LA CONSULTA SEMANAL

JUNIO 2000

CONSULTA:

Cleve Clin J Med 2000 May;67(5):353-60 
Infective endocarditis: prevention, diagnosis, treatment, referral. 
Keys TF 
Department of Infectious Disease, Cleveland Clinic, USA. keyst@ccf.org 
Infective endocarditis is a challenge to the primary care physician, who is not likely to see more than several cases a year. With proper diagnosis and treatment, the overall cure rate is over 80% and major complications such as congestive heart failure can be avoided. In some patients, even in some with acute infection, surgical intervention to restore cardiac function significantly improves the outcome. Guidelines for prophylaxis before various surgical procedures are presented. 
Publication Types: 
Review 

Am Fam Physician 2000 Mar 15;61(6):1725-32, 1739 [Texto completo] 
Management of bacterial endocarditis. 
Giessel BE, Koenig CJ, Blake RL Jr 
University of Missouri-Columbia School of Medicine, USA. 
Most cases of bacterial endocarditis involve infection with viridans streptococci, enterococci, coagulase-positive staphylococci or coagulase-negative staphylococci. The choice of antibiotic therapy for bacterial endocarditis is determined by the identity and antibiotic susceptibility of the infecting organism, the type of cardiac valve involved (native or prosthetic) and characteristics of the patient, such as drug allergies. Antibiotic therapies discussed in this report are based on recommendations of the American Heart Association. Treatment with aqueous penicillin or ceftriaxone is effective for most infections caused by streptococci. A combination of penicillin or ampicillin with gentamicin is appropriate for endocarditis caused by enterococci that are not highly resistant to penicillin. Vancomycin should be substituted for penicillin when high-level resistance is present. Resistance of enterococci to multiple antibiotics including vancomycin is becoming an increasing problem. Native valve infection by methicillin-susceptible staphylococci is treated with nafcillin, oxacillin or cefazolin. The addition of gentamicin for the first three to five days may accelerate clearing of bacteremia. Infection of a prosthetic valve by a staphylococcal organism should be treated with three antibiotics: oral rifampin and gentamicin and either nafcillin, oxacillin, cefazolin or vancomycin, depending on susceptibility to methicillin. Vancomycin is substituted for penicillin in patients with a history of immediate-type hypersensitivity to penicillin. 
Publication Types: 
Review 

J Am Coll Cardiol 1999 Mar;33(3):788-93 
A critical appraisal of the quality of the management of infective endocarditis. 
Delahaye F, Rial MO, de Gevigney G, Ecochard R, Delaye J 
Hopital Cardio-Vasculaire et Pneumologique, Lyon, France. 
OBJECTIVES: The purpose of this study was to assess the quality of the management of infective endocarditis. BACKGROUND: Although many guidelines on the management of infective endocarditis exist, the quality of this management has not been evaluated. METHODS: We collected data on all patients (116) hospitalized with infective endocarditis over 1 year in all hospitals in the Rhone-Alpes region (France). RESULTS: Prophylactic antibiotics were not given before infective endocarditis to 8/11 cardiac patients at risk and who underwent an at risk procedure. Among the 55 cardiac patients at risk and with fever and who consulted a physician, blood cultures were not performed before antibiotic therapy was initiated for 32 patients. In-hospital antibiotic therapy was incorrect for 23 patients. The portal of entry was not treated for 16/61 patients with an accessible portal of entry. Among the 19 patients who had severe heart failure or fever persisting more than 2 weeks in spite of antibiotic therapy and who could have undergone early surgery, surgery was delayed for five, and not performed for three. Overall, the average score was 15/20. CONCLUSIONS: More information on the management of infective endocarditis should be widely disseminated to the physicians' and the dentists' communities and to the patients at risk. 
Publication Types: 
Multicenter study 
Comments: 
Comment in: J Am Coll Cardiol 1999 Mar;33(3):794-5 

Pediatr Clin North Am 1999 Apr;46(2):275-87 
Pediatric bacterial endocarditis. Treatment and prophylaxis. 
Brook MM 
Department of Pediatrics, University of California-San Francisco, USA. 
Endocarditis is a rare but serious complication often related to complex CHD. The incidence, particularly among smaller infants with cyanotic heart disease, seems to be increasing. The pathophysiology is related to a combination of host and bacterial factors that predispose to endothelial colonization and infection. Diagnosis, although occasionally difficult, is life saving, but the treatment is prolonged. Prophylaxis before appropriate procedures may significantly decrease the risk for development in appropriate patients. 
Publication Types: 
Review 

Infect Dis Clin North Am 1998 Dec;12(4):879-901, vi 
Outpatient intravenous antibiotic therapy for endocarditis. 
Rehm SJ 
Department of Infectious Disease, Cleveland Clinic Foundation, Ohio, USA. 
The clinical spectrum of endocarditis continues to evolve, as does its diagnosis and management. Outpatient parenteral antimicrobial therapy has been demonstrated to be safe and effective for medically stable patients with viridans streptococcal endocarditis. Other carefully selected and monitored patients with infective endocarditis may also be considered for completion of therapy outside the hospital setting. Publication Types: 
Review 

