IVDA carries a very high risk for NVE and PVE. Therapy can be revised based upon subsequent culture results. “2015 ESC Guidelines for the Management of Infective Endocarditis”. TEE also allows the detection of abscesses, fistulas, and perivalvular leaks. Prosthetic valve endocarditis (PVE) is an endovascular, microbial infection occurring on parts of a valve prosthesis or on reconstructed native heart valves.7 It is recommended to determine whether (a) a mechanical prosthesis, (b) a bioprosthetic xenograft, stented or unstented, (c) an allograft, (d) a homograft, or (e) a repaired native valve with or without implantation of an annular ring is … were second in frequency. The diagnosis and treatment of PVE typically requires subspecialty expertise, when feasible. There are mimics of blood culture negative endocarditis, including: Similar studies of material excised at cardiac surgery, when valve replacement is required, will be diagnostic. If greater than 5mm, they may be detected by MRI or spiral CT, whereas small ones are only reliably detected by cerebral angiography. Intravenous catheter associated bacteremia or candidemia results in PVE in 15 to 20 percent of exposed patients. Coagulase-negative staphylococci cause approximately one third of early-onset prosthetic valve endocarditis (onset <2 months after valve insertion) and 40% of intermediate-onset disease (onset 2 to 12 months after valve insertion).Unlike PVE, native valve endocarditis caused by coagulase-negative staphylococci is relatively rare, occurring in only 5% to 8% of endocarditis cases.Specific management of PVE consists of obtaining blood cultures and initiating empiric antibiotic therapy.
If symptoms suggest an end-organ complication, targeted imaging or other testing of that organ system may be indicated, e.g. Early PVE usually follows wound sepsis that may initially appear trivial. Positive blood cultures for organisms that rarely cause NVE or PVE more likely reflect extracardiac infection. If in this setting infection persists untreated for some weeks, typical so called “peripheral manifestations of endocarditis” may be noted; these include: Prophylaxis should be discontinued within 48 hours to reduce emergence of antimicrobial resistance and drug toxicity.Late-onset PVE acquired in the community is usually caused by endogenous microbiota such as viridans group streptococci and enterococci. Infection is categorized as early-onset PVE (EO-PVE) and late-onset PVE (LO-PVE) from the time of surgery until development of infection (In the first few months after surgery, the sutures, the valve cuff, and the valve itself become endothelialized. In 40 to 55 percent of cases, infection extends beyond the valve into paravalvular tissue resulting in valve dehiscence and paravalvular regurgitation, myocardial abscess, intracardiac fistula, or further extension disrupting the conduction system or extension into the pericardium causing pericarditis. Management requires neurosurgical evaluation. )(This paper provides an overview of the clinical features and treatment of PVE. )(This is a detailed guideline statement on the treatment of endocarditis from the European Society for Cardiology. Baddour, LM, Wilson, WR, Bayer, AS, Fowler, VG . Cases that present between 2 and 12 months after valve surgery are a blend of delayed onset cases where infection relates to the perioperative period and the earlier onset of hematogenously seeded infection from sites unrelated to surgery. It addresses which patients with S. aureus PVE might benefit from surgery. Promptly consult infectious disease, cardiology, and cardiac surgery. Double beta-lactam therapy (ampicillin 12gm IV daily plus ceftriaxone 2gm IV q 12 hours) have been effective in treating E. faecalis NVE and might be considered in PVE.
All rights reserved. Karchmer, AW , Bayer, AS. By continuing you agree to the Copyright © 2020 Elsevier B.V. or its licensors or contributors. Published by Elsevier Ltd.ScienceDirect ® is a registered trademark of Elsevier B.V. For PVE caused by staphylococci, a multi-drug regimen that includes rifampin, an antibiotic which kills these bacteria even when in stationary phase in biofilm, is recommended. (See "Complications and outcome of infective endocarditis", section on 'Outcome' .) 172-175 The infection is usually health care–related (resulting from inoculation at the time of surgery) and manifests within 12 months of valve placement. “Staphylococcus aureus prosthetic valve endocarditis: Optimal management and risk factors for death”. In fact, in general, if these core services are not available the patient should be transferred to a facility that can provide the necessary expertise. The cause of PVE varies to some degree by the time interval from valve surgery to onset of symptomatic infection – early onset 2 months or less, intermediate onset of 2 to 12 months, and late onset of over 12 months (Table I).
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