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PubMed1995

Determinants of early mortality and late survival in mitral valve endocarditis.

BACKGROUND: Infective mitral valve endocarditis continues to be a significant surgical challenge. The objective of this study was to examine our experience with mitral valve endocarditis surgery and identify determinants of early mortality and late survival. METHODS AND RESULTS: Over a 24-year period, mitral valve surgery was performed in 96 patients for infective mitral valve endocarditis. Patient age ranged from 20 to 78 years (median age, 52 years). There were 44 women (46%), and 48 of the 96 patients (50%) were in New York Heart Association functional class IV before surgery. Native valve endocarditis (NVE) and prosthetic valve endocarditis (PVE) were present in 72 patients (75%) and 24 patients (25%), respectively. Surgery during the active phase of endocarditis (AE) was required in 60 patients (62%) and during the healed phase (HE) in 36 (38%). The main indications for surgery in the AE group were congestive heart failure (60%), active sepsis (67%), peripheral emboli (47%), and acute renal failure (20%), and for the HE group the main indication was progressive congestive heart failure (69%). The overall operative mortality was 5.2%. Multivariate logistic regression analysis identified PVE (odds ratio [OR] 22.5; +/- 95% confidence interval, CI, 1.9 to 268; P = .014) and an associated procedure (OR 13.3; +/- 95% CI, 1.5 to 120; P = .021) to be independent predictors for early mortality. Follow-up was 97% complete, with a median of 3.5 years. Overall 5- and 10-year survivals were 83 +/- 4% and 63 +/- 8%, respectively. Multivariate analysis for late mortality identified PVE to be a significant predictor of late mortality (hazards ratio = 3.1, +/- 95% CI, 1.4 to 6.8, P = .006). There were no significant differences in long-term morbidity results among the various subsets of mitral valve endocarditis. CONCLUSIONS: Mitral valve surgery for infective endocarditis is a significant high-risk procedure for PVE and when combined with associated procedures. The activity of endocarditis does not appear to have any influence on early mortality or long-term survival.

Adult↗

PubMed1996

Diagnostic value of echocardiography in suspected endocarditis. An evaluation based on the pretest probability of disease.

BACKGROUND: We hypothesized that for the diagnosis of endocarditis, (1) transthoracic echocardiography (TTE) would be most valuable in patients with an intermediate clinical probability of the disease and (2) transesophageal echocardiography (TEE) would be most useful in patients with an intermediate probability when TTE either does not yield an adequate study or indicates an intermediate probability of endocarditis. We also sought to investigate the influence of echocardiographic results on antibiotic usage and its duration. METHODS AND RESULTS: TTE and TEE were performed in 105 consecutive patients with suspected endocarditis. Patients were classified as having either low, intermediate, or high probability of endocarditis on the basis of clinical criteria and separately on the basis of both TTE and TEE findings. TTE and TEE classified the majority (82% and 85%, respectively) of the 67 patients with a low clinical probability of endocarditis as having a low likelihood of the disease. Of the 14 patients with intermediate clinical probability, 12 had technically adequate TTE studies; 10 of these (83%) were classified as either high or low probability. All patients with intermediate clinical probability were classified as high or low probability by TEE. The majority of the 24 patients with high clinical probability were placed in the low-likelihood category by echocardiography (15 by TTE and 12 by TEE). There was concordance between TTE and TEE in 83% of all cases. TEE was useful for the diagnosis of endocarditis in patients with prosthetic valves and in those in whom TTE indicated an intermediate probability; these constituted < 20% of patients in our study. The course of antibiotic therapy was influenced only by the clinical profile and not by the echocardiographic results. CONCLUSIONS: Echocardiography should not be used to make a diagnosis of endocarditis in those with a low clinical probability of the disease. In those with an intermediate or high clinical probability, TTE should be the diagnostic procedure of choice. TEE for the diagnosis of endocarditis should be reserved only for patients who have prosthetic valves and in whom TTE is either technically inadequate or indicates an intermediate probability of endocarditis.

Adolescent↗

PubMed1997

Prevention of bacterial endocarditis. Recommendations by the American Heart Association.

