Prosthetic Valve Endocarditis
by Opportunistic Pathogens Alberto
Juffe, MD; Alfonso L. Miranda, MD; Juan J. Rufilanchas, MD; Jose
\s=b\ The incidence of endocarditis produced by the so-called "opportunists" as a complication of prosthetic valve surgery is progressively increasing in frequency and gradually transforming the clinical picture habitually associated with this disease. We report six cases of endocarditis produced by opportunistic microorganisms (two cases by Candida, and the remaining by Serratia, Actinobacillus, Acinetobacter calcoaceticus, and Bacteriodes fragilis, and by Corynebacterium diphtheriae) in four male and two female patients, making special comment on our findings, diagnostic criteria, and treatment. The patients' ages ranged from 9 to 54 years, and all six patients had long-term complications, with symptoms appearing between 45 days and four years after prosthetic valve surgery. The progressive increase of this new type of prosthesis infection is favored by the indiscriminate use of certain drugs and especially by the prophy-
lactic
use
of antibiotics.
(Arch Surg 112:151-153, 1977)
clinical picture classically associated with endocar¬ ditis has experienced an evident transformation the last 20 years due to the appearance of infection by a new species group, the so-called "opportunistic" microorganisms. This term is applied to those nonpathogenic microorganisms that form part of the normal flora of the skin and mucous membranes and which, under certain circumstances, may be capable of producing subacute infections with difficult diagnosis and treatment.
The during
Accepted
for publication July 21, 1976. From the Department of Cardiothoracic Surgery, Clinica Puerta de Hierro, Autonomous University of Madrid, San Martin de Porres. Reprint requests to San Martin de Porres, 4, Madrid\p=n-\20\p=n-\Spain(Dr
Juffe).
M.
Maronas, MD; Diego Figuero, MD REPORT OF CASES
a 54-year-old woman received a because of aortic insufficiency. Four¬ teen months after this intervention, the valve was discovered to be insufficient, and it was subsequently replaced with a Starr ball valve. Eleven months after this second intervention, a new aortic valve insufficiency, with partial prosthesis detachment, was demonstrated by angiography; fever and anemia were the only clinical symptoms present, and all blood cultures were negative. The patient underwent a third operation, and the valve was replaced with a prosthesis of fascia lata. Cultures of the removed valve demonstrated large amounts of Candida, and treatment with flucytosine was pursued for one year. At present, the patient shows an angiographically slight aortic insufficiency and remains
Case l.-In November
1967,
lyophilized aortic homograft
clinically asymptomatic.
Case 2.—Because of a double aortic valve lesion, a 47-year-old received a prosthesis of fascia lata in October 1970, with mild fever and anemia appearing during the postoperative period. In May 1972, prosthesis dysfunction was demonstrated, and it was replaced with a ball valve. Two months after this second interven¬ tion, fever, anemia, and splenomegaly appeared. Despite the fact that repeated blood cultures were negative, regimens of G sodium penicillin (30 million units/day) and streptomycin sulfate (1 gm/ day) were administered for 25 days, after which sudden clinical deterioration and multiple embolism occurred, and the patient eventually died of renal failure and sepsis. The necropsy revealed vegetations of Serratia on a dysfunctioning prosthesis. Case 3.—A 29-year-old man had a history of rheumatic endocar¬ ditis at the age of 9 years. Because of severe aortic insufficiency, the aortic valve was replaced with a ball valve when the patient was 24 years of age. In March 1973, fever, anemia, and splenomeg¬ aly appeared, and an aortic dyastolic murmur was discovered. Blood cultures yielded Actinobacillus, and cure was achieved after a one-month treatment with penicillin G sodium (35 million units/ day) and streptomycin (1 gm/day). The patient was discharged and remained asymptomatic until July 1975, when fever, anemia, and splenomegaly reappeared. Blood cultures yielded Strepto¬ coccus viridans, and regimens of penicillin and streptomycin were man
Downloaded From: http://archsurg.jamanetwork.com/ by a West Virginia University Library User on 06/20/2015
on the eighth day after admission, detachment of the prosthesis resulted in acute aortic insufficiency and death. Case 4.—A 41-year-old woman was discharged from the hospital in good general health after undergoing an aortic valve replace¬ ment with a ball valve and replacement of the mitral and tricuspid valves with disc prostheses. Fifteen days after leaving the hospi¬ tal, mild fever appeared, and 30 days after discharge, the patient was readmitted with spiking fever and severe heart failure. She died shortly after of pulmonary edema. Necropsy findings included an almost total occlusion of the mitral and aortic pros¬ thesis by Candida. Case 5.