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PubMed1995

[The immunogenetic status of patients with infectious endocarditis].

On the basis of a deep clinico-immunological examination of 23 patients with septic endocarditis it was established that HLA B35 antigen and haplotype A2-B35 are the most probable markers of the genetic predisposition to the development of infective endocarditis. Immune deficiency is accompanied by a decreased content of T-helpers, decreased activity of natural killers and phagocytic activity of granulocytes. A combination of a genetically determined defect of the immune response with a modification of histocompatibility antigens by infective agents, drugs (narcotics, antigens etc.) and other factors are thought to be of pathogenetic significance in the development of infective endocarditis.

Adolescent↗
PubMed1994

[Prophylaxis of infectious endocarditis].

In spite of introducing antibacterial agents in prophylaxis of infective endocarditis (I.E.) more than 50 years ago, the optimal scheme for indication and application of the prophylaxis has not been solved. Evidences accumulate that prophylaxis (being developed to cover some medical procedures leading to bacteremia) can prevent only a small part (< 10%) of cases of I.E. The most effective protection from I.E. is the systematic care for gums and mucosae of the mouth cavity.

Anti-Bacterial Agents↗
PubMed1994

[Infectious endocarditis following artificial insemination. A clinical case report and review of the literature].

We describe a case of infective endocarditis in a 33 year old patient, with mitral valve prolapse (MVP), who underwent nine attempts of artificial insemination with semen by donor. Several blood cultures demonstrated the presence of Enterococcus faecalis; the same agent was identified in some vaginal cultures. Despite antibiotic therapy, infective endocarditis was complicated by severe mitral regurgitation, followed by the rupture of a chorda tendinea. The patient underwent cardiac surgery: valvuloplasty of posterior mitral cusp, chordae tendineae in Goretex and anulus reinforcement with autologous pericardium. MVP is the most common heart disease associated with infective endocarditis in non-drug addict patients (32-54%). The review of the literature did not show any other case of infective endocarditis after artificial insemination procedures. Because of the large spread of these procedures, we think antibiotic prophylaxis of infective endocarditis should be considered in patients with MVP.

Adult↗
PubMed1994

[Infectious endocarditis in non-addict patients without predisposing heart disease. Differential features].

INTRODUCTION AND AIMS: Although uncommonly, infective endocarditis in non-addict patients may involve people without predisponente heart disease. The aim of our study was to assess the clinical and prognostic features of this type of endocarditis and to compare them with those of the more common type of endocarditis with underlying lesion. METHODS: With this aim, we have reviewed 71 consecutive cases of non-addict infective endocarditis diagnosed in our hospital in the last 7 years; there was no preexisting cardiac lesion in 9 patients (13% of all endocarditis and 21% of native valve endocarditis), while underlying heart disease, including mitral valve prolapse, was present in the remaining 62 patients. RESULTS: Mean age was significantly lower in 9 patients without preexistent lesion (28 +/- 18 versus 46 +/- 17 years, p < 0.01), while there was no differences for gender. Infection involved the aortic valve in 56%, the tricuspid or pulmonary valve in 33% and the mitral valve in only 11% of the patients without underlying cardiopathy (for 44%, 4% and 49%, respectively, in patients with cardiopathy). Staphylococcus aureus caused 67% of cases in patients without cardiopathy and only 9% in those with cardiopathy. Surgery was required in a similar proportion by both groups of patients (55% and 56%), although mortality was more than twice higher in patients with prior cardiac lesions (25% versus 11%). CONCLUSIONS: A significant proportion of non-addict infective endocarditis involves patients without predisponente heart disease. These cases have some differential features (younger age, aortic and right heart valves involvement, S. aureus as the main causative agent and lower mortality) in comparison to those of endocarditis in patients with underlying cardiopathy.

Adolescent↗
PubMed1994

[Pathogenesis of infectious endocarditis].