OBJECTIVE: To update recommendations issued by the American Heart Association last published in 1990 for the prevention of bacterial endocarditis in individuals at risk for this disease. PARTICIPANTS: An ad hoc writing group appointed by the American Heart Association for their expertise in endocarditis and treatment with liaison members representing the American Dental Association, the Infectious Diseases Society of America, the American Academy of Pediatrics, and the American Society for Gastrointestinal Endoscopy. EVIDENCE: The recommendations in this article reflect analyses of relevant literature regarding procedure-related endocarditis, in vitro susceptibility data of pathogens causing endocarditis, results of prophylactic studies in animal models of endocarditis, and retrospective analyses of human endocarditis cases in terms of antibiotic prophylaxis usage patterns and apparent prophylaxis failures. MEDLINE database searches from 1936 through 1996 were done using the root words endocarditis, bacteremia, and antibiotic prophylaxis. Recommendations in this document fall into evidence level III of the US Preventive Services Task Force categories of evidence. CONSENSUS PROCESS: The recommendations were formulated by the writing group after specific therapeutic regimens were discussed. The consensus statement was subsequently reviewed by outside experts not affiliated with the writing group and by the Science Advisory and Coordinating Committee of the American Heart Association. These guidelines are meant to aid practitioners but are not intended as the standard of care or as a substitute for clinical judgment. CONCLUSIONS: Major changes in the updated recommendations include the following: (1) emphasis that most cases of endocarditis are not attributable to an invasive procedure; (2) cardiac conditions are stratified into high-, moderate-, and negligible-risk categories based on potential outcome if endocarditis develops; (3) procedures that may cause bacteremia and for which prophylaxis is recommended are more clearly specified; (4) an algorithm was developed to more clearly define when prophylaxis is recommended for patients with mitral valve prolapse; (5) for oral or dental procedures the initial amoxicillin dose is reduced to 2 g, a follow-up antibiotic dose is no longer recommended, erythromycin is no longer recommended for penicillin-allergic individuals, but clindamycin and other alternatives are offered; and (6) for gastrointestinal or genitourinary procedures, the prophylactic regimens have been simplified. These changes were instituted to more clearly define when prophylaxis is or is not recommended, improve practitioner and patient compliance, reduce cost and potential gastrointestinal adverse effects, and approach more uniform worldwide recommendations.

American Heart Association↗

PubMed1991

Value of transesophageal echocardiography as an adjunct to transthoracic echocardiography in evaluation of native and prosthetic valve endocarditis.

To determine if transesophageal echocardiography provides better visualization of valvular vegetations than transthoracic echocardiography, we used both methods to evaluate 24 consecutive patients (mean age, 54 years; 15 female patients and nine male patients) referred for symptoms suggestive of infectious endocarditis. Ten of the 24 patients had one or more valvular prostheses. Echocardiograms were classified as positive or negative based on visualization of valvular vegetations or abscesses. Of ten patients with a final diagnosis of infectious endocarditis on extended follow-up, transthoracic echocardiography was positive in five patients. Transesophageal echocardiography not only yielded abnormal findings in all ten of these patients, but also revealed additional information in four of the five patients with abnormal transthoracic echocardiographic examinations. Among the 14 patients who, on subsequent follow-up, were found not to have infectious endocarditis, transthoracic echocardiography was normal in 13 and falsely abnormal in one. Transesophageal echocardiography revealed no evidence of infectious endocarditis in any of these patients. The ten patients who were determined to have infectious endocarditis all had positive blood cultures and no alternative cause for their clinical presentation; in seven patients in this group who underwent operative or postmortem evaluation, infectious endocarditis was confirmed. All patients without infectious endocarditis were demonstrated to have other causes for their clinical presentation. We conclude that transesophageal echocardiography is a highly valuable test in the work-up of patients with suspected infectious endocarditis, especially those patients with inconclusive or normal transthoracic echocardiograms. In addition, transesophageal echocardiography may be of benefit to patients with previously documented infectious endocarditis and a complicated clinical course in whom additional cardiac lesions are suspected but not demonstrated by transthoracic echocardiography.