-Because of double aortic and mitral valve lesions, a 22year-old man had received two Bjòrk prostheses in November 1973. Persistently high fever, intense sweating, anemia, spleno¬ megaly, and leukocytosis appeared one week after surgery; blood cultures, however, were negative. The patient was treated with penicillin G sodium (40 million units/day) and gentamicin sulfate (60 mg/8 hr), but on the 20th day of treatment, two blood cultures yielded Acinetobacter calcoaceticus and Bacteroides fragilis. Both being sensitive to carbenicillin disodium, therapy (24 gm/day) was started and maintained for 20 days. The patient was discharged in good health. Case 6.—A 9-year-old boy was treated for congenital mitral stenosis and ventricular septal defect in another center, under¬ going a banding of the pulmonary artery and receiving a Bjòrk mitral prosthesis at the same time. The patient's family related that fever had been present since the fourth postoperative day. Two months after surgery, the patient was admitted to our service with recurrent fever, malaise, anemia, and splenomegaly. No unusual auscultatory signs were heard, but eight of the ten blood cultures performed demonstrated Corynebacterium diphtheriae, and because of a history of previous penicillin hypersensitivity, treatment with cefazolin sodium (6 gm/day) and gentamicin sulfate (40 mg/8 hr) was initiated. On the 11th day of treatment, fever reappeared, and the treatment was changed to erythromycin (2 gm/day) and gentamicin sulfate (5 mg/kg of body weight), based on the antibiogram. New symptomatic improvement was obtained. Signs of nephrotoxicity were observed on the 21st day of gentamicin treatment, but they disappeared after administration of the drug was discontinued. All the following blood cultures were negative. The total duration of antibiotic therapy was 40 days, and the patient was discharged in good health.
started; however,
COMMENT
Because of the indiscriminate
use
of
drugs such
as
antibiotics, steroids, and immunosuppressants, the increas¬
ing use of progressively more complex surgical techniques, and the prolonged survival of patients with severely debil¬ itating disease, an increasing number of clinical infections and potentially lethal diseases caused by a group of lowvirulence microorganisms is being observed. Nevertheless, postoperative antibiotic prophylaxis of at least one month's duration is essential for all recipients of prosthetic heart valves. The postoperative prophylactic program that we have carried out in all patients is as follows: cephalothin sodium (intravenously), 4 gm/day in divided doses every six hours, for four days and then orally for 26 additional days; and gentamicin sulfate intravenously, 2 to 3 mg/kg of body weight daily for seven days. The doses of gentami¬ cin were modified according to the creatinine clearance. In our opinion, the results obtained with this prophy-
lactic program have been quite good as the global incidence of endocarditis among patients with prosthetic valves has been 2.3%. For this reason we feel that it is not necessary to modify our program at the present time. For the further prevention of endocarditis after this period, we advocate the following prophylaxis: 600,000 units of a preparation of penicillin G and procaine penicil¬ lin, given intramuscularly several hours before and during the two days following any future otorhinolaryngological or odontological explorations or interventions. Infections of any kind (cutaneous, respiratory, urinary, or others) should receive prompt and energetic treatment with the appropriate antibiotics. In patients having a known history of hypersensitivity to penicillin, a wide-spectrum antibiotic, such as erythromycin (250 mg/6 hr) or tetracycline (250 mg/6 hr), should be given for days, beginning the morning of the day of any future surgical exploration or intervention. Even if the cure of an infected prosthesis is obtained with medical treatment, we believe that the risk of a new bacterial infection remains elevated; for this reason, we favor a prolonged antibiotic prophylaxis. The course of action to be followed once prosthesis reinfection occurs, however, has not been clearly established. In our opinion, if prosthesis function is normal, medical treatment should be tried initially; however, if dysfunction appears, we advo¬ cate early replacement in order to minimize the possibility of prosthesis detachment. Since the first description appeared in 1930,' a wide variety of infections by Serratia marcescens, especially of the respiratory and urinary tracts,-' have been reported, although Serratia endocarditis is rare. A review of the literature by Alexander et al" showed that four of the six cases reported had been diagnosed at autopsy. This was also the occurrence in our case 2, in whom, despite pre¬ senting clinical signs highly suggestive of endocarditis, the diagnosis could be verified only by a postmortem culture of the prosthesis. We therefore believe that, in cases similar to these, positive blood cultures are not necessary before instituting treatment, and we feel that endocarditis by Serratia should be suspected whenever this microorganism is repeatedly evidenced in the sputum or urine of patients with clinical signs of endocarditis.'' The