The principles of pathogenesis of infective endocarditis are reviewed. Predisposing factors include not only rheumatic and congenital, but also degenerative cardiopathies, such as valvulopathy, and some extracardial factors of increasing importance. These abnormalities promote the development of nonbacterial thrombotic vegetations, which may become infected when bacteremia occurs. The ability of some microorganisms to produce an infective endocarditis is related to their capacity of adherence to valvular tissue. The pathogenesis of the infected vegetations explains most of the pathophysiologic mechanisms responsible for the variety of the clinical manifestations of infective endocarditis.

Bacteremia↗
PubMed1994

[Clinical aspects and diagnosis of infectious endocarditis].

The first step in the diagnosis of infective endocarditis is a high level of clinical suspicion. Only rarely are all the classic signs of infective endocarditis, namely fever, a new cardiac murmur, splenomegaly, anemia and embolic phenomena, found. Every organ system can be involved by embolic or immunologic complications. We have to look specially for manifestations in skin and mucosa, CNS, kidney, locomotor system and lungs. The clinical spectrum has changed over the last decades. More elderly patients, patients with prosthetic heart valves and i.v. drug users are affected. The traditional classification into acute and subacute infective endocarditis has been replaced by a classification based on the microbiological etiology or on the involved valve (native, prosthetic, left- or right sided). In particular, the clinical presentation of right-sided infective endocarditis differs from the left-sided one. A diagnosis of infective endocarditis has to be considered in every patient with unexplained fever or a multisystem disease. A definite diagnosis of infective endocarditis rests on a multidisciplinary approach that involves the clinician and the echocardiography and microbiology laboratories.

Adult↗
PubMed1994

[Therapy of infectious endocarditis].

The response of infective endocarditis to antimicrobial therapy is slow because host defence mechanisms in heart valves are absent, high bacterial densities occur in vegetations and the infecting agents have a low metabolic activity. In this situation, only an optimal antibiotic treatment can be effective; therefore early identification of the microorganism by means of blood cultures and the use of bactericidal antibiotics with proven efficacy in clinical trials are essential. The antibiotics should be administered intravenously, because constant and high serum levels are important. The choice of the empirical therapy is based on the patient's history, on clinical signs and symptoms as well as on some additional examinations in order to define the most probable organisms involved. As soon as the infecting agent is identified, the treatment should be optimized. A daily clinical examination of the patient and frequent laboratory controls are needed. In case of poor clinical response to the antimicrobial therapy, the search for complications is frequently more appropriate than changing the antibiotics. The duration of therapy depends on the infecting agent, the evolution and the antibiotic regimen that has been chosen. After treatment, blood cultures should be taken at four and eight weeks, since most relapses appear within this period.

Anti-Bacterial Agents↗
PubMed1994

[Infectious endocarditis and congenital heart defects in adults].

BACKGROUND: Infective endocarditis still remains a cardiological menace. However, the type of predisposing diseases has changed: the incidence of rheumatic heart disease in advanced countries has declined, advances made in the surgical and medicamentous treatment of inborn heart disease are the reasons why we are encountering, with increasing frequency, infective endocarditis which develops on their background. METHODS AND RESULTS: The objective of the investigation was to assess the frequency of infective endocarditis and predisposing diseases. During the time interval between 1987 and 1991 16 patients (50% younger than 50 years) were hospitalized with the diagnosis of infective endocarditis. Rheumatic valvular damage and inborn heart disease were the predisposing factor in 25%. All patients were younger than 30 years (mean 24, range 18-30), and half the patients suffered from defects of the ventricular septum. Other defects were tetralogy of Fallot and inborn aortic stenosis. In 10% of the patients infective endocarditis developed on the background of a mitral valve prolapse with regurgitation. Echocardiographic examination confirmed the diagnosis in almost 70% by revealing vegetation. Bacteriological examination revealed the agent in 60%, most frequently it was Streptococcus viridans. The mortality rate in the group was 13%. CONCLUSIONS: The recorded incidence of infective endocarditis, 1.5 pro mille, is consistent with data in the literature. Corrected and not corrected heart disease plays an important role as predisposing disease. Despite the opportunity of intensive antibiotic treatment, the mortality remains high--13%.