Abscess↗

PubMed1989

Predictive risk factors for periannular extension of native valve endocarditis. Clinical and echocardiographic analyses.

The study objective is to identify clinical, microbiologic, and/or echocardiographic risk factors present early in the course of native valve endocarditis that predict subsequent development of periannular extension of infection. A multivariate computer-generated analysis of 21 clinical-microbiologic parameters and 11 two-dimensional echocardiographic parameters in patients with native valve endocarditis was designed. These parameters were statistically compared in operated-on patients with native valve endocarditis with and without periannular extension of infection. The study took place in a 600-bed acute-care, nonreferral, municipal hospital primarily servicing an indigent patient population. Seventy-three documented episodes of native valve endocarditis occurred between the years of 1973 and 1987, including 29 operated-on patients with surgically confirmed periannular extension of infection and 44 operated-on patients without periannular extension of infection. Multivariate logistic-regression analyses of multiple clinical, microbiologic, and echocardiographic parameters which are potentially predictive of eventual periannular extension of native valve endocarditis were carried out. The only two independent parameters that significantly predicted periannular infection among patients with native valve endocarditis were (1) aortic valve involvement and (2) abuse of intravenous (IV) drugs (p less than 0.01; p less than 0.01, respectively, multivariate analysis). The relative risk of developing periannular extension of endocarditis among patients with aortic valve involvement and/or IV drug abuse was increased by approximately 2.5-fold compared with patients without these characteristics. Factors not significantly associated with increased risk of periannular extension of native valve endocarditis included the following: prolonged febrile morbidity; Staphylococcus aureus etiology; or two-dimensional echocardiographic demonstration of vegetations, large vegetations (greater than or equal to 1 cm), multiple vegetations, or enlargement of aortic root or annulus. These data suggest that patients with native aortic valve endocarditis, particularly in the setting of IV drug abuse, should be considered for routine, serial noninvasive evaluation for the early detection of periannular extension of their infection.

Adult↗

PubMed1997

Prevention of bacterial endocarditis: recommendations by the American Heart Association.

OBJECTIVE: To update recommendations issued by the American Heart Association last published in 1990 for the prevention of bacterial endocarditis in individuals at risk for this disease. PARTICIPANTS: An ad hoc writing group appointed by the American Heart Association for their expertise in endocarditis and treatment with liaison members representing the American Dental Association, the infectious Diseases Society of America, the American Academy of Pediatrics and the American Society for Gastrointestinal Endoscopy. EVIDENCE: The recommendations in this article reflect analyses of relevant literature regarding procedure-related endocarditis, in vitro susceptibility data of pathogens causing endocarditis, results of prophylactic studies in animal models of endocarditis and retrospective analyses of human endocarditis cases in terms of antibiotic prophylaxis usage patterns and apparent prophylaxis failures. MEDLINE database searches from 1936 through 1996 were done using root words endocarditis, bacteremia and antibiotic prophylaxis. Recommendations in this document fall into evidence level III of the U.S. Preventive Services Task Force categories of evidence. CONSENSUS PROCESS: The recommendations were formulated by the writing group after specific therapeutic regimens were discussed. The consensus statement was subsequently reviewed by outside experts not affiliated with the writing group and by the Science Advisory and Coordinating Committee of the American Heart Association. These guidelines are meant to aid practitioners but are not intended as the standard of care or as a substitute for clinical judgment. CONCLUSIONS: Major changes in the updated recommendations include the following: (1) emphasis that most cases of endocarditis are not attributable to an invasive procedure; (2) cardiac conditions are stratified into high-, moderate- and negligible-risk categories based on potential outcome if endocarditis develops; (3) procedures that may cause bacteremia and for which prophylaxis is recommended are more clearly specified; (4) an algorithm was developed to more clearly define when prophylaxis is recommended for patients with mitral valve prolapse; (5) for oral or dental procedures the initial amoxicillin dose is reduced to 2 g, a follow-up antibiotic dose is no longer recommended, erythromycin is no longer recommended for penicillin-allergic individuals, but clindamycin and other alternatives are offered.

