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Jan 03, 5 · Kiefer 5, Park L, Tribouilloy C, Cortes C, Casillo R, Chu V, et al.

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Association between valvular surgery and mortality among 5 with infective endocarditis complicated by heart failure. JAMA. 2011 Nov 23. 306(20):2239-47. Kang 5, Kim YJ, Kim SH, et al.

Infective Endocarditis Treatment & Management: Approach Considerations, Antibiotic Therapy, Management of S aureus Bacteremia

Early surgery versus conventional treatment for infective endocarditis.
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The latter includes both the intracardiac and extracardiac consequences of IE.
Some of the effects of IE require surgical intervention.
Emergent care should focus on making the correct diagnosis and stabilizing the patient with acute disease and 5 instability.
No special diets are recommended for patients with endocarditis; however, if the patient has congestive heart failure, administer a sodium-restricted diet.
Activity limitations are determined by the severity of the illness, complications eg, strokeand the presence of significant congestive heart failure.
Mild congestive heart failure resulting from valvular insufficiency or myocarditis may be managed with standard medical therapy.
Often, this is progressive, and despite achieving a microbiological cure, it requires valvular surgery.
In the setting of acute IE, institute 5 therapy as soon as possible to minimize valvular damage.
Three to 5 sets of blood cultures are obtained within 60-90 minutes, followed by the infusion of the appropriate antibiotic regimen.
By necessity, the initial antibiotic choice is empiric in nature, determined by clinical history and physical examination findings.
Empiric antibiotic therapy is chosen based on the most likely infecting organisms.
Native valve endocarditis NVE has often been treated with penicillin G and gentamicin for synergistic coverage of streptococci.
Patients with a history of intravenous IV drug use have been treated with nafcillin and gentamicin to cover for methicillin-sensitive staphylococci.
The emergence of methicillin-resistant S aureus MRSA and penicillin-resistant streptococci has led to a change in empiric treatment with liberal substitution of vancomycin in lieu of a penicillin antibiotic.
Rifampin is necessary in treating individuals with infection of prosthetic valves or other foreign bodies because it can penetrate the biofilm of most of the pathogens that infect these devices.
However, it should be administered with vancomycin or gentamicin.
по этому адресу 5 2 agents serve to prevent the development of resistance to the rifampin.
Substitution of linezolid for vancomycin should be considered in patients with unstable renal function because of the of achieving therapeutic trough levels in this situation.
Linezolid or daptomycin are options for считаю, Проектор Sony VPL-SW235 аффтара with intolerance to vancomycin or resistant organisms.
Appropriate regimens should be devised in consultation with a specialist in infectious disease.
In the case of subacute IE, treatment may be safely delayed until culture and sensitivity results are available.
Waiting does not increase the risk of complications in this form of the disease.
Eradicating bacteria from the fibrin-platelet thrombus is extremely difficult because 1 the high concentration of organisms present within the vegetation ie, 10-100 billion bacteria per gram of tissue2 their position deep within the thrombus, 3 their location in both a reduced metabolic and reproductive state, and 4 the interference of fibrin and white cells with antibiotic action.
For all of these reasons, bactericidal antibiotics are considered necessary for то, Проектор Optoma S341 вашему of valvular infection.
IV administration of antimicrobials has been preferred because more reliable therapeutic levels are achieved with this route.
Orally administered antibiotics have been used as suppressive therapy for incurable valvular infections ie, inoperable PVE.
Recently, evidence has shown that patients with left-sided endocarditis in stable condition who received at least 10 days of intravenous antibiotics could be switched to oral administration for the remainder of their therapeutic course.
Treat all patients in a hospital or skilled nursing facility to allow adequate monitoring of the development of complications and the response to antibiotic therapy.
The American Heart Association AHA has developed guidelines for treating IE caused by the most frequently encountered microorganisms.
It may be given intramuscularly IM for short periods if venous access problems develop; ceftriaxone allows once-a-day outpatient IV therapy for clinically stable patients.
This may be combined with gentamicin for 4-6 weeks of treatment.
Enterococcal PVE generally responds as well as disease involving native valves.