initial treatment should be medical, given the sensitivity that this microor¬ ganism shows to gentamicin, kanamycin sulfate, and chlo¬ ramphenicol.1 It should be remembered, however, that the mortality associated with sepsis by Serratia is approxi¬ mately 40%,' and consequently, we advocate surgery when¬ ever resistance to antibiotics develops, clinical deteriora¬ tion occurs, or embolism appears. Numerous cases of endocarditis by Candida have been reported since the first description of this type of infection appeared in 1956,7 one of the most extensive reviews being done by Seeling et al.s Serological tests may be useful in establishing diagnosis in patients with negative blood cultures, since the titers of agglutinins and precipitins to Candida tend to rise very early in the course of infection and undergo a progressive decrease once medical treat¬ ment is begun." "
Downloaded From: http://archsurg.jamanetwork.com/ by a West Virginia University Library User on 06/20/2015
The detachment of endocarditic vegetations is frequent in Candida endocarditis, and embolisms may appear before the diagnosis of infection has been clearly estab¬ lished. We therefore recommend the careful culture of all the material extracted in the course of any eventual embolectomy performed in patients susceptible to this type of infection. Since the risk of contamination of the new prosthesis is present in those patients who have undergone prosthesis replacement because of Candida infection, a prophylactic treatment of one year's duration has been proposed." This is especially important in those patients where homografts have been used; in these subjects, the prophylaxis should be intensified, since the incidence of Candida infection on bioprostheses is increased/ Some authors recommend the use of laminar flow in the construction of these valves.'" In cases where Candida endocarditis is suspected, the use of flucytosine at a dosage of 150 mg/kg/day is recommended. Once the diagnosis has been confirmed, or if resistance to this drug appears, amphotericin should be given, beginning with 10 mg/day intravenously, in order to evaluate tolerance to this drug, and gradually increasing to 50 mg/day until a total of 2,500 mg have been given. Nevertheless, prosthesis replacement is frequently re¬ quired in this type of infection." Human infection by diphtheriform Corynebacterium organisms is extremely rare, and prosthetic valve infection is even more so. The prognosis of this type of endocarditis is uncertain, and all reviews have emphasized the fact that prophylactic antibiotic therapy currently used in cardiac surgery increases the possibility of bacteremia by diphtheroids."" The clinical picture of prosthetic valve infection by opportunistic microorganisms is frequently very insidious, and in many cases, only moderate fever is present. This relative clinical silence is partly due to the routine use of antibiotics, in addition to the differences in behavioral characteristics existing between these microorganisms and the usual pathogens. For these reasons, we believe that the possibility of endocarditis should be considered in all patients having persistent fever during the postoperative period, and that strict surveillance should be maintained and oriented toward its early diagnosis.
Nonproprietary Names
and Trademarks of
Drugs
Flucytosine-A ncobon. Gentamicin sulfate—Garamycin. Cefazolin sodium—Ancef. Cephalothin sodium-Äe/iin. Amphotericin B-Fungizone.
References 1. Holloway WJ, Taylor WA: Clinical Antibiotic Solution. New Futura Publishing Company, 1973, vol 1, p 110.
York,
2. Dodson WH: Serratia marcescens septicemia. Arch Intern Med 121:145-150, 1968. 3. Wilfert JN, Barret FF, Kass EH: Bacteremia due to Serratia marcescens. N Engl J Med 279:286-289, 1968. 4. Altemeir WA, Culbertson WR, Fullen WD, et al: Serratia marcescens septicemia. Arch Surg 99:232-238, 1969. 5. Crowder JG, Gilkey GH, White AC: Serratia marcescens bacteriemia:
Clinical observations and studies of precipitin reactions. Arch Intern Med 128:247-253, 1971. 6. Alexander RH, Reichenbach DD, Meredino KA: Serratia marcescens endocarditis: A review of the literature and report of a case involving a homograft replacement of the aortic valve. Arch Surg 98:287-291, 1969. 7. Koelle WA, Pastor BH: Candida albicans endocarditis after valvulotomy. N Engl J Med 255:997-1,001, 1956. 8. Seeling MS, Speth CP, Kozinn PJ, et al: Patterns of Candida endocarditis following cardiac surgery. Prog Cardiovasc Dis 17:125-160, 1974. 9. Turner E, Kay JH, Bernstein S, et al: Surgical treatment of Candida endocarditis. Chest 67:262-268, 1975. 10. Juffe A, Perea JE, Castillo JL, et al: Reducci\l=o'\nde la contaminaci\l=o'\n microbiana por el uso de flujo laminar en la construcci\l=o'\nde v\l=a'\lvulas cardiacas. Pre Med Arg 62:109-111, 1975. 11. Kaplan K, Weinstein L: Diphtheroid infections of man. Ann Intern Med 70:919-929, 1969. 12. Reid JD, Green WL: Corynebacterial endocarditis. Arch Intern Med 119:106-110, 1967. 13. Johnson WD, Cobbs CG, Arditi LI, et al: Diphtheroid endocarditis after insertion of a prosthetic heart valve. JAMA 203:117-119, 1968.