Algorithms↗

PubMed1999

[Survey of infective endocarditis in the last 10 years: analysis of clinical, microbiological and therapeutic features].

Infective endocarditis still presents problems with early diagnosis, selection of antibiotics and timing of surgical procedure despite modern antibiotics and investigative procedures. A retrospective study was performed to clarify the clinical and microbiological spectrum of recent infective endocarditis in the Japanese population in 38 patients with infective endocarditis (mean age 42.7 +/- 12.5 years) treated from March 1986 to March 1996. The portal of entry to bacteremia was unknown in most cases (57.9%), but the commonest identified portal was dental procedure (18.4%). Overall, the aortic valve was infected most frequently (44.7%) and followed by the mitral valve (36.8%). The most common complication of infective endocarditis were emboli (11/38, 28.9%) and congestive heart failure, NYHA class III and IV (14/38, 36.8%). Organisms were isolated from 26 of the 38 (68.4%) patients. Streptococcus viridans was the most frequent organism (34.2%), and then Staphylococcus aureus (13.2%). The blood culture positivity of microorganism was significantly higher in patients not receiving antibiotics than in those the received antibiotics (87.5% vs 50%, p < 0.05). The prevalence of streptococcal endocarditis decreased in the 1990s (1992-1996) in comparison with those in the 1980s (1986-1988). Multiple antibiotics were used frequently in 1990s and the sensitivity titer to piperacillin reduced from 3.0 in the 1980s to 1.8 in the 1990s. In contrast to reduction of streptococcal endocarditis, Staphylococcus aureus endocarditis has increased recently from 12.5% to 30.8%. The most common clinical features are valve destruction, low sensitivity of penicillin, and significantly higher in-hospital mortality. Surgical treatment was indicated most commonly in cases of uncontrollable heart failure, and infected valves were replaced during the active stage in 11/23 cases (47.8%). In-hospital mortality was higher in the medical treatment group than in the surgical group, but a long-term mortality of mean observation term 4.2 +/- 3.2 years was identical in the chronic phase. In patients with infective endocarditis and successful treatment in the acute stage, a long-term survival rate in medically treated patients was found almost comparable to surgically treated patients in our series. However, it should be emphasized that streptococcal endocarditis is being replaced by infection by Staphylococcus aureus, which is resistant to penicillin and requires intensive chemotherapy and proper decision at suitable timing for surgical therapy in the early stage.

Adult↗

PubMed2002

Is there an advantage in using homografts in patients with acute infective endocarditis of the aortic valve?

BACKGROUND AND AIM OF THE STUDY: Acute infective endocarditis is a surgical challenge, particularly when paravalvular abscesses and annular destruction are present. The choice of a homograft or mechanical valve prosthesis is an important issue in these patients. The study aim was to compare the outcome with homografts and mechanical valves in patients with acute infective endocarditis. METHODS: A total of 77 patients (mean age 49+/-9 years) operated on for acute endocarditis of the aortic valve was included in the study and analyzed retrospectively. The causative bacterium was isolated from blood cultures in 71 cases. Preoperatively, 21 patients required artificial ventilation and 24 had inotropic support due to hemodynamic instability. Aortic homografts were implanted in 43 patients, and mechanical valve prostheses in 34. The two patient groups were similar in terms of gender, age and preoperative inotropic support. In total, 31 patients (44%) had paravalvular abscesses, and a homograft was used significantly more often (77%, p <0.05) in these cases. Follow up examinations (clinical examination, ECG and transthoracic echocardiography) were performed six months postoperatively and continued on an annual basis. Endocarditis relapse was defined as persisting infection, whereas re-endocarditis indicated a new infection after an interval of at least six months. RESULTS: Perioperative mortality was 11.5% (5/43) in homograft patients. In the 38 survivors, follow up was complete and averaged 5.0+/-1.2 years. One patient had an endocarditis relapse three months after surgery. Re-endocarditis occurred in three patients after two or three years. One other patient had pseudoaneurysm formation without a need for intervention, and one had repeat aortic valve replacement due to dysfunction of the graft after four years. The other 33 patients had an uneventful follow up. Echocardiography revealed aortic insufficiency grade 1 in 12 cases (36%), with no progression during follow up. Perioperative mortality in mechanicat valve patients was 20.5% (n = 7) (p <0.05 versus homograft), and in those with paravalvular abscess, perioperative mortality was even higher than in homograft patients (4/7, 57.1% versus 3/24, 12.5%; p <0.05). When considering only patients without paravalvular abscess, there was no significant difference between groups (10.5% versus 12.5%). Three relapses occurred in mechanical valve patients (10.3%), but no endocarditis recurred during follow up. One late death (3.7%) occurred due to bleeding complicating long-term anticoagulation. CONCLUSION: The study results do not permit a general recommendation to be made for homograft use in patients with acute endocarditis. In cases with paravalvular abscesses, however, there was a trend towards improved outcome in the homograft group.

