3.</span>Immunological responses, much less frequent in children than in adults: petechias, haemorrhages, injuries of Roth or Janeway, Osler nodules or splenomegaly.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic"> 4.</span>Embolic phenomena may involve the kidneys, abdominal viscera, brain or heart.</p><p class="elsevierStylePara">In newborns, the presentation is non-specific. Septic emboli are frequent, causing: osteomyelitis, meningitis or pneumonia <span class="elsevierStyleSup">4</span>.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Etiology and Laboratory data</span></p><p class="elsevierStylePara">Blood culture is indicated in all children with fever of unknown origin, pathological murmur, a history of cardiac malformation or antecedents of endocarditis. During endocarditis, bacteraemia is continuous; therefore, blood cultures can be done at any time <span class="elsevierStyleSup"> 9</span>. It is important to collect an adequate amount of blood; in small children, this can vary from 1 to 3 ml, and in older children, 5-7 ml. Three blood cultures <span class="elsevierStyleSup">4,5</span> detect more than 95 % of endocarditis in children not exposed to antibiotics, and 90 % in children who have received antibiotics <span class="elsevierStyleSup"> 10-13</span>.</p><p class="elsevierStylePara">Most agents which cause endocarditis are gram-positive cocci <span class="elsevierStyleSup">14</span>: <span class="elsevierStyleItalic"> Streptococci</span>, <span class="elsevierStyleItalic">Staphylococci</span>, <span class="elsevierStyleItalic">Enterococci</span>. The organisms most frequently detected in infectious endocarditis are the <span class="elsevierStyleItalic">S. viridans</span> and the <span class="elsevierStyleItalic">S. aureus</span><span class="elsevierStyleSup">4</span>. In endocarditis caused by catheters, the <span class="elsevierStyleItalic"> S. aureus</span> and the <span class="elsevierStyleItalic">Staphylococci</span> coagulase-negative are frequent. In addition to those 2 agents, it is necessary in newborns to include the presence of <span class="elsevierStyleItalic">Candida</span>, <span class="elsevierStyleItalic">Klebsiella</span> and <span class="elsevierStyleItalic">Enterobacter</span><span class="elsevierStyleSup">14</span>. The organisms classified as the HACEK group are less frequently found at a paediatric age: <span class="elsevierStyleItalic">Haemophilus parainfluenzae</span>, <span class="elsevierStyleItalic">H. aphrophilus</span>, <span class="elsevierStyleItalic">H. paraphrophilus</span>, <span class="elsevierStyleItalic">H. influenzae</span>, <span class="elsevierStyleItalic">Actinobacillus actinomycetemcomitans</span>, <span class="elsevierStyleItalic">Cardiobacterium hominis</span>, <span class="elsevierStyleItalic">Eikenella corrodens, Kingella Kingae</span> and <span class="elsevierStyleItalic">K. denitrificans</span><span class="elsevierStyleSup">4</span>. Fungi are represented by <span class="elsevierStyleItalic">Candida</span> and <span class="elsevierStyleItalic"> Aspergillum</span>. Mylonakis et al <span class="elsevierStyleSup">15</span> enumerated the percentage of microbiological agents detected according to patient age (table 1).</p><p class="elsevierStylePara"><img src="37v63n05-13080399tab01.gif"></img></p><p class="elsevierStylePara">Endocarditis is diagnosed despite negative blood culture if clinical symptoms and heart ultrasound show evident signs of infection. The incidence of negative blood culture is approximately 5-7 %, mostly occurring in patients taking antibiotics or in endocarditis produced by pathogens other than bacteria <span class="elsevierStyleSup">4,16</span>. Vegetation culture can help in the diagnosis <span class="elsevierStyleSup">16</span>. Other laboratory results are non-specific: anaemia, leucocytosis, abnormal sedimentation rate, protein C-reactivity, hyper-gammaglobulinaemia, haematuria, proteinuria.