Treatment of infective endocarditis

Treatment of infective endocarditis consists of a long course of antimicrobial therapy. Surgical intervention may be necessary for complications that disrupt the biomechanics of the valve apparatus, or resistant microorganisms. As a rule, antibiotics are prescribed intra-virally. Since the duration of therapy is 2-8 weeks, intravenous injections are often performed on an outpatient basis.

Actively eliminate any sources of bacteremia: surgical excision of necrotic tissues, drainage of abscesses, removal of foreign materials and infected devices. Intravenous catheters (especially central venous catheters) must be replaced. If endocarditis develops in a patient with a newly established central venous catheter, it must be removed. Microorganisms present on catheters and other devices are unlikely to respond to antimicrobial therapy, leading to treatment failure or relapse. If continuous infusions are used in place of fractional bolus administration, the interruption between such infusions should not be too long.

Modes of antibacterial treatment of infective endocarditis

Drugs and doses depend on the microorganism and its resistance to antimicrobial therapy. Initial treatment before identification of a microorganism is carried out with a broad-spectrum antibiotic to cover all probable pathogens. Patients with native valves that do not inject intravenously receive ampicillin 500 mg / hr with continuous intravenous injection plus nafcillin 2 g intravenously every 4 h plus gentamicin at 1 mg / kg intravenously every 8 h. Patients with prosthetic valves are prescribed vancomycin for 15 mg / kg iv every 12 h plus gentamycin at 1 mg / kg every 8 h plus rifampicin at 300 mg vagus every 8 h. Persons injecting drugs intravenously receive nfcillin 2 g intravenously every 4 h. In all regimens, patients with allergies for penis preparations illinovogo series need to replace them on vancomycin 15 mg / kg intravenously every 12 hours. People injecting drug users, often lack of adherence to treatment, continue to take drugs and have a tendency to quickly leave the hospital. Such patients can be given a short course of treatment with the use of intravenous medication or (less preferably) oral medication. With right-sided endocarditis caused by methicillin-sensitive Staphylococcus aureus, nafcillin is effective at a dose of 2 g intravenously every 4 h plus gentamicin at 1 mg / kg intravenously every 8 h for 2 weeks, as does ingestion of ciprofloxacin 750 mg twice daily plus rifampicin inside 300 mg 2 times a day. Left-sided endocarditis does not respond to a 2-week course of treatment.