Adult↗

PubMed2003

[Variations of the profile of infective endocarditis in France. Results of an epidemiologic survey carried out during a year].

Since the first modern clinical description of the infective endocarditis by Osler at the late 19th century, the profile of this disease never stopped changing, which has been well described by several epidemiological studies, especially the one performed in France in 1991. The aim of this study was to update data obtained in 1991 on the epidemiology of infective endocarditis in France. This is a transversal survey conducted between January and December 1999 in all hospitals of 6 French regions representing 26% of the whole population (16 million inhabitants). Among them 390 subjects presented the diagnosis of definite infective endocarditis according to the Duke criteria. The age- and sex-adjusted annual incidence was at 31 cases per million (95% interval confidence 28-35). In 47% of cases, no pre-existing cardiac disease was known for the patient. The rate of prosthetic valve endocarditis was at 16%. Micro-organisms involved were distributed as follows: streptococci 48% (D-group 25%, oral streptococci 17%, pyogenic streptococci 6%); enterococci 8%, Abiotrophia sp.: 2%, staphylococci 29%, others or multiple micro-organisms: 8%. Blood cultures were negative in 9% of cases and neither micro-organism was identified in 5% of cases. Early valvular surgery was performed in 49% of them. The in-hospital mortality was at 16%. Compared to the 1991 study, this one highlights a decrease of endocarditis incidence in patients with known cardiac disease (20.6 cases per million vs. 15.1 cases per million, p < 0.001) and a decrease of the incidence of endocarditis due to oral streptococci, which is partially counter-balanced by an increase of the proportion of endocarditis due to D-group streptococci (5.3 cases per million vs. 6.2 cases per million, p = 0.67) and to staphylococci (4.9 cases per million vs. 5.7 cases per million, p = 0.97), an increased rate of surgery in the in-hospital period (31.2% vs. 49.7%, p < 0.001), a decrease of hospital mortality (21.6% vs. 16.6%, p = 0.008). Even though the global incidence of endocarditis did not change significantly, this study highlights important modification in the infective endocarditis profile, especially concerning the culprit agents, the underlying cardiac disease, the therapeutic strategies engaged and the prognosis.

Adolescent↗

PubMed2006

[Surgical treatment of infective endocarditis: 8 year experience].

