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Infective Endocarditis and Other Intravascular Infections PDF

250 Pages·1982·7.728 MB·English
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Infective Endocarditis and Other Intravascular Infections CURRENT TOPICS IN INFECTIOUS DISEASE Series Editors: William B. Greenough III Thomas C. Merigan Division of Geographic Medicine Head, Division of Infectious Disease The Johns Hopkins University Stanford University Medical Center School of Medicine Stanford, California Baltimore, Maryland The Atypical Mycobacteria and Human Mycobacteriosis Johns S. Chapman Infections of the Gastrointestinal Tract: Microbiology, Pathophysiology, and Clinical Features Herbert L. DuPont and Larry K. Pickering Coccidioidomycosis: A Text Edited by David A. Stevens Cytomegalovirus: Biology and Infection MontoHo Infective Endocarditis and Other Intravascular Infections Lawrence R. Freedman A Continuation Order Plan is available for this series. A continuation order will bring delivery of each new volume immediately upon publication. Volumes are billed only upon actual ship ment. For further information please contact the publisher. Infective Endocarditis and Other Intravascular Infections Lawrence R. Freedman, M.D. VA Wadsworth Medical Center UCLA School oj Medicine Los Angeles, California PLENUM MEDICAL BOOK COMPANY New York and London Library of Congress Cataloging in Publication Data Freedman, Lawrence, R. Infective endocarditis and other intravascular infections. (Current topics in infectious disease) Includes index. I. Endocarditis, Bacterial. 2. Blood-vessels-Infections. I. Title. II. Series. [DNLM: I. Endocarditis, Bacterial. 2. Vasculitis. WG 285 F853i] RC685.E5F73 1982 616.1 82-12361 ISBN 978-1-4684-8210-2 ISBN 978-1-4684-8208-9 (eBook) DOl 10.1007/978-1-4684-8208-9 © 1982 Plenum Publishing Corporation Softcover reprint of the hardcover 1st edition 1982 233 Spring Street, New York, N.Y. 10013 Plenum Medical Book Company is an imprint of Plenum Publishing Corporation All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher To the four women I love and admire Hanna, Julia, Leora, Rina Acknowledgments I wish to thank the National Institute of Allergy and Infectious Diseases (U.S.P.H.S.) for their support of my studies of intravascular infection while at Yale University, New Haven, Connecticut. I subsequently continued these in vestigations at the University of Lausanne, Switzerland, at the Centre Hospitalier Universitaire Vaudois, whose support was essential to the work. At this time I am pursuing these studies under the auspices of the Veterans Administration at the VA Wadsworth Medical Center at the University of Cal ifornia at Los Angeles. My thanks go to Mr. Samuel Lunenfeld (Toronto, Canada) and to Professor and Mrs. Franz Joseph (Lausanne, Switzerland) for their help and interest in this project. To Dr. and Mrs. Bruce Rapapport and the Interrnaritime Foundation (Ge neva, Switzerland) I want to express deep appreciation for their commitment to medical research and education and for their friendship and generous encour agement of my research. LAWRENCE R. FREEDMAN, M.D. Los Angeles vII Contents Chapter 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.1. Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4 Chapter 2. The Pathogenesis of Intravascular Infection . . . . . . . . 5 Chapter 3. The Nonbacterial Thrombotic Vegetation. . . . . . . . . . . 9 3.1. Endothelial Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 10 3.2. Hypercoagulability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 11 3.3. Cancer.................................................. 13 3.4. Infection................................................ 14 3.5. Immune Complexes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 15 3.6. Limitation of Growth of Vegetations ......................... 16 3.6.1. Embolization.................. . . . . . . . . . . . . . . . . . .. 16 3.6.2. Fibrinolysis, Organization, and Endothelialization ....... 18 3.7. Fibroblastic Parietal Endocarditis with Eosinophilia (Loffter's Endocarditis) . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 19 3.8. Arteriosclerosis........................................... 20 3.9. Nonbacterial Thrombotic Vegetation in the Venous System. . . . . .. 20 References .............................................. 22 Chapter 4. Establishment of Intravascular Infection ........... 27 4.1. Bacteremia-The Capacity to Induce Infection . . . . . . . . . . . . . . . .. 27 4.2. Types and Source of Bacteria Responsible for Intravascular Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 30 4.2.1. Infective Endocarditis .............................. 30 4.2.2. Mycotic Aneurysm ................................ 34 4.2.3. Vascular-Graft Infections ........................... 35 Ix x Contents 4.3. Susceptibility of Nonbacterial Thrombotic Vegetation to Infection 36 4.3.1. Size of Nonbacterial Thrombotic Vegetation. . . . . . . . . . .. 36 4.3.2. Localization and Frequency within the Vascular System.. 38 4.3.3. Pathology of Thrombotic Vegetation. . . . . . . . . . . . . . . . .. 50 References .............................................. 55 Chapter 5. Prophylaxis of Intravascular Infection. . . . . . . . . . . . .. 63 5.1. Infective Endocarditis ..................................... 63 5.1.1. Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 64 5.1.2. Bacterial Sticking. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 64 5.1. 3. Microorganisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 65 5.1.4. Choice of Antibiotics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 66 5.1.5. Choice of Subjects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 68 5.2. Prosthetic-Valve Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 70 5.3. Vascular Grafts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 73 References .............................................. 73 Chapter 6. Consequences of Intravascular Infection. . . . . . . . . .. 77 6.1. Establishing the Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 77 6.1.1. Clinical Presentation of Infective Endocarditis .......... 77 6.1.2. Mycotic Aneurysm (Primary) . . . . . . . . . . . . . . . . . . . . . . .. 83 6.1.3. Infection in Peripheral Veins ........................ 83 6.1.4. Clinical Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 84 6.2. Prolonged Bacteremia ..................................... 