A combination of an inhibitor of cell wall synthesis ie, penicillin, vancomycin with an aminoglycoside ie, gentamicin, streptomycin is necessary to achieve bactericidal activity against the enterococci.
Tobramycin or amikacin does not act synergistically with antibiotics active against the bacterial cell wall.
Increasing numbers of enterococci have aminoglycoside-inactivating enzymes that make them relatively resistant to the usual synergistic combinations.
Of gentamicin-resistant enterococcal strains, 25% are susceptible to streptomycin.
Alternative choices are imipenem, ciprofloxacin, or ampicillin with sulbactam.
Vancomycin does not appear to be as useful as the aforementioned antibiotics.
Enterococcus faecalis may become resistant to the penicillins because of their production of beta-lactamases.
These strains can be treated with ampicillin combined with sulbactam or with vancomycin combined with gentamicin.
This combination may be effective against enterococcal isolates that are resistant to high doses of gentamicin.
High peak levels of gentamicin are not necessary to establish synergistic bactericidal activity against enterococci.
Once-a-day gentamicin dosing should not be used because a prolonged postantibiotic effect against gram-positive organisms does not occur, and synergistic killing requires the simultaneous presence of an agent active in the cell wall and an aminoglycoside.
A study indicates как сообщается здесь gentamicin usage, even for synergy, нажмите чтобы узнать больше associated with decreasing renal function.
However, overall mortality does not appear to be increased.
Certainly, gentamicin therapy should be continued to achieve synergy against enterococci, but the practice of administering gentamicin for 5 days in the treatment of S aureus IV drug Проектор NEC NP-M332XS IVDA IE should be questioned.
Presently, no therapy has been proven highly effective for IE caused by strains of VRE.
Other options for therapy include linezolid, a combination of ampicillin and imipenem, and chloramphenicol.
In one small series, the combination of ampicillin and ceftriaxone was found to be useful against VRE.
Often, the valve must be replaced to achieve a cure.
It appears that vancomycin should not be used to treat infections with staphylococci with an MIC of greater than 1.
In these cases, alternative agents such as linezolid or daptomycin should be used.
Treatment with linezolid appears to result in outcomes superior to those with vancomycin against many types of infections caused by MRSA and MSSA.
The use of linezolid should be strongly considered instead of vancomycin in patients who are seriously ill.
Another advantage of linezolid is that its dose does not need to be adjusted in patients with renal failure.
White blood cell counts, red blood cell counts, and platelet counts need to be monitored frequently while the patient is on linezolid.
The risk of developing serotonin syndrome is low.
After the fourth week of therapy, the risk of hematological and neuropathic complications rapidly increases.
Patients who have received vancomycin have a higher rate of resistance to daptomycin.
Because of the increased risk of renal failure with gentamicin, the latter regimen is preferred.
Patients with culture-negative PVE are usually given vancomycin and gentamicin, targeting possible enterococcal or CoNS infections.
In patients with suspected PVE who have previously received antibiotics, enteric therapy should consist of vancomycin, gentamicin, cefepime, and rifampin.
Because of the risk of developing resistance to rifampin, many clinicians would start this antibiotic only after the blood cultures results become negative.
All patients with PVE require at least 6 weeks of antimicrobial therapy.
Rifampin is the key drug in the treatment of PVE, as it is one of the only antimicrobial agents that penetrate the biofilm laid down by S aureus and CoNS.
Because of the risk of these organisms developing resistance to rifampin, many clinicians withhold the addition of rifampin until blood cultures have cleared.
Penicillin-sensitive S увидеть больше PVE should be treated with 2 weeks of penicillin G or ceftriaxone combined with gentamicin, followed by 4 weeks of penicillin G детальнее на этой странице ceftriaxone.
If the S viridans PVE is caused by an organism with a penicillin MIC of 0.
If the combination therapy is administered for only 4 weeks, penicillin G or ceftriaxone should be continued for an additional больше информации weeks.
Vancomycin is substituted for penicillin or ceftriaxone if the patient has a history of severe, immediate penicillin hypersensitivity, such as urticaria, anaphylaxis, or angioedema.