BACKGROUND: A retrospective study analysing effects of surgical treatment of active infective endocarditis was performed in our centre between January 1998 and December 2005. METHODS AND RESULTS: 57 consecutive patients with infective endocarditis underwent surgical intervention in active phase of infection (fulfilment of Durack diagnostic criteria, persisting elevation CRP at the time of cardiac surgery, indications for surgery according to actual guidelines of the Czech Society of Cardiology). Male to female ratio was 38:19. The patients' mean age was 52.5 years without any significant differences among men and women. The most frequent causative agents were staphylococci--28.1 % and streptococci--19.3 %. 26 cases of aortic valve involvement were the most frequent, followed by 21 cases of mitral endocarditis, and 7 cases were both aortic and mitral valve endocarditis. 3 cases of tricuspid endocarditis were also observed. Native valve endocarditis prevailed over the prosthetic ones--49 versus 8. Surgery was most often performed using a mechanical prosthesis (45 cases), bioprostheses were implanted in 13 patients and 6 patients underwent mitral or tricuspid valve repair operation. In 1 patient, the procedure was complemented with mitral valve annuloplasty, and in 5 patients, the operation was completed with tricuspid annuloplasty--because of significant regurgitation of other aetiology. Coronary artery bypass surgery (at the same time) was necessary in 9 patients. Surgery was followed by a significant shift from classes III and IV to classes I and II of NYHA classification. Relapsing or recurrent endocarditis developed in 7 %. Thirty-day mortality of patients who had undergone surgery for active infective endocarditis was 15.8 %, 9 patients died. During follow up period 7 patients died, the overall mortality was 28.1 %. Survivors were followed up for 0.5-90 (median 40) months. CONCLUSIONS: Operation for active infective endocarditis carries a relatively higher mortality in comparison with elective surgery. Nevertheless, this is acceptable because the operation in active phase is enforced by life-threatening complications and it also reduces assumed mortality at conservative therapy. Our results are comparable with data from other studies.

Bioprosthesis↗

PubMed1983

A general survey of antibiotic treatment of staphylococcal septicaemia and endocarditis.

The penicillinase-resistant penicillins (methicillin, oxacillin, nafcillin) have been the mainstay of antibiotic therapy for S. aureus septicaemia and endocarditis. In experimental rabbit S. aureus endocarditis, these three antibiotics were equally effective. There has been no prospective comparative clinical studies to determine the relative effectiveness of these antibiotics. In experimental rabbit S. aureus endocarditis, cephalothin and cefazolin are less effective than methicillin and nafcillin. The results of therapy with cephalosporins in patients with S. aureus endocarditis are variable. Clindamycin therapy of S. aureus endocarditis has been associated with clinical relapse. Vancomycin has been used to treat S. aureus septicaemia and endocarditis with good results. Fusidic acid has been used in combination with another effective drug in treating S. aureus septicaemia and endocarditis. Although the combination of a cell-wall acting antibiotic with an aminoglycoside has been shown to have an enhanced anti-staphylococcal activity in vitro and in animal studies, there is no evidence that such a combination reduces morbidity or mortality clinically. Rifampin in combination with a cell-wall acting antibiotic is antagonistic against S. aureus in vitro and in experimental endocarditis in rabbits. The use of such a combination has not shown consistent benefits clinically. The clinical importance of tolerance (MBC/MIC greater than or equal to 32) of cell-wall acting antibiotics to S. aureus is not clear. It appears not to be important in animal studies. Cephalosporins appear not to be effective in the treatment of methicillin-resistant S. aureus infections. The treatment of choice of sepsis and endocarditis due to such strains is vancomycin which is effective against all strains of methicillin-resistant S. aureus.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

PubMedDate not supplied

Clinical features, site of involvement, bacteriologic findings, and outcome of infective endocarditis in intravenous drug users.

BACKGROUND: Intravenous drug use is an increasingly common condition predisposing to infective endocarditis. Data on infective endocarditis in intravenous drug users are limited. OBJECTIVE: To determine the clinical features, bacteriologic findings, site of involvement, complications, and mortality associated with infective endocarditis in intravenous drug users. METHODS: Cohort study of intravenous drug users with native valve infective endocarditis. RESULTS: A total of 125 cases of infective endocarditis occurred in 114 patients (84 cases [67%] in men and 41 cases [32%] in women) with a mean (+/- SD) age of 37 +/- 7 years. The tricuspid valve was involved in 58 cases (46%), the mitral valve in 40 cases (32%), and the aortic valve in 24 cases (19%). The microorganisms identified included Staphylococcus in 82 cases (65.6%) and Streptococcus in 32 cases (25.6%). Twenty-three patients (18%) underwent surgery, and two (9%) of them died. One hundred two patients (82%) were treated medically, and nine (9%) of them died. Fifteen patients (63%) with aortic valve involvement vs 17 patients (17%) without aortic valve involvement underwent surgery or died without surgery (odds ratio, 8.24; 95% confidence interval, 3.1 to 21.8). Among the survivors, at least one major cardiovascular complication occurred in 79 cases (69.3%). CONCLUSIONS: Infective endocarditis in intravenous drug users affects the right and left sides of the heart with approximately equal frequency. At present, more than 90% of cases of infective endocarditis in intravenous drug users in Chicago are caused by staphylococci or streptococci. Involvement of the aortic valve is predictive of increased morbidity and mortality in intravenous drug users with infective endocarditis. With medical treatment, and surgery when medical treatment fails, intravenous drug users with infective endocarditis have an in-hospital survival rate of 91%.

