Infective endocarditis and kidney damage - Treatment

Treatment of kidney damage in infective endocarditis depends on the characteristics of the pathogen, localization and severity of the valve damage, the presence of systemic manifestations of the disease (in the development of glomerulonephritis - on the state of kidney function). Antibacterial therapy is a method of etiotropic treatment of infective endocarditis. The main principles of using antibacterial drugs are given below.

• It is necessary to use antibacterial drugs with bactericidal action.
• To create a high concentration of the antibacterial drug in vegetations (which is necessary for effective treatment), intravenous administration of drugs in high doses over a long period of time (at least 4-6 weeks) is indicated.
• If the patient's condition is severe and there is no information about the infectious agent, empirical therapy should be started until the results of microbiological blood tests are available.
• In case of subacute infective endocarditis or atypical clinical picture, etiotropic antibacterial therapy should be carried out after identification of the pathogen.
• After healing of infective endocarditis, antibacterial drugs are indicated to prevent recurrence of infection in situations that cause transient bacteremia.

[ 1 ], [ 2 ], [ 3 ], [ 4 ], [ 5 ], [ 6 ], [ 7 ]

Empirical treatment of renal damage in infective endocarditis

• The drug of choice for empirical therapy of acute infective endocarditis are antibacterial drugs active against Staphylococcus aureus, the main causative agent of this form of the disease: intravenous oxacillin 2 g 6 times a day or cefazolin 2 g 3 times a day for 4-6 weeks in combination with gentamicin at a dose of 1 mg / kg 3 times a day for 3-5 days. If acute infective endocarditis caused by resistant staphylococci or enterococci is suspected, intravenous vancomycin 1 g 2 times a day and gentamicin 1 mg / kg 3 times a day are prescribed. An alternative to vancomycin in case of a high risk of nephrotoxicity is rifampicin intravenously at 300-450 mg 2 times a day.
• For subacute infective endocarditis of the native valve, ampicillin is indicated intravenously for 4 weeks at 2 g 6 times a day in combination with gentamicin at 1 mg/kg 3 times a day or benzylpenicillin at 3-4 million IU 6 times a day in combination with gentamicin at 1 mg/kg 3 times a day.
• In case of subacute infective endocarditis of the tricuspid valve (in drug addicts who take drugs intravenously), the drug of choice is oxacillin 2 g 6 times a day in combination with gentamicin 1 mg/kg 3 times a day intravenously for 2-4 weeks. Alternative drugs are also recommended: cefazolin 2 g in combination with gentamicin 1 mg/kg intravenously 3 times a day for 2-4 weeks or vancomycin 1 g 2 times a day in combination with gentamicin 1 mg/kg 3 times a day intravenously for 4 weeks.

[ 8 ], [ 9 ], [ 10 ], [ 11 ]

Etiotropic treatment of kidney damage in infective endocarditis

• In case of streptococcal etiology of the disease (Streptococcus viridans, Strept. bovis), the following schemes are shown.
  • In case of high sensitivity of the viridans streptococcus, benzylpenicillin is prescribed at 2-3 million units 6 times a day intravenously for 4 weeks or ceftriaxone at 2 g once a day intravenously or intramuscularly for 4 weeks.
  • In case of high sensitivity of streptococci, duration of the disease more than 3 months or presence of complications, patients without contraindications to the use of aminoglycosides are prescribed benzylpenicillin 2-3 million IU 6 times a day + gentamicin 1 mg/kg 3 times a day intravenously for 2 weeks, and then only benzylpenicillin for 2 weeks.
  • If penicillin-resistant streptococci, Enterococcus faecalis, E.faecium and other enterococci are detected, ampicillin 2 g 6 times a day + gentamicin at a dose of 1 mg/kg 3 times a day or benzylpenicillin 4-5 million IU 6 times a day + gentamicin 1 mg/kg 3 times a day or vancomycin 15 mg/kg (or 1 g 2 times a day) + gentamicin 1-1.5 mg/kg 3 times a day intravenously for 4-6 weeks are recommended.
• For staphylococcal etiology of the disease, the following drugs are indicated.
  • Oxacillin-sensitive Staphylococcus aureus, coagulase-negative staphylococci: intravenously oxacillin 2 g 6 times a day for 4 weeks or oxacillin 2 g 6 times a day + gentamicin 1 mg/kg 3 times a day for 3-5 days, then up to 4-6 weeks only oxacillin or cefazolin 2 g 3 times a day + gentamicin 1 mg/kg 3 times a day for 3-5 days, then up to 4-6 weeks only cefazolin.
  • Oxacillin-resistant Staphylococcus aureus: intravenous vancomycin 15 mg/kg or 1 g 2 times a day for 4-6 weeks.
• For infections caused by microorganisms of the HASEK group, ceftriaxone 2 g per day intravenously or intramuscularly for 4 weeks, or ampicillin 3 g 4 times per day intravenously for 4 weeks + gentamicin 1 mg/kg 3 times per day.
• For infections caused by Pseudomonas aeruginosa, tobramycin is administered intravenously for 6 weeks at 5-8 mg/kg per day + ticarcillin/clavulanic acid at 3.2 g 4 times per day or cefepime at 2 g 3 times per day or ceftazidime at 2 g 3 times per day.

Specific treatment of glomerulonephritis in infective endocarditis is not performed. Effective antibacterial therapy of endocarditis leads to persistent remission of glomerulonephritis in most patients. Treatment of patients with glomerulonephritis with antibacterial drugs should be carried out under control of the complement content in the blood. In case of renal dysfunction in patients with glomerulonephritis, which persists despite adequate antibacterial therapy of infective endocarditis, prednisolone in moderate doses (30-40 mg/day) is indicated. If the nephrotoxic effect of antibacterial drugs develops, manifested in renal dysfunction, the antibacterial drug should be replaced in accordance with the sensitivity spectrum of the pathogen.

[ 12 ], [ 13 ], [ 14 ]

Prognosis of renal damage in infective endocarditis

The prognosis of patients with glomerulonephritis in the context of infective endocarditis is determined primarily by the severity and severity of the infection and, to a lesser extent, by the nature of glomerulonephritis. An unfavorable outcome is more often observed in exhausted and elderly patients, in the presence of septicemia with the development of abscesses in the internal organs, as well as in the development of vasculitis (skin purpura). Even with a significant deterioration in renal function at the onset of infective endocarditis, the prognosis depends more on the outcome of the underlying disease than on the morphological variant of nephritis. Adequate antibacterial therapy for infective endocarditis in most patients leads to a cure for glomerulonephritis. However, factors of chronicity of glomerulonephritis after cure of infective endocarditis may be concentration of creatinine in blood more than 240 μmol/l and nephrotic syndrome at the beginning of the disease, as well as presence of crescents and interstitial fibrosis in renal biopsy, if nephrobiopsy was performed. In such patients after treatment of infective endocarditis persistence of urinary syndrome and addition of signs of renal failure are possible.