Enterococcal PVE therapy is complicated by the multiple types of enterococcal antimicrobial resistance, including beta-lactamase production raredifferent types of aminoglycoside-inactivating enzymes more commonand VRE increasingly common.
If the enterococci are highly resistant to both gentamicin and streptomycin, ampicillin should be administered for 8-12 weeks by Il Coquelicot infusion.
Patients with PVE must be monitored carefully for signs of valve dysfunction, congestive heart failure, and heart block.
They should also be monitored for clinical response нажмите для продолжения therapy, увидеть больше of привожу ссылку blood culture results, renal function status, and serum blood levels of vancomycin and aminoglycosides.
Valve replacement surgery should be ссылка promptly if any of the following occurs: moderate-to-severe congestive heart failure, valve издевка Проектор Epson EMP-835 рекомендовать, perivalvular or myocardial abscess formation, the presence of an unstable valve that is becoming detached from the valve ring, more than one embolic episode with persistent vegetations observed on transesophageal echocardiogram, or the presence of vegetations larger than 1 cm in diameter.
If PVE does not respond to antimicrobial therapy and blood cultures results remain positive or if a relapse of bacteremia occurs after infection, the prosthetic valve should be replaced.
In the presence of microorganisms that have no microbicidal agent eg, VRE, fungi or in the presence of other recalcitrant organisms eg, P aeruginosa, S aureus, enteric gram-negative rods, Brucella species, C burnetiipast clinical experience shows that early replacement of the prosthetic valve improves the chances for cure.
Fungal endocarditis is rare and primarily occurs after prosthetic valve surgery and in individuals who abuse intravenous drugs.
Candida species and Aspergillus species are the organisms most frequently encountered.
Currently available antifungal agents have not been successful in eliminating fungal IE.
The only cures for proven fungal IE have resulted when surgical excision of the infected valves was combined with amphotericin B therapy.
Empiric therapy of IVDA IE should be aimed at S aureus.
Generally, gram-negative organisms occur infrequently, and delay in covering them initially is acceptable.
Some clinicians obtain peak and trough blood samples during the course of antimicrobial therapy of IE in order to run serum bactericidal tests.
Peak antimicrobial concentrations that inhibit and kill the bacteria at a 1:32 or greater dilution in serum are a consistent predictor of a favorable clinical response.
Antimicrobial dosages are adjusted to try to attain this goal.
However, many clinicians feel that the serum bactericidal test does not have a reproducible result, and these clinicians rely on standardized tests of antimicrobial susceptibility ie, MICs and serum antimicrobial assays of peak and trough levels to determine whether sufficient amounts of antimicrobial agents are being administered.
If follow-up blood culture and 5 findings were negative and no evidence of metastatic infection was found, two weeks of antistaphylococcal therapy was believed to be appropriate.
If the follow-up blood culture findings are positive, TEE should be performed.
If TEE demonstrates findings of valvular infection, the patient is to be treated for 4-6 weeks with antistaphylococcal antibiotics.
Although resorting immediately to TEE is becoming more common, it is often unnecessary.
A scoring system has been developed to help differentiate patients with valvular infection from those with S aureus bacteremia that represents metastatic infection from sites such as splenic abscesses or osteomyelitis.
Individuals with an underlying implantable cardiac device or whose S aureus bloodstream infections developed in the community are at highest risk of IE and so should undergo immediate TEE.
If the TEE findings are negative, it should be repeated in 5 days.
A good deal of these may be explained by endotheliosis.
For the time being, the duration of antibiotic therapy for each case of S aureus catheter-related BSI must be individualized.
The author and others would treat cases that meet the criteria of continuous bacteremia for a total of 4 weeks despite a negative TEE result.
Indeed, evidence indicates patients who are anticoagulated have worse outcomes than those who are not anticoagulated.
Patients who are treated with anticoagulation appear to have a higher rate of intracerebral bleeding.
If an established reason for anticoagulation eg, deep venous thrombosis, presence of a mechanical prosthetic valve exists, a standard regimen of anticoagulation should be followed.
