Treatment Of Native Valve Endocarditis Research Articles

Treatment of native valve endocarditis due to coagulase negative staphylococci, complicated by a drug reaction with eosinophilia and systemic symptoms (DRESS syndrome)

Coagulase negative staphylococci (CoNS) are a rare cause of native valve endocarditis (NVE). However, they are emerging as important pathogens of NVE. We describe a 61 year old male who developed NVE caused by CoNS and presented with cerebral embolic phenomena. He was treated with vancomycin and subsequently with linezolid. He developed a drug reaction with eosinophilia and systemic symptoms (DRESS syndrome) to linezolid which was managed successfully. The patient’s recovery was good after six weeks of treatment with anti-staphylococcal antibiotics.

Daptomycin compared to standard therapy for the treatment of native valve endocarditis

In a recent randomized trial of Staphylococcus aureus bacteremia and native valve endocarditis, daptomycin was found not inferior to standard therapy. We summarized findings in the subgroup of patients with endocarditis according to the Duke criteria. Patients were randomly assigned to receive daptomycin 6 mg/kg/day or standard therapy (vancomycin 1g every 12h or antistaphylococcal penicillin 2g every 4h, both with gentamicin 1mg/kg every 8h for the first 4 days). The primary end point was success in the modified intent-to-treat population 6 weeks after the end of therapy. Fifty-three patients were included: 35 with right-sided endocarditis (RIE) and 18 with left-sided endocarditis (LIE). The success rates in patients with RIE were similar between daptomycin and the comparator (42% vs 44%). Patients with RIE with septic pulmonary infarcts responded similarly to treatment with daptomycin and standard therapy (60% vs 67%). In the LIE population, treatment success rates were poor in both arms (11% vs 22%). Daptomycin is an efficacious and well-tolerated alternative to standard therapy in the treatment of RIE. Patients with LIE had a poor outcome regardless of the treatment received. Daptomycin is also effective in treating endocarditis with septic pulmonary infarcts.

Predictors of recurrence and reoperation for prosthetic valve endocarditis after valve replacement surgery for native valve endocarditis

Surgical treatment of native valve endocarditis remains challenging, especially in cases with paravalvular destruction. Basic principles include complete debridement and reconstruction. This study is designed to evaluate the outcomes of surgical reconstruction of complex annular endocarditis using standard techniques and materials, including autologous and bovine pericardium. From 1975 to 2000, 358 cases (357 patients, mean age 49 +/- 16 years, range 18-88 years) of native valve endocarditis were surgically managed. Bioprosthetic valves were implanted in 189 cases, and mechanical prostheses were implanted in 169 cases. A total of 78 cases of paravalvular destruction were identified: 62 annular abscesses, 8 fistulas, and 8 combined abscesses/fistulas. These were managed with 46 pericardial patches and 32 isolated suture reconstructions after radical debridement and prosthetic valve replacement. The overall early mortality was 8.4% (n = 30). The mortality with paravalvular destruction was 17.9%, and the mortality with simple leaflet infection was 5.7% (P = .001). The unadjusted survival at 20 years was 26.4% +/- 4.9% for bioprosthetic valves and 56.5% +/- 8.1% for mechanical prostheses (P = .007). The freedom from recurrent prosthetic valve endocarditis was 78.9% +/- 4.4% at 15 years. The freedom from reoperation for recurrent prosthetic valve endocarditis was 85.8% +/- 4.2% at 15 years. The freedom from reoperation after reconstruction for paravalvular destruction was 88.2% +/- 6.9% at 15 years. The freedom from mortality for recurrent prosthetic valve endocarditis was 92.7% +/- 3.4% at 15 years. The independent predictors of reoperation were age (hazard ratio 0.930, P = .005) and intravenous drug use/human immunodeficiency virus plus surgical technique (hazard ratio 12.8, P = .003 for patch reconstruction plus valve and hazard ratio 3.6, P = .038 for valve replacement only). Prosthesis type was not predictive when separated from intravenous drug use/human immunodeficiency virus (hazard ratio 3.268, P = .088). Paravalvular destruction is associated with a higher operative mortality. Native valve endocarditis can be managed with reasonable long-term survival and low rates of reinfection with radical debridement and pericardial reconstruction with bioprostheses and mechanical prostheses. The type of prosthesis implanted does not influence long-term outcome. Patients with a history of intravenous drug use and human immunodeficiency virus are at increased risk for recurrent infection and reoperation.

Comment on: The role of aminoglycosides in combination with a -lactam for the treatment of bacterial endocarditis: a meta-analysis of comparative trials

Sir, Falagas and colleagues performed a meta-analysis of comparative trials to determine the role, if any, of aminoglycosides in combination with a b-lactam antibiotic for the treatment of infective endocarditis caused by Gram-positive cocci. 1 They are to be congratulated on their thorough analysis and their many fine contributions to the literature. One point in the Discussion section of the article 1 deserves further clarification. The authors state that ‘the addition of gentamicin to penicillin G or ceftriaxone is highly recommended by the AHA for the first 2 weeks of treatment’ in the latest published statement 2 and that findings from their meta-analysis did not support this position. As outlined in their review, only one trial 3 that pertained to streptococci was included in the analysis and that investigation examined monotherapy versus dual therapy for native valve endocarditis caused by either viridans group streptococci or Streptococcus bovis. It is noteworthy that only patients who had streptococcal isolates that were susceptible to penicillin, ceftriaxone and gentamicin were included in the study; ‘resistance’ to penicillin of the initial blood culture isolate was an exclusion criterion. The authors did not, however, provide the specific in vitro susceptibility data (MIC) for the isolates. Due to the success of b-lactam monotherapy in this trial 3 and other investigations, both the current 2 and previous 4 versions of the AHA ‘treatment guidelines’ listed only b-lactam monotherapy as a 4 week treatment option for native valve endocarditis caused by penicillin-susceptible (MIC £ 0.12 mg/L) viridans group streptococci and S. bovis. The current guidelines do recommend that the first 2 weeks of treatment of native valve endocarditis caused by streptococci that have higher (>0.12 to £0.5 mg/L) MICs of penicillin receive combination therapy with gentamicin.

Short-Course Ceftriaxone and Gentamicin for

Two weeks of intravenous penicillin and gentamicin has proved as effective as 4 weeks of penicillin alone for treatment of native valve endocarditis