Adult↗

PubMed1993

[Acquired data on the antibiotic treatment of bacterial endocarditis on native or prosthetic valves].

Antimicrobial therapy of infective endocarditis is based on periodically updated expert recommendations that derive from both clinical and experimental data. Streptococcal and enterococcal endocarditis should be treated intravenously with a combination of penicillin+aminoglycoside in the absence of allergy to penicillin. The choice of either penicillin or ampicillin, the dose and the length of treatment plainly depend on susceptibility of streptococcal strain to penicillin. In patients allergic to penicillin, vancomycin is the optimal choice. The treatment of native valve meticillin-susceptible staphylococcal endocarditis is based on a combination of oxacillin or cefamandole+aminoglycoside. Vancomycin is recommended in case of allergy to penicillin and in meticillin resistant staphylococcal endocarditis. Prosthetic valve staphylococcal endocarditis are often due to meticillin-resistant coagulase negative staphylococci. Therefore they should be treated with vancomycin in combination with rifampicin and an aminoglycoside unless the strain is resistant to either of these 2 antibiotics. For the treatment of culture-negative endocarditis, different situations should be considered: in native valve endocarditis, the possible responsibility of deficient streptococci justifies an ampicillin+aminoglycoside combination; in recently implanted (< 1 year) prosthetic valve endocarditis a combination of vancomycin+rifampicin+aminoglycoside should be used because of the high probability of meticillinresistant staphylococci: if prosthetic valve is implanted for more than a year endocarditis may be due to streptococci, staphylococci and fastidious gram-negative bacilli; a combination of vancomycin+aminoglycoside +/- third generation cephalosporin is therefore recommended.

Anti-Bacterial Agents↗

PubMed1994

Myths of dental-induced endocarditis.

Although the latest (1990) American Heart Association recommendations for the prevention of bacterial endocarditis are by far the simplest yet, many physicians and dentists still do not comply with them. One of the reasons for this low compliance is that many clinicians rely on "myths" of dental-induced endocarditis prevention. To educate clinicians on endocarditis and its prevention, the myths of dental-induced endocarditis prevention are analyzed. Myth 1: For the most part, physicians and dentists are aware of and comply with American Heart Association guidelines on antibiotic prophylaxis for prevention of infective endocarditis. Myth 2: Most cases of bacterial endocarditis of oral origin are caused by dental procedures. Myth 3: American Heart Association antibiotic regimens give almost total protection against endocarditis after dental procedures. Myth 4: Antibiotics should be administered for any dental procedure that causes bleeding. Myth 5: If a patient was receiving recent antibiotic therapy before the dental procedure, there is no need to change the dose or the antibiotic before the dental procedure. Myth 6: The risk of endocarditis is almost always greater than the risk of antibiotic toxic effects. Myth 7: Parenteral antibiotics before dental procedures are preferable for most patients with high-risk conditions (eg, prosthetic heart valves and previous history of endocarditis). Myth 8: All patients with mitral valve prolapse should routinely receive antibiotic prophylaxis for dental procedures. Myth 9: Clinicians should err on the positive side of antibiotic prophylaxis to prevent lawsuits.

American Heart Association↗

PubMed1997

Prevention of bacterial endocarditis. Recommendations by the American Heart Association.

Antibiotic Prophylaxis↗

PubMed1998

[Infective endocarditis caused by unusual microorganisms].