Congestive heart failure in a patient with NVE is the primary indication for surgery.
A second relapse, during or after completion of treatment, requires replacement of the valve.
Paravalvular abscess and intracardiac fistula almost always require surgical intervention.
Patients with culture-negative NVE who remained febrile for more than 10 days should be considered surgical candidates.
Persistent hypermobile vegetations, especially those with a history of embolization beyond 7 days of antibiotic therapy, should be treated with surgery.
Cardiac surgery should be considered in patients with multiresistant organisms eg, enterococci.
The indications for surgery in patients with PVE are the same as those for patients with NVE, with the addition of the conditions of valvular dehiscence and early PVE.
Orally administered antibiotics have been used as suppressive therapy for incurable valvular infections ie, inoperable PVE.
Surgery is often required for treatment of metastatic infections eg, cerebral and other types of aneurysms and macroabscesses of the brain and spleen.
Many cerebral abscesses may not be accessible.
If this is the case, they can be monitored because 30% may heal when treated medically.
Occasionally, local debridement and the administration of appropriate antibiotics may be sufficient to cure an uncomplicated pacemaker pocket infection.
However, most studies indicate that complete removal of the system is necessary for cure in most cases.
Many patients in whom this is not possible eventually die of complications from relapsing infection.
This aggressive approach is especially necessary when dealing with pacemaker IE.
Immediate insertion of a permanent pacemaker at a new site can be safely accomplished.
The AHA 2010 guideline update on CIED infection recommends careful evaluation of each patient to determine if a CIED is still needed.
Replacement device implantation should not be ipsilateral to Реле времени F&F (ЕА02.001.018) extraction site.
The guideline suggests the contralateral side, the iliac vein, and epicardial implantation as preferred alternative locations.
If valvular infection is present, placement of new transvenous lead should be delayed for at least 14 days after CIED system removal.
The use of laser technology to dissolve the pacemaker lead adhesions has proven successful, with a 94% success rate.
The risk of dislodging vegetations during removal of infected leads is negligible.
Patients whose leads cannot be removed are started on permanent antibiotic suppression.
Such therapy should not be administered to patients who are candidates for CIED removal.
Because only 50% of those who developed valvular infection following a procedure were identified as being candidates for antibiotic prophylaxis, only approximately 10% of cases of IE can be prevented by the administration of preprocedure antibiotics.
Maintaining good oral hygiene is probably more effective in the overall prevention of valvular infection because gingivitis is the most common source of spontaneous bacteremias.
Consider prophylaxis against IE in patients at higher risk.
Protective factors include the insertion and maintenance of catheters by an infusion therapy team, the use of topical disinfectants and antibiotics, and the practice of coating catheters with antimicrobial agents.
No double-blind studies have been performed to support the use of systemically administered antibiotics for the prevention of pacemaker or intracardiac defibrillator infections.
However, awaiting definitive studies, the authors recommend prophylactic antibiotics, as with any implantable device.
Of course, strict sterile technique must be followed.
Antibiotic prophylaxis is not recommended for prevention of CIED infection in patients with or intracardiac defibrillators during invasive procedures not directly related to device manipulation.
The guidelines remain unproven by randomized controlled clinical trials.
Indeed, many examples of failure по этому сообщению these recommendations have been noted, even when they are applied appropriately.
In general, bactericidal antibiotics are used.
However, bacteristatic agents are probably effective in most circumstances.
Although the 2007 guidelines are a marked improvement because they prioritize the cardiac conditions and procedures that require antibiotic prophylaxis and emphasize the importance of promoting good oral hygiene, they offer little direction in dealing with the ever-growing problem of antibiotic-resistance patterns of S viridans and enterococci.
The importance of antibiotic prophylaxis of calcific valvular disease in elderly patients also needs to be more fully discussed.
Calcific valvular disease is the most common underlying cardiac risk factor for the development of IE in Лампа для проектора ( Совместимая лампа без ) age group.
The NICE guidelines do not recommend antibiotic 5 for IE in patients undergoing dental procedures; however, they agree with the AHA guidelines in not recommending prophylaxis for those undergoing procedures in the upper and lower gastrointestinal tracts, the genitourinary tract, or the upper and lower respiratory tracts.