Enferm Infecc Microbiol Clin 1998 Nov;16(9):423-30 
[Indications for admission to the intensive care service of adult patients with severe infections]. 
[Article in Spanish] 
Alvarez Lerma F, Cisneros JM, Fernandez-Viladrich P, Leon C, Miro JM, Pachon J, Palomar M, Rello J 
Servicio de Medicina Intensiva, Hospital del Mar, Barcelona. 16839@imas.imim.es 
Publication Types: 
Review 

Circulation 1998 Dec 22-29;98(25):2936-48 
Diagnosis and management of infective endocarditis and its complications. 
Bayer AS, Bolger AF, Taubert KA, Wilson W, Steckelberg J, Karchmer AW, Levison M, Chambers HF, Dajani AS, Gewitz MH, Newburger JW, Gerber MA, Shulman ST, Pallasch TJ, Gage TW, Ferrieri P 
Publication Types: 
Review 

J Infect 1998 Mar;36(2):137-9 
Antimicrobial therapy for bacterial endocarditis on native valves. 
Littler WA 
Cardiovascular Medicine, University of Birmingham, Queen Elizabeth Hospital, Edgbaston, UK. 
Publication Types: 
Review 

Drugs 1997 Nov;54(5):730-44 
Recognition, management and prophylaxis of endocarditis. 
Stamboulian D, Carbone E 
Fundacion del Centro de Estudios Infectologicos (FUNCEI), Buenos Aires, Argentina. funcei@cei.com.ar 
Infective endocarditis (IE) remains a disease with high morbidity and mortality. In recent years, a higher frequency of IE has been observed in the elderly, in intravenous drug users and in patients with prosthetic valves. The diverse manifestations of this disease demand a high degree of suspicion from the practitioner, in order to make an early diagnosis. Advances in and increasing use of echocardiography (especially transoesophageal) allow us to identify valvular changes earlier and more precisely. The use of the new Duke's diagnostic criteria, based on clinical manifestations and microbiological and echocardiographic findings, facilitates the diagnosis and categorisation of IE. An increase in staphylococci and other problem pathogens, such as penicillin-resistant streptococci, enterococci resistant to beta-lactams, aminoglycosides and methicillin-resistant staphylococci has been observed. Important changes have also taken place in the management of IE. There is a clear trend towards the use of shorter treatment courses, oral and once-daily regimens and outpatient programmes, all of which aim to reduce costs and provide patients with improved quality of life. Antibiotic prophylaxis for the prevention of IE is still controversial. In the past few years more rational regimens have been used, and indications are now more precise. In spite of all this, however, few cases are prevented and patient compliance to the prophylaxis regimens remains low. 
Publication Types: 
Review 

Infect Dis Clin North Am 1996 Dec;10(4):811-34 
Acute infective endocarditis. Diagnostic and therapeutic approach. 
Cunha BA, Gill MV, Lazar JM 
State University of New York School of Medicine, Stony Brook, USA. 
Acute bacterial endocarditis (ABE) is clinically distinct from subacute bacterial endocarditis in terms of pathologic virulence, acuteness and severity of illness, complications, and prognosis. The term infectious endocarditis may be useful as a general term but conveys no meaningful clinical information. ABE presents as an acute, fulminant intracardiac infection with fevers (temperature > 102 degrees F) that are caused by highly virulent known pathogens. Septic embolic phenomena, valve dysfunction, and congestive heart failure are characteristic. Parenteral and oral antibiotic treatment regimens are discussed. 
Publication Types: 
Review 

QJM 1996 Apr;89(4):267-78 
Early surgery in infective endocarditis. 
Olaison L, Hogevik H, Myken P, Oden A, Alestig K 
Department of Infectious Diseases, Goteborg University, Sweden. 
Optimal timing of surgical intervention in infective endocarditis is important in reducing mortality. We prospectively studied 126 consecutive episodes of infective endocarditis treated in one institution over 5 years, with special emphasis on long-term results and on the effects on outcome of surgical interventions. Twenty-six patients (21%) underwent acute surgery on median treatment day 14. Mortality during treatment was 8% for patients undergoing acute surgery vs. 11% for those not undergoing surgery, and the adjusted 5-year survival rate of acute surgically treated patients was 91%, compared with 69% for the medically treated patients. Using univariate analysis, excess mortality during 5 years follow-up was associated with new cardiac decompensation at entry (p < 0.01), age (p < 0.01), no acute surgery (p < 0.05) and mitral valve involvement (p < 0.05). Multivariate analysis showed new cardiac decompensation at entry to be an independent predictor of cardiac death at 5 years follow-up (relative risk 2.39; CI 1.05-5.45), while no surgery during active disease implied a relative risk of 3.45, though not statistically significant. Patients undergoing surgery very early (< or = 10 days of treatment) did not have a poorer outcome. Acute valve replacement, as compared with medical therapy only, might be important to increase both short-term and long-term survival in infective endocarditis. 

Ann Intern Med 1996 Mar 15;124(6):606-8 
Treatment of infective endocarditis. 
Kaye D 
Publication Types: 
Editorial