</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> Echocardiography</span></p><p class="elsevierStylePara">For more than 15 years, heart ultrasound has been revolutionizing the diagnosis of endocarditis. This technique visualizes the place of infection, the vegetation, the extent of injury to the valves, and cardiac function. It also evaluates disease severity and influences medical or surgical treatment decisions. Doppler ultrasound allows the diagnosis of stenosis and valve insufficiency. Transthoracic echocardiography, with a sensitivity of 81 %, is very helpful in the diagnosis of paediatric endocarditis <span class="elsevierStyleSup">16</span>. Transoesophagic echocardiograpahy is employed less often in children, and frequently if transthoracic echocardiography is incapable of detecting vegetation <span class="elsevierStyleSup">17-19</span>. However, the absence of vegetation does not exclude the diagnosis of endocarditis. Endocarditis affects the valves, but it can also be located in a defect of the septum, the tendinous cords or wall of the endocardium.</p><p class="elsevierStylePara">The diagnosis of endocarditis is difficult <span class="elsevierStyleSup">20</span> as its clinical manifestations are numerous and non-specific. This explains why the differential diagnosis of endocarditis is important. Considering the consequences of misdiagnosed endocarditis, false-positives do occur. In countries with high immigration rates, it is necessary to remember that recurrence of rheumatic fever can present with the same clinics as endocarditis <span class="elsevierStyleSup">21,22</span>. Echocardiography in conjunction with clinical suspicion is the best criterion for the diagnosis of endocarditis.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Criteria for diagnosis</span></p><p class="elsevierStylePara">In 1909, Sir Thomas Horder <span class="elsevierStyleSup">1</span> from England described the first criteria for diagnosis: the signs and symptoms of endocarditis. Throughout the 20<span class="elsevierStyleSup">th</span> century, these criteria have undergone various modifications. In 1981, Von Reyn et al <span class="elsevierStyleSup">23</span> (table 2) proposed criteria to facilitate the diagnosis of the disease. These authors presented 123 adults treated at the Beth Israel Hospital in Boston and classified endocarditis as: definitive, probable, possible, or rejected. In 1994, at Duke University in North Carolina, Durack et al <span class="elsevierStyleSup">24</span> (tables 2 and 3) proposed new diagnostic criteria with the introduction of echocardiography: definitive, possible or rejected endocarditis. According to the criteria of Durack <span class="elsevierStyleSup">24</span> et al, any case of endocarditis not rejected must be considered possible. These criteria seem to present good sensitivity, but are non-specific. In 2000, Li et al <span class="elsevierStyleSup">25</span> (tables 2 and 3) tried to be stricter in endocarditis diagnosis and modified the earlier criteria of Durack <span class="elsevierStyleSup">24</span> et al.</p><p class="elsevierStylePara"><img src="37v63n05-13080399tab02.gif"></img></p><p class="elsevierStylePara"><img src="37v63n05-13080399tab03.gif"></img></p><p class="elsevierStylePara">The above-mentioned diagnostic criteria have been validated for use in adult cardiology <span class="elsevierStyleSup">26</span>. Some authors have tried to validate these criteria in paediatric cardiology <span class="elsevierStyleSup">27-29</span>. However, infectious endocarditis is a disease with a very variable clinical presentation. Isolated criteria are not sufficient to make a diagnosis. The various criteria are clinical guides to help in the diagnosis, but they do not replace clinical judgement. Molecular diagnosis can be helpful in cases with negative blood culture <span class="elsevierStyleSup"> 30</span>. Echocardiography also has been very useful. In the paediatric population, transthoracic echocardiography gives considerable information; transoesophagic echocardiography is rarely necesary <span class="elsevierStyleSup">17-19</span>. Echocardiography is not indicated if there is no clinical evidence to support the diagnosis of endocarditis. Each patient with suspicion of endocarditis deserves critical evaluation, to improve the clinical-microbiological diagnosis and treatment <span class="elsevierStyleSup">31</span>.