84 6.2.1. Blood Culture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 84 6.2.2. Fever and Constitutional Symptoms. . . . . . . . . . . . . . . . . .. 90 6.2.3. Hematological Findings. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 90 6.2.4. Splenomegaly..................................... 91 6.2.5. Metastatic Infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 91 6.3. Host Responses to Bacteremia .............................. 91 6.3.1. Intravascular Coagulation. . . . . . . . . . . . . . . . . . . . . . . . . .. 91 6.3.2. Anticoagulants....... . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 92 6.3.3. Specific Circulating Antibody. . . . . . . . . . . . . . . . . . . . . . .. 93 6.3.4. Circulating Immune Complexes. . . . . . . . . . . . . . . . . . . . .. 94 6.4. Local Invasion ........................................... 102 6.4.1. Valve Destruction ................................. 103 6.4.2. Congestive Heart Failure ............................ 103 6.4.3. Valve-Ring Abscess ................................ 105 6.4.4. Valve Obstruction ................................. 106 6.5. Peripheral Emboli ......................................... 107 6.5.1. Nervous System ................................... 108 6.5.2. Spleen, Gallbladder, and Liver ....................... 109 Contents xl 6.5.3. Kidney .......................................... 109 6.5.4. Bone ............................................ 110 6.5.5. Major Arteries .................................... 110 6.5.6. Mycotic Aneurysms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 111 6.5.7. Heart ............................................ 111 6.6. Mortality and Factors Affecting Prognosis. . . . . . . . . . . . . . . . . . . .. 112 References .............................................. 113 Chapter 7. Host Defense Mechanisms ........................ 125 7.1. Location within the Vascular System ......................... 126 7.2. Polymorphonuclear Leukocytes .............................. 128 7.3. Healing-Endothelialization ................................. 130 7.4. Role of Foreign Body ..................................... 131 7.5. Aging of Bacteria ......................................... 133 7.6. Serum Bactericidal Activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 133 References .............................................. 134 Chapter 8. Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 137 8.1. Decision to Treat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 137 8.2. Negative Blood Cultures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 138 8.3. Positive Blood Cultures .................................... 144 8.4. Antibiotics .............................................. 145 8.4.1. Principles ........................................ 145 8.4.2. Recommended Treatment Programs ................... 147 8.5. Special Problems of Microbial Infection ...................... 155 8.5.1. Gram-Negative Bacilli. ............................. 155 8.5.2. Gram-Positive Bacilli ("Diphtheroids") ................ 164 8.5.3. Anaerobic Bacteria ................................ 167 8.5.4. Chlamydiae ...................................... 168 8.5.5. Mycobacteria ..................................... 168 8.5.6. Q Fever ......................................... 169 8.5.7. Viruses .......................................... 170 8.5.8. Fungi ........................................... 170 8.5.9. Pneumococci ..................................... 175 8.5.10. Neisseria Species ..................... '" ......... 175 8.5.11. Staphylococcus epidermidis, Coagulase-Negative Staphylococci, and Micrococci Species ................. 000 8.5.12. Streptococci ..................................... 177 8.6. Surgery ................................................. 180 8.6.1. Valve Destruction-Congestive Heart Failure ........... 181 8.6.2. Antibiotic Failure .................................. 181 xII Contents 8.6.3. Peripheral Embolization ............................ 182 8.6.4. Cardiac Conduction Abnormalities .................... 183 8.6.5. Peripheral Arterial Grafts ........................... 184 8.6.6. Purulent Thrombophlebitis .......................... 184 8.6.7. Cardiac Catheterization and Endocardial Pacemakers ..... 185 8.6.8. Miscellaneous ..................................... 186 8.7. Treatment of Septic Arthritis and Osteomyelitis ................ 186 8.8. Treatment of Glomerulonephritis ............................ 186 8.9. Special Aspects of Patient Care ............................. 187 References .............................................. 187 Chapter 9. Indices of Effectiveness of Treatment. . . . . . . . . . . . . . 207 9.1. Clinical ................................................. 207 9.2. Laboratory .............................................. 208 9.2.1. Serum Bactericidal Activity ......................... 208 9.2.2. Other Studies ..................................... 209 9.3. Bacteriology of Surgically Removed Vegetations ............... 210 References ........ . ..................................... 211 Chapter 10. Outcome of Treatment ... ........................ 215 10.1. Medical ................................................. 215 10.2. Surgical ................................................. 216 References .............................................. 218 Chapter 11. Complications of Treatment ...................... 219 Appendix. AHA Committee Report: Prevention of Bacterial Endocarditis .................................................2 21 Dental Procedures and Upper Respiratory Tract Surgical Procedures ............................................... 222 Regimens for Dental Procedures and Surgery of the Upper Respiratory Tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224 Regimen A-Penicillin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224 Regimen B-Penicillin plus Streptomycin. . . . . . . . . . . . . . . . . . . 225 Genitourinary Tract and Gastrointestinal Tract Surgery or Instrumentation .......................................... 226 Regimens for Gastrointestinal and Genitourinary Tract Surgery and Instrumentation . . .. . ..................................... 227 Cardiac Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228 Status Following Cardiac Surgery ........................... 229

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