Infective Endocarditis and Other Intravascular Infections

250 Pages·1982·7.728 MB·English

by  Lawrence R. Freedman M.D. (auth.)

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