Antibiotic regimens for endocarditis

Microorganism	Medicinal / Adults Doses	Drug / Doses for adults who are allergic to penidylline drugs
Penicillin-susceptible streptococci (penicillin MIC G <0.1 μg / ml), including the majority of S. viridans	Benzylpenicillin (penicillin G sodium salt sterile) 12-18 million units per day continuously or 2-3 million units at 4 hours for 4 weeks, or for 2 weeks if the patient simultaneously receives gentamicin 1 mg / kg * in / in (up to 80 mg) in 8 hours	Ceftriaxone 2 g once a day IV for 4 weeks, or the same for 2 weeks, if simultaneously the patient receives gentamicin 1 mg / kg * IV (up to 80 mg) after 8 hours. The drugs are injected through the central venous catheter ( it is possible out-patient). The patient should not have anaphylaxis on penicillin drugs. Vancomycin 15 mg / kg IV after 12 hours for 4 weeks
Streptococci relatively resistant to penicillin (MIC penicillin G> 0.1 μg / ml), including enterococci and some other strains of streptococci	Gentamicin 1 mg / kg * IV after 8 hours plus benzylpenicillin (penicillin G sodium salt sterile) 18-30 million units per day IV or ampicillin 12 g / day iv continuously or 2 g after 4 hours for 4 -6 weeks ++	Desensitization to penicillins. Vancomycin 15 mg / kg IV (to 1 g) after 12 hours plus gentamicin 1 mg / kg * IV after 8 hours for 4-6 weeks
Pneumococci or streptococcus group A	Benzylpenicillin (penicillin G sodium salt is sterile) 12-18 million units per day iv continuously for 4 weeks if microorganisms are susceptible to penicillins. Vancomycin 15 mg / kg IV after 12 hours for 4 weeks for pneumococci with MIC Penicillin G> 2 μg / ml	Ceftriaxone 2 g 1 time per day IV for 4 weeks through the central venous catheter (can be outpatient) if there is no anaphylaxis in the anamnesis for penicillins. Vancomycin 15 mg / kg IV after 12 hours for 4 weeks
Strains of Staphylococcus aureus, resistant to oxacillin and nafcillin	Vancomycin 15 mg / kg IV after 12 hours - only this antibiotic, if the native valve is affected, gentamicin 1 mg / kg * iv is added to it at 8 hours for 2 weeks, rifampicin inside 300 mg after 8 hours if involved Prosthetic valve for 6-8 weeks
Microorganisms of the group NASEK	Ceftriaxone 2 g once a day IV for 4 weeks. Ampicillin 12 g / day iv or continuously 2 g after 4 hours plus gentamicin 1 mg / kg * IV after 8 hours for 4 weeks	Ceftriaxone 2 g 1 time per day IV for 4 weeks or 2 weeks if at the same time the patient receives gentamicin 1 mg / kg * IV (80 mg) after 8 hours. The patient should not have an anaphylaxis on penicillin
Bacteria of the intestinal group	B-Lactam antibiotics with proven sensitivity (eg, ceftriaxone 2 g IV after 12-24 hours or ceftazidime 2 g IV every 8 hours) plus an aminoglycoside (eg, gentamicin 2 mg / kg * IV after 8 hours) for 4-6 weeks
Pseudomonas aeruginosa	Ceftazidime 2 g IV every 8 hours or cefepime 2 g IV every 8 hours or imipenem 500 mg IV 6 hours plus tobramycin 2.5 mg / kg after 8 hours for 6-8 weeks; 5 mg / kg of amikacin replaces tobramycin after 12 hours if the bacteria are sensitive to it	Ceftazidime 2 g IV every 8 hours or cefepime 2 g IV every 8 hours plus tobramycin 2.5 mg / kg after 8 hours for 6-8 weeks; 5 mg / kg of amikacin after 12 hours replaces tobramycin, if the bacteria are sensitive only to kamikatsinu
Penicillin-resistant strains of Staphylococcus aureus	Patients with lesions of left-sided native valves: oxacillin or nafcillin 2 g IV after 4 hours for 4-6 weeks. Patients with lesions of right-sided native valves: oxacillin or nafcillin 2 g IV after 4 hours for 2-4 weeks plus gentamicin 1 mg / kg * IV after 8 hours for 2 weeks Patients with a prosthetic valve: oxacillin or nafcillin 2 g IV after 4 hours for 6-8 weeks plus gentamicin 1 mg / kg * IV after 8 hours for 2 weeks plus rifampicin inside 300 mg after 8 hours for 6-8 week	Cefazolin 2 g IV in 8 hours for 4-6 weeks if staphylococcus is susceptible to oxacillin or nafcillin and if there is no anaphylaxis in the anamnesis for penicillins. Cefazolin 2 g IV after 8 hours for 2-4 weeks plus gentamicin 1 mg / kg * IV after 8 hours for 2 weeks Cefazolin 2 g IV in 8 hours for 4-6 weeks plus gentamicin 1 mg / kg * IV after 8 hours for 2 weeks plus rifampicin inside 300 mg after 8 hours for 6-8 weeks. Vancomycin 15 mg / kg iv every 12 hours - this antibiotic alone, if a native valve is affected, gentamicin 1 mg / kg * iv is added to it at 8 h for 2 weeks, rifampicin inside 300 mg after 8 hours if a prosthetic valve for 4-6 weeks

* Count on the ideal, not the actual body weight, if the patient is obese. When appointing vancomycin, it is necessary to control its concentration in the blood serum if the dose exceeds 2 g for 24 h. ⁺⁺ If endocarditis of enterococcal etiology lasts more than 3 months and causes large vegetations or vegetations on prosthetic valves, treatment should be performed more than 6 weeks. Some clinicians add gentamicin 1 mg / kg IV after 8 hours for 3-5 days in patients with a native valve.

Cardiosurgery of valvular pathology

Surgical treatment (surgical treatment, valve plastic or prosthetics) is often indicated in an abscess, persisting infection, despite antimicrobial therapy (persistent positive blood cultures or recurrent embolisms), or severe valvular regurgitation.

The timing of surgical intervention requires clinical experience. If heart failure caused by a potentially correctable lesion is aggravated (especially when the process is caused by Staphylococcus aureus, Gram-negative bacteria or fungi), surgical treatment may be required immediately after a 24-72-hour course of antimicrobial therapy. In patients with prosthetic valves, surgical treatment may be required in the following cases:

• TTE demonstrates splitting of the valve or presence of a near-valve abscess;
• valve dysfunction causes heart failure;
• repeated embolisms were found;
• the infection is caused by antibiotic-resistant microorganisms.

[1], [2]

Response to treatment of infective endocarditis

After starting therapy, patients with penicillin-susceptible streptococcal endocarditis usually feel better, and fever decreases within 3-7 days. Fever may persist for other reasons unrelated to infection (for example, due to drug allergy, phlebitis, the formation of a heart attack due to embolism). Patients with staphylococcal endocarditis usually respond more slowly to treatment.

Relapse in most cases occurs within 4 weeks. Sometimes repeated antibiotic therapy is effective, in other cases surgical treatment of infective endocarditis is necessary. In patients without prosthetic valves, the resumption of endocarditis after 6 weeks is usually the result of a new infection, rather than a relapse. Even after successful antimicrobial therapy, sterile embolisms and valve ruptures can occur for up to 1 year.

Prophylaxis of infective endocarditis

Antimicrobial prophylaxis is recommended to patients in high and moderate risk of infective endocarditis before procedures associated with bacteremia and subsequent infective endocarditis. In most cases, a single dose of a drug shortly before the procedure is effective.