Coxiella burnetii (the causative agent of Q fever) can also cause a subacute infection. Similarly to most examples of IE, Staphylococcus aureus is the causative agent in majority of IE cases (60–70%) related to IDU and is mostly MSSA. However, less common infections including Methicillin resistant iv drug use staphylococcus aureus (MRSA) (up to 26%), streptococci viridans (8–10%), enterococci (2–5%), streptococci bovis or other streptococci species (3%), coagulase-negative staphylococci (3%), and fungi (1–2%), do occur (6, 7). Other rare causes include Pseudomonas aeruginosa, HACEK organisms, E.

Infective endocarditis of a transcatheter pulmonary valve in comparison with surgical implants

Demographic and clinical data for analysis were retrieved from electronic hospital charts. The local Ethics Committee approved the study (authorization n 12113_oss) and, given the retrospective and non-interventional nature of the study, granted a waiver of informed consent. The diagnostic work-up and treatment strategies adhered to the current international IE guidelines [7].

Infective endocarditis in persons who use drugs: Epidemiology, current management, and emerging treatments

The patient underwent irrigation, debridement, and a spacer device placement in the affected knee joint for PJI and was medically treated for IE with six weeks of antibiotic therapy. The patient successfully recovered and was discharged to a rehabilitation facility. We conclude that PJI and IE secondary to TJA are very rare, but given the high morbidity and mortality, if diagnosis and treatment are delayed, physicians should always remain vigilant for these complications in the appropriate clinical context. Infective endocarditis (IE) is a notorious complication of intravenous drug use (IDU).

• The remainder of the systemic review and physical examination were unremarkable.
• Tonsillectomy, dental extraction, and dental cleaning can result in bacteremia and lead to infection.
• If fever persists, the sensitivity of the infecting organism should be checked and drug levels monitored.

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Early onset usually results from perioperative valve contamination with staphylococci, whereas the etiology of late prosthetic valve endocarditis resembles native valve infection, usually due to streptococci. The lesions, called vegetations, are masses composed of fibrin, platelets, and infecting organisms, held together by agglutinating antibodies produced by the bacteria. As inflammation continues, ulceration may result in erosion or perforation of the valve cusps, leading to valvular incompetence, damage to the conduction pathway (if in the septal area), or rupture of a sinus of Valsalva (if in the aortic area). If any of these signs occur together with a fever, the patient should be urgently referred to a cardiologist for blood cultures and echocardiography – the level of risk will determine whether this is transesophageal echo (TEE) or transthoracic echo. Blind treatment with antibiotics should not be undertaken since it will delay diagnosis and identification of the causal organism.

However, IE in this particular patient population is more difficult to treat, and has a high recurrence rate compared to other patient populations, because of continuing IDU and medical non-compliance. Here, we present an interesting case of IE in a relatively young IDU patient with severe MSSA positive sepsis. The updated diagnostic and treatment strategies, as well as the ethical issues involved in the management of IE patients in the setting of current active IDU will also be discussed. Given bacteremia and septic pulmonary emboli, transthoracic echocardiography was performed which showed tricuspid valvular vegetation consistent with infective endocarditis.

• Diagnosis of endocarditis can become challenging in patients with an atypical clinical presentation.
• These sites in turn provide extra surface area to which microorganisms can adhere and form vegetations3 (Figure 1).
• Over time, the etiology, as well as causes of IE, have evolved and doubled in numbers because of a greater number of patients with indwelling cardiac devices and central lines.
• A special subset of endocarditis is that affecting prosthetic valves.
• Cerebral emboli, which usually affect the middle cerebral artery, result in hemiplegia and sensory dysfunction.
• If the onset is acute, staphylococci need to be covered and treatment should include IV cloxacillin (flucloxacillin) (3 g, 6 hourly, in place of penicillin) with oral fusidic acid.

Given that dalbavancin is not FDA-approved for endocarditis, insurers may decline to cover its cost, thereby shifting the cost to hospitals and patients. However, multiple analyses have suggested that costs to the system may be offset by decreased hospital length of stay.71,73 Further research is needed to examine the economic impact and cost-effectiveness of these antibiotics. Another barrier to dalbavancin use is the lack of a defined optimal dosing and monitoring schedules. Several dosing strategies have been proposed that include once and twice weekly dosing with variable loading and maintenance dosages.67,68 Despite anecdotal success, more rigorous evaluation is clearly needed.

FOLLOW-UP AND PATIENT EDUCATION

Coagulase-negative staphylococci cause 30%–50% of prosthetic valve endocarditis. It is generally accepted that turbulent flow and the resulting endocardial injury can predispose valve surfaces to bacterial seeding. Patients with valvular heart abnormalities such as bicuspid aortic valve, mitral valve prolapse or any other acquired lesion causing stenosis or regurgitation, are at increased risk of endocarditis [43,44]. The tricuspid valve may be more susceptible to heroin use, as heroin can cause an increase in pulmonary arterial pressure, creating more turbulence at the tricuspid valve.

Surgical therapy

The heart valves, which keep blood flowing in the right direction, are gates at the chamber openings. In the treatment of IE, from any source, fever may still be present 2 weeks after starting the appropriate treatment, even with drug-sensitive organisms. This could be due to the presence of an underlying large vegetation or abscess. If fever persists, the sensitivity of the infecting organism should be checked and drug levels monitored. Repeat echo should be performed to exclude increasing vegetation size or abscess formation. If, despite these measures, the fever remains, the possibility of antibiotic resistance should be considered and a further synergistic antimicrobial treatment may be required.

Infective endocarditis in heroin addicts

• A proper evaluation by a health care provider is needed to make the diagnosis.
• Although endocarditis can affect native and prosthetic valves, infection seldom affects a previously normal heart – the majority (60%) of IE patients have a predisposing cardiac condition.
• Multiple pink, macular, irregular lesions were seen on the patient’s right thumb and hand (Fig. 1).
• It is in these patients that the majority of the complications occur.

Sami et al. reported a case of tricuspid valve IE in a non-IV drug user after a breast skin abscess [12]. Similarly, Hirakawa et al. reported another case of tricuspid valve IE in a patient with an abscess of an endogenous arteriovenous fistula in a chronic hemodialysis patient [13]. Very rarely, it can happen without any known risk factors, as was reported by Andrijašević et al. in a young, healthy patient without any significant medical history or risk factors [14]. Antibiotic treatment should start immediately after blood cultures are obtained.

Intravenous catheters should be removed promptly after antibiotic therapy is complete. Transthoracic echocardiography should be performed to establish a new baseline. In patients with a history of infectious endocarditis, three sets of blood cultures should be obtained from separate sites before antibiotics are initiated for febrile illness.