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  • Title: [Therapy and prevention of infectious endocarditis].
    Author: Horstkotte D, Rosin H.
    Journal: Schweiz Med Wochenschr; 1984 Nov 10; 114(45):1575-86. PubMed ID: 6515354.
    Abstract:
    Only 40 years ago infectious endocarditis (IE) was lethal in most cases. Due to the development of numerous antibiotics and continuous improvements in heart valve surgery, a wide range of possibilities for therapy and prophylaxis of IE are available. The prognosis depends essentially on rapid and relevant diagnosis, which should be followed by immediate and adequate therapy consisting of general measures for treatment of septicaemic disease and specific antibiotic therapy. As multiple complications may develop during IE, careful follow-up by clinical, laboratory and mechanical examinations is necessary to decide whether surgical intervention is urgently indicated or not. In case of complications such as myocardial failure, septicaemic embolism or acute renal failure, as well as septicaemia persisting for more than 72 hours in spite of antibiotic treatment, immediate valve replacement is usually indispensable. Furthermore, large vegetations found by echocardiography, or infections caused by staphylococci, gramnegative bacteria or fungi are arguments for early surgery. For most of the IE pathogens the antibiotic treatment concept is nowadays widely acknowledged. Penicillin-sensitive streptococci are treated with a combination of penicillin S and an amino-glycoside (streptomycin). If the penicillin-MBK is very low, combined treatment can usually be abandoned. In patients allergic to penicillin, treatment with lincomycin has advantages over vancomycin or cephalosporins. In enterococcal IE, ampicillin plus aminoglycoside is the combination of choice. Streptomycin has preference over gentamicin here only if the enterococci are not streptomycin-resistant. If penicillin allergy is evident, the new beta-lactam antibiotic imipenem offers a way out of the present therapy dilemma. For penicillin-sensitive staphylococci a combination of penicillin-G with gentamicin given over 6 weeks is recommended. In case of penicillin allergy, cefazolin or vancomycin may provide a substitute for penicillin. In penicillin-resistant staphylococci the combination of oxacillin or flucloxacillin with gentamicin is established. Fungal endocarditis can be treated with a combination of amphotericin-B and flucytosin. Cure without surgery, however, is rare. For the large remaining number of pathogens which are less frequently responsible for IE, antibiotic management depends on sensitivity test in vitro, as the sensitivity of pathogens may vary widely. Though not only groups of patients with high infection rates are widely known, but also the events provoking the infections, the prophylaxis of IE continues to be inadequate.(ABSTRACT TRUNCATED AT 400 WORDS)
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