Infectious Diseases in Critical Care Medicine

THERAPY
Nonantibiotic Therapy
An operative approach is eventually required in 25% of cases of IE. Twenty-five percent of
these surgeries are performed during the early stages of this disease. The remainder take place
later on even after microbiologic cure has been achieved. Surgery has improved outcomes of
valvular infection for many. Because of the increase in IE, that is due toS. aureus, gram-
negatives aerobes and fungi, especially among impaired hosts, overall outcomes have not
improved in the last 30 years (193,194).
In both NVIE and PVE, congestive heart failure, that is refractory to standard medical
therapy, is the most common indication for surgical intervention. The major indications for
operative intervention are: (i) fungal IE (excluding that causedHistoplasma capsulatum); (ii) BSI
that persists past seven days of appropriate antibiotic therapy and is not determined to
originate from an extracardiac source; (iii) recurrent septic emboli occurring after two weeks of
appropriate antibiotic therapy; (iv) rupture of an aneurysm of the sinus of Valsalva; (v)
conduction disturbances secondary to a septal abscess; and (vi) “kissing” infection of the
anterior mitral valve leaflet in cases of aortic valve IE.
Indications for surgery in cases of PVE are the same as above with the addition of the
presence of prosthetic valve dehiscence and cases of early acquired PVE. Because of the
difficulty in eradicating organisms from prosthetic devices, surgery plays a far more
immediate role in the treatment of PVE than in NVIE. Not all cases of PVE require surgery.
Characteristics of PVE associated with successful treatment by medical therapy alone include:
(i) infection due to susceptible organisms, (ii) late PVE, (iii) mitral valve PVE, and (iv) prompt
initiation of antibiotic treatment of BioPVE (195,196).

Table 11 Mimics of Infective Endocarditis

Disease Type of valvular involvement Comments

Antiphospholipid syndrome Stenosis or regurgitation Patients have thrombotic events and/or
recurrent spontaneous abortions.
Antibody titers have no direct
correlation with disease activity.
Systemic lupus erythematosus Stenosis or regurgitation occurs
in 46% of patients (usually of
the mitral valve)

4% of cases of Libman–Sacks
endocarditis become secondarily
infected usually early in the course
of the disease.
Rheumatoid arthritis Regurgitation occurs in 2% of
patients

Valvular infection usually occurs later
in the course of the disease.
Atrial Myxoma Primarily obstruction of the
mitral valve due to its "ball
valve " effect

It is the most effective mimic due to its

valvular involvement, embolic

events and constitutional signs and

symptoms.

Table 12 Mimics of Infective Endocarditis: Clinical and Laboratory Features

Mimics of endocarditis Bacteremia

Cardiac

vegetation Fever Splenomegaly Emboli :ESR

Abnormal

SPEPa

Marantic endocarditis þ
Viral myocarditis þþ
SLE (Libman–Sacks
endocarditis

þþþþ

Atrial myxoma þþþþ
Infective endocarditis þþþþ

aPolyclonal gammopathy on SPEP.

Abbreviations: ESR, erythrocyte sedimentation rate; SLE, systemic lupus erythematosus; SPEP, serum protein
electrophoresis.
Source: From Ref. 189.

238 Brusch