The rise in the rate of IE cases since 2007-2008 has called into serious question the validity of abolishing IE antibiotic prophylaxis.
This increase has particularly affected individuals who would be deemed at high risk for developing valvular infection.
Many malpractice suits are caused by a failure to diagnose and a delay in diagnosis accompanied by a poor outcome for the patient.
As a rule for primary care clinics, do not administer antimicrobial agents to febrile patients with heart murmurs without first obtaining at least 2 sets of cultures.
The perception that most IE is preventable is wrong.
Frequent episodes of transient bacteremia occur with chewing and other activities of daily life.
Proving that a failure to give prophylaxis before dental and surgical procedures resulted in IE is difficult.
However, this does not prevent legal action alleging IE as a consequence of failing to give the antimicrobial prophylaxis recommended by the AHA.
When a central venous line is needed, not inserting the line when a patient is known to be bacteremic is advisable.
If no alternative to placing the line is available, bactericidal antimicrobial agents should be administered to try to prevent the development of IE.
In general, both a cardiologist and an infectious diseases specialist should be involved in the care of patients with IE.
A bedside consultation by an infectious disease specialist results in far better outcomes than the more frequent telephone consultation.
Personnel in the clinical microbiology laboratory must have the skill to isolate the organism, properly identify it, and perform susceptibility testing appropriate for the growth characteristics and requirements of ссылка на подробности organism with determination of the MIC of clinically relevant antimicrobial agents.
To obtain the best possible information, the attending physician 5 work closely with the microbiology laboratory personnel.
Patients should have blood cultures taken after 3-4 days of treatment to document eradication of the bacteremia.
Blood cultures during treatment are essential if persistent fever or other signs develop that suggest failing treatment.
Failure to sterilize the bloodstream, despite adequate serum levels of appropriate antibiotics, should prompt a search for metastatic infection eg, abscesses, especially splenic, or mycotic aneurysm.
Fever lasting longer than 10 days into therapy with an indicated antibiotic regimen should be of concern and should prompt a search for suppurative complications.
Approximately 30% of patients have a return of fever after the initial response.
This is usually caused Коммутатор Level One GEP-0822 an intracardiac abscess or metastatic infection.
Causes of unresponsive fever include myocardial or septal abscesses, large vegetations that resist sterilization, and metastatic infection.
Occasionally, fever in patients with uncomplicated IE may take as long as 3 weeks to abate.
Complications, such as congestive heart failure resulting from valvular insufficiency and embolization, may occur after bacteriologic cure has been achieved.
Note that the diagnosis of developing congestive heart failure or valvular insufficiency is based on clinical findings, not solely on echocardiographic measurements.
The onset of valve dysfunction or moderate-to-severe congestive heart failure should lead to an evaluation for immediate valve replacement.
Relapse of IE usually occurs within 2 months of finishing clinically effective therapy.
Infection with S aureus, enterococci, and gram-negative organisms especially P aeruginosa is associated with a high rate of relapse.
Enterococcal infection of the mitral valve has the greatest potential for relapse.
Recurrent IE occurs most often in individuals who abuse IV drugs.
Valvular infections in these patients recur at a rate of 40%.
Other significant risk factors for recurrence include a previous episode of IE, the presence of a prosthetic valve, and congenital heart disease.
In general, infected vascular catheters should be removed and should not be replaced over a guidewire.
Surgically implanted devices, such as Broviac or Hickman catheters, do not necessarily need to be removed unless evidence of IE, a tunnel infection, or suppurative thrombophlebitis is present or if the infecting organism is a Corynebacterium species, a Pseudomonas species, a fungus, S aureus, or a Mycobacterium species.
If bacteremia persists longer than a few посетить страницу источник, the catheter must be removed.
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Ampicillin-Ceftriaxone Effective for E.
Ampicillin Plus Ceftriaxone Is as Effective as Ampicillin Plus Gentamicin for Treating Enterococcus faecalis Infective Endocarditis.
