Fast Five Quiz: Refresh Your Knowledge on Key Aspects of Infective Endocarditis

Michael Stuart Bronze, MD

Disclosures

December 05, 2017

Approximately 15%-25% of patients with infective endocarditis eventually require surgery. Indications for surgical intervention in patients with NVE are as follows:

  • Congestive heart failure that is refractory to standard medical therapy

  • Fungal infective endocarditis (except that caused by Histoplasma capsulatum)

  • Persistent sepsis after 72 hours of appropriate antibiotic treatment

  • Recurrent septic emboli, especially after 2 weeks of antibiotic treatment

  • Rupture of an aneurysm of the sinus of Valsalva

  • Conduction disturbances caused by a septal abscess

  • Kissing infection of the anterior mitral leaflet in patients with infective endocarditis of the aortic valve

Congestive heart failure in a patient with NVE is the primary indication for surgery. A second relapse, during or after completion of treatment, requires replacement of the valve.

In the case of subacute infective endocarditis, treatment may be safely delayed until culture and sensitivity results are available. Waiting does not increase the risk for complications in this form of the disease.

PVE may be caused by methicillin-resistant S aureus or coagulase-negative staphylococci; thus, vancomycin and gentamicin may be used for treatment, despite the risk for renal insufficiency. Rifampin is necessary in treating individuals with infection of prosthetic valves or other foreign bodies because it can penetrate the biofilm of most of the pathogens that infect these devices. However, it should be administered with vancomycin or gentamicin. These latter two agents serve to prevent the development of resistance to rifampin.

Continuously infused ampicillin (serum level of 16 µg/mL) is probably the best therapy for aminoglycoside-resistant enterococci. Alternatives are imipenem, ciprofloxacin, or ampicillin with sulbactam. Vancomycin does not appear to be as useful as the aforementioned antibiotics.

For more on the treatment of infective endocarditis, read here.

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