All series of infective endocarditis had a variable proportion of cases without an etiologic agent because all cultures were negative. New microbiologic techniques have permitted the discovery of the role of many microorganisms in infective endocarditis. C. burnetii is an increasing causative agent of subacute infective endocarditis. In the diagnosis, to the detection of antiphase-I antibodies, immunohistochemical, molecular techniques and cellular cultures have been added. Total cure is difficult to obtain. The combination of doxicicline plus ciprofloxacin for at least 3 years has been proposed as the treatment of choice. Surgery must be reserved for patients with cardiac insufficiency. Less than 2% of cases of acute brucellosis are complicate with infective endocarditis. Infective endocarditis produces serious and rapid valvular destruction with high mortality rates if valve surgery is not performed. For medical treatment at least 3 active agents are required. Bartonella has recently been described as an etiologic agent of infective endocarditis. It mainly affects to homeless people living in poor hygienic conditions. The aortic valve is most commonly involved and, frequently, valve insufficiency requires valve replacement. Blood culture isolation needs long incubation periods. Parenteral nutrition, immunosuppression, wide spectrum antibiotic regimens, intravenous drug addiction and cardiovascular surgery are risk factors previously described in the development of fungal endocarditis. C. albicans and Aspergillus spp. are most frequent etiologic agents. Infective endocarditis should be suspected in any patient with systemic fungal disease. Blood cultures are often negative except for Candida spp. Peripheral emboli and large vegetations are frequent. Mortality is high, antifungal therapy combined with surgery is the treatment of choice. Legionella, Mycoplasma, Chlamydia, Mycobacteria, viruses are potential agents of infective endocarditis, and difficult to diagnose because of special culture requirements. Epidemiological clues, serologic and molecular techniques and blood cultures could identify them.

Anti-Bacterial Agents↗

PubMedDate not supplied

Twelve-year review of recurrent native-valve infective endocarditis: a disease of the modern antibiotic era.

Recurrent cases of native-valve endocarditis have been seen for only the past four decades. In a review of the English-language literature over the past 12 years, 281 cases of recurrent infective endocarditis were found. Males were more than three times more commonly identified than females. Intravenous drug use was a designated risk factor for endocarditis in 43% of patients. Compared with patients with other risk factors for endocarditis, patients with intravenous drug use were significantly more likely (P less than .005) to suffer a recurrent bout of native-valve endocarditis within 12 months after the primary (or previous) episode. A greater variety of organisms were isolated from patients with recurrent endocarditis than from those with primary endocarditis. Valvular involvement was evenly distributed among the aortic, mitral, and tricuspid valves for both primary and recurrent episodes of infection. While complications of recurrent native-valve endocarditis were relatively common, the mortality rate associated with the recurrences was less than 30%.

Endocarditis↗

PubMed1990

Increasing frequency of staphylococcal infective endocarditis. Experience at a university hospital, 1981 through 1988.

To determine the characteristics of infective endocarditis in our hospital, we reviewed all patients with that diagnosis at the University of Massachusetts Medical Center, Worcester, between 1981 and 1988. Of 113 patients with infective endocarditis, 56 (50%) had staphylococcal endocarditis. Despite aggressive medical and surgical therapy, in-hospital mortality was 25%. Forty-five (80%) of the 56 cases of staphylococcal endocarditis involved Staphylococcus aureus with a mortality of 28% vs 9% in the non-S aureus group. Mortality was higher in patients with congestive heart failure (35%), atrioventricular block (45%), atrial fibrillation (42%), and prosthetic valve endocarditis (50%). Seventy-six percent of the patients with congestive heart failure required surgery. Patients with congestive heart failure and S aureus infection had a mortality of 45%. Thirty-six patients (64%) were alive at late follow-up (mean, 28.6 months). Mortality was highest (23%) during the first 3 months following diagnosis of staphylococcal endocarditis. Staphylococcal endocarditis represents an increasingly large proportion of patients with infectious endocarditis. Mortality rates remain high despite aggressive management of the patient's condition.

Adolescent↗