The Preoperative Evaluation of Infective Endocarditis via 3-Dimensional Transesophageal Echocardiography.
Tex Heart Inst J.
Acute bacterial endocarditis caused by Staphylococcus aureus with perforation of the aortic valve and aortic valve vegetations.
Courtesy of Janet Jones, MD, Laboratory Service, Wichita Veterans Administration Medical Center.
Courtesy of Janet Jones, MD, Laboratory Service, Wichita Veterans Administration Medical Center.
He was diagnosed with right-sided staphylococcal endocarditis.
There is a small curvilinear vegetation on the mitral valve as indicated.
The patient presented with a headache and fever, and CT scan of the brain revealed an occipital hemorrhage.
The patient had a history of intravenous drug use and multiple blood cultures grew Staphylococcus aureus.
Pulmonary lesions on chest radiograph are most prominent in the right upper lobe with both solid and cavitary appearance.
Note the posterior leaflet of the mitral valve, with an irregular vegetation on the atrial surface, resulting in valve destruction at the commissure between the anterior leaflet and the posterior leaflet.
Note the gaping hole with the fibrous rim, and a small strand at the free edge.
The hole is at the line of closure.
The affected valve is the left cusp.
Note the right noncoronary cusp immediate to the left in this image demonstrates a small, multichanneled fenestration at the commissure, immediately adjacent to similar fenestrations in the left coronary cusp.
These are physiologic lesions occurring with age and are unrelated to endocarditis.
In this excised valve, note the bulky vegetations on the ventricular surfaces, with distortion of the valve surfaces.
A defect is seen in the scarred valve, with focal surface hemorrhage.
The patient also underwent aortic valve replacement, as there was contiguous infection.
Degenerated bacterial colonies are seen жмите the left.
Also, areas of microcalcification may mimic bacterial deposits.
Hemorrhage and Телефон Fly F+ F195 granulation tissue with neovascularity is apparent throughout.
This aortic valve showed fibrin exudate on the ventricular surface belowwith more prominent organization and granulation on the aortic surface above.
A chronic infiltrate is seen, just under the denuded thrombosed surface, with primarily macrophages and focal macrophage giant cells.
Note the large bacterial colony staphylococci by culture in the absence of significant inflammation; the xenograft tissue is not viable, and nuclear detail is not apparent.
S aureus infection is the second most common cause of nosocomial BSIs, second only to CoNS infection.
Sixty percent of individuals are intermittent carriers of MRSA or MSSA.
Other risk factors include cancer, diabetes, corticosteroid use, IVDA, alcoholism, and renal failure.
BSIs are acquired not only in the hospital but also in any type of health care facility eg, nursing home, dialysis center.
S lugdunensis frequently causes IE.
Bartonella must be considered in cases of culture-negative endocarditis among homeless individuals.
Chief Editor Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London Michael Stuart Bronze, MD is a member of the following medical societies:, Disclosure: Nothing to disclose.
Acknowledgements Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies:,, and Disclosure: Nothing to disclose.
Steven A Conrad, MD, PhD Chief, Department of Emergency Medicine; Chief, Multidisciplinary Critical Care Service, Professor, Department of Emergency and Internal Medicine, Louisiana State University Health Sciences Center Steven A Conrad, MD, PhD is a member of the following medical societies:American College of Critical Care Medicine, and Disclosure: Nothing to disclose.
Jon Mark Hirshon, MD, MPH Associate Professor, Department of Emergency Medicine, University of Maryland School of Medicine Jon Mark Hirshon, MD, MPH is a member of the following medical societies:, and Disclosure: Nothing to disclose.
Thomas M Kerkering, MD Chief of Infectious Diseases, Virginia Tech Carilion School of Medicine Thomas M Kerkering, MD is a member of the following medical societies:,and Disclosure: Nothing to disclose.
Keith A Marill, MD Faculty, Department Emergency Medicine, Massachusetts General Hospital; Assistant Professor, Harvard Medical School Keith A Marill, MD is a member of the following medical societies: and Disclosure: Medtronic Ownership Апдайк Джон, Рот Филип Кролик, беги.

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