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INFECTIVE ENDOCARDITIS

- Definition
- A few explanations
- The Symptoms
- How to make the diagnosis?
- The gravity of the infective endocarditis
- The Causes
- The different presentations of the infective endocarditis
- Evolution
- Treatment
- Conclusion

TREATMENT

1 - Goal

Sterilizing the infectious lesions at the level of the valve, most often by a medical treatment.

The surgical treatment is sometimes indicated and has considerably improved the prognosis of the affection.

Knowing and applying the prevention measures against the occurrence of an endocarditis.

2 - Means

The antibiotic treatment must obey some rules: it must be strong enough and in any case administered without waiting for the result of the blood cultures; it must be associated to other medicines; it must be adapted to the germ and administered to be efficient throughout the whole day, and finally prolonged.

The length is 4 weeks for the non-groupable streptococci, 6 weeks for the resistant germs, sometimes more for the infectious endocarditises on prosthesis.

The treatment of the main entrance doorand of all potential entrance doors in particular dental must be administered during the hospitalisation.

The surgical treatment consists in replacing the valve affected by the endocarditis when it is too much attacked.

3 - Indications

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- Non-groupable streptococci, Streptococcus D: Penicillin G (20 or 30 Millions units in continuous drip) + gentamycin (3 mg/kg/day in 2 injections) for 15 days for Penicillin and 4 to 7 days for gentamycin; then only Penicillin G for another 15 days (orally). In case of medicinal allergy, vancomycin advantageously replaces Penicillin G. The choice between a Penicillin G and an aminopenicillin essentially depends on the germ sensitivity to the G Penicillin.

- Staphylococcus: in case of sensitive strain, the Oxacylline/aminosid association is efficient. In case of a resistance, the association vancomycin/aminosid is recommended. The length of the treatment is 6 weeks. Other anti-staphylococci can be used, such as rifampycine, fosfomycine and fluoroquinolones.

In the particular case of the infective endocarditis with staphylococcus on a prosthesis, a triple treatment by antibiotics is recommended: vancomycin/aminosid/rifampycin.

- Negative gram bacilli: a third-generation cephalosporin or a penicillin (ureidopenicillin) associated to an aminosid permits controlling the infection, including the pseudomonas aeruginosa.

- Fungi: the treatment by antibiotics is also associative, amphotherycin B in progressive doses and Ancotyl. It does not usually dispense from the surgery.

+ The negativity of the blood cultures leads to propose a Penicillin G/aminosid association if it is a native valve, in a possible slow streptococcus. On a prosthesis implanted since less than one year, a triple anti-staphylococcus association is started. Beyond one year, the vancomycin/aminosid association, to which one adds a third-generation cephalosporin in case of inefficiency, is recommended.

An anticoagulant treatment is instituted in case of a metallic valvular prosthesis, of cerebrovascular accident due to a failure of contribution in blood, of an embolism of a member or phlebitis.

Surgery is indicated in 3 schematic circumstances:

- The occurrence of a cardiac failure, especially due to an aortic insufficiency;

- The existence of a little sensitive germ or of a focus non-accessible to an antibiotic treatment. It is often due to the infectious fungi or on a prosthesis endocarditises.

- The occurrence of an embolism of a part of the valvular vegetation is an important element in the discussion. The most frequent embolisms are the embolisms at the level of the brain, and of the spleen.

As soon as the decision to intervene has been taken, it is no use to wait: the signs of ill- tolerance are the major argument of the decision. However, an ideal 10 days period without fever is preferable and the antibiotic treatment will be reinforced.

As for the decision of a new intervention on a prothesis, the union of 2/4 of the following propositions is sufficient:

- Non-streptococcical nature of the germ;

- Occurrence or aggravation of a murmur;

- Occurrence of a cardiac failure;

- Persistence of the fever after an 8 days antibiotic treatment.

In the drug addict's infective endocarditis, because of a good tolerance and a risk of relapse, the valvular replacement indication is often delayed.

4 - Results

Most often, the temperature decreases within 3 to 7 days. The blood cultures become negative, and the signs of infective endocarditis stabilize or regress.

5 - Monitoring

It is based on the clinical exam achieved by the physician and on the same exams as the ones necessary to make the diagnosis of infective endocarditis:

- Measure of the activity against the germ of every antibiotic and against the association. Negativisation of the blood cultures. However, the bacteriological exams do not permit affirming the recovery.

- Monitoring of the cardiac valves evolution by echocardiography as well as the patient's cardiovascular condition.

- Monitoring of the biological inflammatory syndrome, of the occurrence of an immunological or neurological renal complication...

The prevention of the infective endocarditis by antibiotics is indicated for all illnesses of the heart valves, Barlow’s illness, congenital cardiopathies and patients with cardiac prosthetic valve.

Different protocols are proposed, according to the importance of the gesture, or an allergy to Penicillin... One distinguishes the A and B protocols with an amoxycillin and gentamycin basis, and pristinamycin or vancomycin in case of allergy to penicillin.

The A protocols are recommended during the current dental care, especially if they touch the periodontium or the dental pulp.

The B protocols are indicated in surgery or pneumology instrumental exploration, of the urinary-genital, entero-gastro tracts, and during the gynaecological acts, and this especially as the patient is carrier of a cardiac valvular prosthesis and/or if he has had antecedents of infective endocarditis.

A card of prevention of the infective endocarditis must be handed by the physician to his patient and presented by him during his next medical consultation.

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File last reviewed on dec 18, 2011