Infective endocarditis and kidney damage: treatment

Treatment of kidney damage in infectious endocarditis depends on the features of the pathogen, localization and severity of valvular lesions, the presence of systemic manifestations of the disease (with the development of glomerulonephritis - from the state of kidney function). Antibacterial therapy is a method of etiotropic treatment of infective endocarditis. The basic principles of the use of antibacterial drugs are given below.

• It is necessary to use antibacterial drugs of bactericidal action.
• To create a high concentration of antibacterial drug in vegetation (which is necessary for effective treatment), intravenous administration of drugs in high doses for a long time (at least 4-6 weeks) is indicated.
• If the patient is in a serious condition and there is no evidence of an infectious agent, empirical therapy should be started before the results of a microbiological blood test.
• In the subacute flow of infective endocarditis or an uncharacteristic clinical picture, etiotropic antibacterial therapy should be performed after identifying the causative agent.
• After the treatment of infective endocarditis for the prevention of recurrence of infection, the appointment of antibacterial drugs in situations that cause transient bacteremia is indicated.

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

Empirical treatment of kidney damage in infectious endocarditis

• The medicinal preparation of the choice of empirical therapy of acute infective endocarditis is 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 suspected acute infectious endocarditis caused by resistant staphylococci or enterococci, intravenously prescribed vancomycin 1 g 2 times a day and gentamicin at 1 mg / kg 3 times a day. An alternative to vancomycin with a high risk of nephrotoxicity is rifampicin intravenously 300-450 mg 2 times a day.
• In subacute infectious endocarditis of the native valve intravenously for 4 weeks ampicillin 2 g 6 times a day in combination with gentamicin 1 mg / kg 3 times a day or benzylpenicillin 3-4 million units 6 times a day in combination with gentamycin by 1 mg / kg 3 times a day.
• In the case of subacute infective endocarditis tricuspid valve (for drug users taking drugs intravenously), the drug of choice is considered oxacillin 2 g 6 times a day in combination with gentamicin 1 mg / kg 3 times a day intravenously for 2-4 weeks. Alternatives are also recommended: cefazolin 2 g in combination with gentamicin 1 mg / kg iv 3 times a day for 2-4 weeks or vancomycin 1 g 2 times a day in combination with gentamycin 1 mg / kg 3 times in day intravenously for 4 weeks.

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

Etiotropic treatment of kidney damage in infectious endocarditis

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

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

[12], [13], [14],

Prognosis of kidney damage in infectious 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. Unfavorable outcome is more often observed in depleted and elderly patients, with septicemia with the development of abscesses in the internal organs, as well as in the development of vasculitis (cutaneous purple). Even with a significant deterioration in kidney function in 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 of infective endocarditis in most patients leads to the cure of glomerulonephritis. However, chronization factors for glomerulonephritis after curing infectious endocarditis may be a creatinine concentration in the blood of more than 240 μmol / L and a nephrotic syndrome at the onset of the disease, as well as the presence of semi-moons and interstitial fibrosis in the renal biopsy if a nephrobiopsy was performed. In such patients, after treatment of infective endocarditis, persistence of the urinary syndrome and attachment of signs of renal failure are possible.