Adolescent↗
PubMed1994

[Infectious endocarditis--a study of 153 cases].

The study describes 153 necropsy cases of infective endocarditis (IE) encountered in a university hospital over a period of 23 years (1970-1992), with necropsy incidence of 0.63%. The average age of patients at the time of death was 51.7 years. Both the incidence and the average age tended to increase during the period studied. The location of infective vegetations was mostly in the left heart and univalvular (mitral in 41%, aortic in 33%). The mitral valves involved by IE were otherwise normal in 62%; the aortic valves were normal in 33%. The spectrum of microorganisms yielded by postmortem cultivations is compared with that obtained by blood cultures during life. Staphylococcus aureus comprised 60% of all positive clinical blood cultures and 40% of all organisms grown postmortally. Gram-negative bacilli, streptococci and mycoses appeared as further important etiologic agents. Discussed in more detail are the subgroups of tricuspid valve IE (5% of all cases), IE in patients on chronic hemodialysis (17%), and IE involving prosthetic valves (9%).

Adolescent↗
PubMed1994

[Current aspects of infectious endocarditis. Apropos of 53 cases].

Fifty-three cases of infective endocarditis are reported: 10 definite, 33 probable, 10 possible. There were: 35 males, 18 females, mean age: 66 +/- 14 years. Twenty-three patients had a known valve involvement, 21 a recently diagnosed valve involvement, 9 a prosthetic valve. Fifty patients had fever, 43 had a regurgitating murmur, 28 weakness and weight-loss, 13 cutaneous lesions, 11 arthritis, 8 splenomegaly, 3 ocular lesions. The portal of entry was suspected or confirmed in 37 cases: intestinal in 12 cases, dental in 11 cases, cutaneous in 7 cases, urinary tract infection in 6 cases, upper respiratory tract infection in 1 case. The micro-organism was found in 45 cases: 10 oral streptococci, 12 D bovis streptococci, 6 enterococci, 5 aureus staphylococci, 3 coagulase-negative staphylococci, 2 Coxiella burnetii, 7 other bacterias. Blood-cultures were negative in 8 cases. Precordial echocardiography found vegetations in 27 native valves and 9 prosthetic alterations. Ten patients had neurologic complications, 27 cardiac complications, 8 acute renal failure. Nine patients needed cardiac surgery, 6 died. Our results, compared with those in the literature, showed older age, a higher frequency of digestive portal of entry and of D bovis streptococci, frequently associated with a colic tumour.

Aged↗
PubMed1994

[Antibiotic therapy of infectious endocarditis (when, with what drug, how long?].

The aim of antibiotic therapy in bacterial endocarditis is to sterilize infected cardiac structures and vegetations. Pathogenic organisms are present in great numbers within vegetations and abscess-formations. They exist in a state of reduced metabolic activity so that they are able to tolerate even therapeutic levels of bactericidal antibiotic concentrations. Because vegetations are normally devoid of blood vessels, impregnation with antibiotic agents is poor. Effective therapy is greatly improved by identification of the pathogenic organism involved. With very few exceptions isolation is possible prior to initiation of antibiotic therapy. In acute cases with signs of septicemia, however, therapy cannot await results of bacterial testing. In these patients selection of antibiotic agents is based on associated evidence such as the presence of a prosthetic heart valve or intravenous drug addiction. Once the pathogen has been identified antibacterial therapy should be tailored according to the test results. Bactericidal antibiotics should always be preferred over bacteriostatic agents; in many cases adequate bactericidal levels can only be achieved by combining various agents, such as ampicillin and gentamycin for treatment of enterococcal endocarditis. Dosing intervals must take into account the resulting trough levels, which should always exceed the minimal inhibitory concentrations for a specific bacterial strain. In cases with inadequate control of infection, congestive heart failure resulting from valve dysfunction, and abscess formation, surgery as the only means of eradicating the infection and restoring cardiac performance should not be delayed.

Anti-Bacterial Agents↗