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INFECTIOUS ENDOCARDITIS

Classification

Infectious endocarditis is divided into the following main categories, depending on the main pathogens and related features of antibiotic therapy.

• infectious endocarditis of natural valves;

• infectious endocarditis in drug addicts using the iv route of drug administration;

• infectious endocarditis of artificial (prosthetic) valves:

• early (developing within 60 days after surgery) - more often due to valve contamination or as a result of perioperative bacteremia;

• late (developing more than 2 months after surgery) - may have the same pathogenesis with early infectious endocarditis, but a longer incubation period; may also develop as a result of transient bacteremia.

Acute and subacute infectious endocarditis is distinguished depending on the nature of the course of the disease. However, the most significant is the unit for bacterial etiology, as this determines the choice of AMP and the duration of therapy.

The main pathogens

Infectious endocarditis can be caused by a variety of microorganisms, however, the vast majority are streptococci and staphylococci (80-90%).

The most common pathogens of infectious endocarditis are presented in table. 1.

Table 1. Etiology of Infectious Endocarditis

Acute infectious endocarditis needs immediate antibiotic therapy, while treatment of subacute endocarditis may be delayed for 24-48 hours while a diagnostic examination is being conducted. The need for urgent treatment of acute endocarditis is due to the fact that one of the most likely pathogens is S.aureus, which can cause toxic shock, septic metastases and the rapid destruction of heart valves.

Subacute infectious endocarditis is usually caused by microorganisms characterized by low virulence, and is rarely accompanied by septicemia or shock. A certain delay in the start of treatment makes it possible within 1-2 days to obtain preliminary data from a microbiological blood test and conduct etiotropic therapy. However, it is unacceptable to postpone the start of the use of AMP for more than 48 hours.

To cure infectious endocarditis, it is necessary to achieve the eradication of microorganisms from vegetation, which is possible only if the following main points are observed:

• use AMPs that are active against potential and established pathogens;

• use bactericidal AMPs, since in vegetation microorganisms are in a state of low metabolic activity;

• use combinations of AMPs with synergism;

• Parenteral administration of AMP to obtain higher and predictable serum concentrations;

• antimicrobial therapy should be long to ensure sterilization of valve vegetation.


Empirical Antimicrobial Therapy

Before obtaining the results of a microbiological blood test, empirical antimicrobial therapy of infectious endocarditis should be directed against the main pathogens taking into account the individual characteristics of the patient (Table 2).

Table 2. Empirical antimicrobial therapy of infectious endocarditis

In acute infectious endocarditis, the drugs of choice are AMPs active against S.aureus.

In "iv drug addicts" antibiotic therapy should include drugs that are active against S.aureus and gram-negative rods (in many regions drug users have a high incidence of MRSA).

In infectious endocarditis of artificial valves, vancomycin and gentamicin are the drugs of choice, since MRSE is high.

After obtaining the results of a microbiological blood test, it is necessary to adjust the therapy. In case of negative blood cultures, the ongoing therapy should be continued if it was effective. Recommended combinations of AMP, doses, frequency and duration of their administration depending on the etiology of endocarditis are given in table. 3.

Table 3. Antimicrobial therapy of infectious endocarditis of established etiology (in accordance with the recommendations of the International Society for Chemotherapy, 1998)

There are no significant differences between the etiology of infectious endocarditis in children and adults. Data on optimal antimicrobial therapy in children is limited, with most antimicrobial regimens being borrowed from adults. In general, these regimens were equally effective and less toxic when used in children.

FEATURES OF TREATMENT OF INFECTIOUS ENDOCARDITIS IN ELDERLY PEOPLE

In patients older than 60 years, a slightly higher incidence of infectious endocarditis is observed, which is associated with the presence of complicating factors (diseases of the cardiovascular system). At the same time, in elderly people, a decrease in renal function is observed, which may require a change in doses and / or dosage interval when using penicillins and cephalosporins, vancomycin and aminoglycosides.
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INFECTIOUS ENDOCARDITIS

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