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Treatment</span></p><p class="elsevierStylePara">In general, treatment is given for 4 weeks, but is extended up to 6 weeks if the symptoms of presentation have lasted more than 3 months (table 4) <span class="elsevierStyleSup">4,6,15,32</span>. Treatment is initiated in the hospital, but in some cases, it is complemented with antibiotic therapy at home.</p><p class="elsevierStylePara"><img src="37v63n05-13080399tab04.gif"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Complications and outcome</span></p><p class="elsevierStylePara">The clinical situations that favour complications <span class="elsevierStyleSup">4,31,32</span> and surgical indications according to the anomalies found at echocardiography are listed in table 5. Coward et al <span class="elsevierStyleSup">33</span> reported a 49 % incidence of complications. Mylonakis et al <span class="elsevierStyleSup"> 15</span> found 20-25 % adult mortality secondary to endocarditis. Danilowicz <span class="elsevierStyleSup">6</span> recorded a 20-30 % incidence of mortality in paediatric age patients, but recently some authors <span class="elsevierStyleSup">33</span> have determined the incidence to be 12 %.</p><p class="elsevierStylePara"><img src="37v63n05-13080399tab05.gif"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Prevention</span></p><p class="elsevierStylePara">The indications and doses of antibiotics to prevent infectious endocarditis are listed in table 6 <span class="elsevierStyleSup">4-6,34-38</span>.</p><p class="elsevierStylePara"><img src="37v63n05-13080399tab06.gif"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conclusion</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic"> 1.</span>Paediatric infectious endocarditis is rare, but its incidence has risen owing to the survival of children with operated congenital heart disease.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic"> 2.</span>In recent decades, the paediatric population at risk of endocarditis has changed, given the increase of children with immunodeficiency disease and children under neonatal and paediatric intensive care.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic"> 3.</span>Infectious endocarditis in healthy children is rare but not exceptional.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic"> 4.</span>Complications continue to be frequent.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic"> 5.</span>Diagnostic criteria are guidelines that do not replace clinical judgement.</p>" "pdfFichero" => "37v63n05a13080399pdf001.pdf" "tienePdf" => true "multimedia" => array:6 [ 0 => array:8 [ "identificador" => "tbl1" "etiqueta" => "TABLE 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "37v63n05-13080399tab01.gif" "imagenAlto" => 769 "imagenAncho" => 924 "imagenTamanyo" => 43070 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Pathogens causing endocarditis according to age" ] ] 1 => array:8 [ "identificador" => "tbl2" "etiqueta" => "TABLE 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "37v63n05-13080399tab02.gif" "imagenAlto" => 1440 "imagenAncho" => 1583 "imagenTamanyo" => 130307 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Criteria for diagnosis" ] ] 2 => array:8 [ "identificador" => "tbl3" "etiqueta" => "TABLE 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "37v63n05-13080399tab03.gif" "imagenAlto" => 1441 "imagenAncho" => 1572 "imagenTamanyo" => 140638 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Criteria for diagnosis" ] ] 3 => array:8 [ "identificador" => "tbl4" "etiqueta" => "TABLE 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "37v63n05-13080399tab04.gif" "imagenAlto" => 818 "imagenAncho" => 907 "imagenTamanyo" => 45814 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Therapy of Infectious Endocarditis 4,6" ] ] 4 => array:8 [ "identificador" => "tbl5" "etiqueta" => "TABLE 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "37v63n05-13080399tab05.gif" "imagenAlto" => 1562 "imagenAncho" => 909 "imagenTamanyo" => 83015 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Risk for complications" ] ] 5 => array:8 [ "identificador" => "tbl6" "etiqueta" => "TABLE 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "37v63n05-13080399tab06.gif" "imagenAlto" => 2236 "imagenAncho" => 909 "imagenTamanyo" => 151879 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Prophylaxis of endocarditis" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:38 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "referenciaCompleta" => "Emerging issues in infective endocarditis. 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Article information
ISSN: 16954033Original language: English
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|---|---|---|---|
| 2024 November | 9 | 20 | 29 |
| 2024 October | 69 | 87 | 156 |
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| 2021 March | 227 | 105 | 332 |
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| 2021 January | 93 | 37 | 130 |
| 2020 December | 122 | 37 | 159 |
| 2020 November | 96 | 33 | 129 |
| 2020 October | 79 | 22 | 101 |
| 2020 September | 38 | 11 | 49 |
| 2020 August | 70 | 27 | 97 |
| 2020 July | 71 | 14 | 85 |
| 2020 June | 66 | 21 | 87 |
| 2020 May | 90 | 19 | 109 |
| 2020 April | 49 | 18 | 67 |
| 2020 March | 59 | 16 | 75 |
| 2020 February | 47 | 16 | 63 |
| 2020 January | 48 | 18 | 66 |
| 2019 December | 55 | 25 | 80 |
| 2019 November | 47 | 14 | 61 |
| 2019 October | 51 | 11 | 62 |
| 2019 September | 30 | 15 | 45 |
| 2019 August | 30 | 15 | 45 |
| 2019 July | 37 | 16 | 53 |
| 2019 June | 69 | 24 | 93 |
| 2019 May | 112 | 29 | 141 |
| 2019 April | 122 | 21 | 143 |
| 2019 March | 40 | 20 | 60 |
| 2019 February | 31 | 9 | 40 |
| 2019 January | 46 | 19 | 65 |
| 2018 December | 52 | 24 | 76 |
| 2018 November | 60 | 30 | 90 |
| 2018 October | 83 | 14 | 97 |
| 2018 September | 34 | 12 | 46 |
| 2018 August | 5 | 0 | 5 |
| 2018 July | 9 | 0 | 9 |
| 2018 June | 5 | 0 | 5 |
| 2018 May | 10 | 0 | 10 |
| 2018 April | 55 | 0 | 55 |
| 2018 March | 35 | 0 | 35 |
| 2018 February | 25 | 0 | 25 |
| 2018 January | 30 | 0 | 30 |
| 2017 December | 32 | 0 | 32 |
| 2017 November | 32 | 0 | 32 |
| 2017 October | 39 | 0 | 39 |
| 2017 September | 44 | 0 | 44 |
| 2017 August | 36 | 0 | 36 |
| 2017 July | 38 | 2 | 40 |
| 2017 June | 48 | 11 | 59 |
| 2017 May | 101 | 18 | 119 |
| 2017 April | 39 | 5 | 44 |
| 2017 March | 35 | 7 | 42 |
| 2017 February | 72 | 9 | 81 |
| 2017 January | 22 | 7 | 29 |
| 2016 December | 44 | 15 | 59 |
| 2016 November | 73 | 8 | 81 |
| 2016 October | 121 | 6 | 127 |
| 2016 September | 155 | 7 | 162 |
| 2016 August | 21 | 6 | 27 |
| 2016 July | 6 | 0 | 6 |
| 2015 December | 1 | 0 | 1 |
| 2015 October | 1 | 16 | 17 |
| 2015 September | 9 | 0 | 9 |
| 2015 August | 1 | 11 | 12 |
| 2015 July | 10 | 0 | 10 |
| 2015 June | 11 | 3 | 14 |
| 2015 May | 18 | 0 | 18 |
| 2015 April | 6 | 1 | 7 |
| 2015 March | 16 | 3 | 19 |
| 2015 February | 5 | 3 | 8 |
| 2015 January | 14 | 0 | 14 |
| 2014 December | 11 | 2 | 13 |
| 2014 November | 6 | 2 | 8 |
| 2014 October | 17 | 2 | 19 |
| 2014 September | 14 | 0 | 14 |
| 2014 August | 11 | 0 | 11 |
| 2014 July | 23 | 1 | 24 |
| 2014 June | 62 | 3 | 65 |
| 2014 May | 67 | 5 | 72 |
| 2014 April | 65 | 5 | 70 |
| 2014 March | 63 | 14 | 77 |
| 2014 February | 47 | 8 | 55 |
| 2014 January | 22 | 8 | 30 |
| 2013 December | 38 | 6 | 44 |
| 2013 November | 41 | 7 | 48 |
| 2013 October | 39 | 7 | 46 |
| 2013 September | 23 | 7 | 30 |
| 2013 August | 28 | 8 | 36 |
| 2013 July | 28 | 4 | 32 |
| 2013 June | 8 | 4 | 12 |
| 2013 May | 4 | 2 | 6 |
| 2013 April | 5 | 1 | 6 |
| 2013 March | 9 | 2 | 11 |
| 2013 February | 19 | 1 | 20 |
| 2013 January | 14 | 0 | 14 |
| 2012 December | 6 | 0 | 6 |
| 2012 November | 3 | 1 | 4 |
| 2012 October | 2 | 1 | 3 |
| 2012 September | 2 | 0 | 2 |
| 2005 November | 1305 | 0 | 1305 |
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