Fungal endocarditis

Recent advances in medicine have caused fungal endocarditis (FE) to be a more common disease entity. A list of fungi is expanding as potential pathogens in FE, with Candida species and Aspergillus species being the most common. The combination of valvular heart disease along with indwelling devices and antibiotic use are the major predisposing factors for yeast endocarditis, whereas the presence of immunosuppression along with valvulopathy predisposes for mold endocarditis. The expanding population of immunosuppresed patients and individuals with intravascular devices has led to increased incidence of FE. Better outcome of FE depends on fast and accurate diagnosis and subsequent treatment. Echocardiography the most valuable recent technique allowed for early diagnosis of FE and is probably responsible for the improved prognosis of patients with FE. Nonculture-based diagnostic tests may further improve the sensitivity, specificity, and rapidity of microbiologic diagnosis of FE. The availability of the newer triazoles and echinocandins, providing broad spectrum antifungal activities with favorable safety profile may assist in achieving cure and further improving the prognosis of this disease entity.     

Streptococcus bovis endocarditis

A case is described of bacterial endocarditis caused by Lancefield group D Streptococcus bovis. Because of its sensitivity to the less toxic antibiotics such as penicillin, the importance of laboratory differentiation from the more resistant enterococci is emphasized. Treatment in this case was complicated by penicillin allergy and cardiac failure. The condition finally responded to clindamycin therapy and aortic valve replacement.     

Prosthetic valve endocarditis.

During 1965 to 1982, 32 episodes of infective endocarditis on prosthetic valves in 30 patients were treated at this hospital. In early endocarditis (presenting within four months of operation) staphylococci were the organisms most commonly responsible. Early endocarditis appears to be declining in incidence and is largely preventable; sternal sepsis was the main predisposing factor, requiring urgent and effective treatment. Streptococci were the most common organisms in late onset disease, but as with natural valve endocarditis a wide range or organisms was responsible. All but one of the patients with early onset disease were treated conservatively, but mortality was high; prompt surgical replacement of infected prostheses is probably indicated in such patients. Medical management was effective in most patients with late onset disease, and for them early surgical intervention may not be justified.     

Rothia dentocariosa endocarditis.

Despite its presence normally in the mouth, R dentocariosa appears rarely to cause infection outside the oral cavity. There is no doubt, however, as additional reports accumulate, that this organism should be recognized as having the ability to cause a serious illness in humans. In addition, in vivo experience seems to suggest that a penicillin regimen should remain first-line therapy for this infection, with the efficacy of other agents remaining unproved.     

Actinobacillus actinomycetemcomitans endocarditis.

Two patients had infective endocarditis due to Actinobacillus actinomycetemcomitans. One, a 52-year-old woman with a prosthetic aortic valve, was successfully treated with carbenicillin and gentamicin. The other, a 47-year old man with calcific aortic valve disease, required emergency valvectomy and prosthetic valve replacement and responded to a combination of penicillin and gentamicin.     

Surgical treatment of infective endocarditis with special reference to prosthetic valve endocarditis.

Patients with native valve endocarditis treated surgically between 1968 and 1978 (n = 15) and all patients presenting with prosthetic valve endocarditis during this period (n = 21) were followed up for at least four years. Five of the patients with native valve endocarditis required urgent early surgical intervention, of whom two died. The remaining 10 underwent valve replacement after a course of antibiotic treatment: all survived, though one required further valve replacement. The 21 patients with prosthetic valve endocarditis suffered 25 attacks. Nine were cured by medical treatment alone; two died before surgical intervention was possible; 11 required valve replacement, of whom three died; and two required valve replacement after a course of antibiotic treatment. The incidence of early prosthetic valve endocarditis--that occurring within two months of operation--was 0.67%, but that of late prosthetic valve endocarditis could not be determined. Medical treatment when started early should cure endocarditis in most patients, but vigilance should be maintained for the appearance of indications for surgery. When such indications exist surgery should not be delayed.