Editorial Comment Serious infection after cardiac surgery is an important problem that has yet to be completely eradicated. The authors of this article contend that opportunistic postoperative infections on cardiac valves are in large part due to the inappropriate use of antibiotics. (They do, however, delineate a rather lengthy program of prophy¬ lactic antibiotics for their own patients.) The potential sources of postoperative infection after cardiac valve replacement are numerous and cannot often be identified in a patient who develops endocarditis. A preventive program for infection should include the following: high-dose short-term preventive cephalosporin ther¬ apy, careful operative technique with the electrocautery, air filtration and on-going environmental survey techniques. High-dose, short-term preventive antibiotic therapy begun prior to the incision and extending for two or three days postoperatively is necessary and appropriate coverage for the intraoperative period when the patient's blood is circulated through and over a variety of foreign materials, including oxygenators and long lengths of tubing. As the authors graphically demonstrate, infec¬ tion in a patient with prosthetic or bioprosthetic valve is, indeed, a catastrophic event justifying, for most surgeons, the use of preventive antibiotic therapy. Recent prospective studies testify to the efficacy of short-term, high-dose preventive antibiotics in a variety of surgical operations, provided the drugs are begun prior to the procedure. As the authors suggest, the indiscriminate and prolonged use of antibiotics, particularly in those patients most susceptible to infections (ie, immunosuppressed or extremely debilitated) should be avoided. Their re-emphasis on meticulous infection prophylaxis for any dental or minor surgical procedure in the late postopera¬ tive period in patients with prosthetic valves is to be commended. Lawrence H. Cohn, MD Boston
Downloaded From: http://archsurg.jamanetwork.com/ by a West Virginia University Library User on 06/20/2015
by Opportunistic Pathogens Alberto
Juffe, MD; Alfonso L. Miranda, MD; Juan J. Rufilanchas, MD; Jose
\s=b\ The incidence of endocarditis produced by the so-called "opportunists" as a complication of prosthetic valve surgery is progressively increasing in frequency and gradually transforming the clinical picture habitually associated with this disease. We report six cases of endocarditis produced by opportunistic microorganisms (two cases by Candida, and the remaining by Serratia, Actinobacillus, Acinetobacter calcoaceticus, and Bacteriodes fragilis, and by Corynebacterium diphtheriae) in four male and two female patients, making special comment on our findings, diagnostic criteria, and treatment. The patients' ages ranged from 9 to 54 years, and all six patients had long-term complications, with symptoms appearing between 45 days and four years after prosthetic valve surgery. The progressive increase of this new type of prosthesis infection is favored by the indiscriminate use of certain drugs and especially by the prophy-
lactic
use
of antibiotics.
(Arch Surg 112:151-153, 1977)
clinical picture classically associated with endocar¬ ditis has experienced an evident transformation the last 20 years due to the appearance of infection by a new species group, the so-called "opportunistic" microorganisms. This term is applied to those nonpathogenic microorganisms that form part of the normal flora of the skin and mucous membranes and which, under certain circumstances, may be capable of producing subacute infections with difficult diagnosis and treatment.
The during
Accepted
for publication July 21, 1976. From the Department of Cardiothoracic Surgery, Clinica Puerta de Hierro, Autonomous University of Madrid, San Martin de Porres. Reprint requests to San Martin de Porres, 4, Madrid\p=n-\20\p=n-\Spain(Dr
Juffe).
M.
Maronas, MD; Diego Figuero, MD REPORT OF CASES
a 54-year-old woman received a because of aortic insufficiency. Four¬ teen months after this intervention, the valve was discovered to be insufficient, and it was subsequently replaced with a Starr ball valve. Eleven months after this second intervention, a new aortic valve insufficiency, with partial prosthesis detachment, was demonstrated by angiography; fever and anemia were the only clinical symptoms present, and all blood cultures were negative. The patient underwent a third operation, and the valve was replaced with a prosthesis of fascia lata. Cultures of the removed valve demonstrated large amounts of Candida, and treatment with flucytosine was pursued for one year. At present, the patient shows an angiographically slight aortic insufficiency and remains
Case l.-In November
1967,
lyophilized aortic homograft
clinically asymptomatic.
Case 2.—Because of a double aortic valve lesion, a 47-year-old received a prosthesis of fascia lata in October 1970, with mild fever and anemia appearing during the postoperative period. In May 1972, prosthesis dysfunction was demonstrated, and it was replaced with a ball valve. Two months after this second interven¬ tion, fever, anemia, and splenomegaly appeared. Despite the fact that repeated blood cultures were negative, regimens of G sodium penicillin (30 million units/day) and streptomycin sulfate (1 gm/ day) were administered for 25 days, after which sudden clinical deterioration and multiple embolism occurred, and the patient eventually died of renal failure and sepsis. The necropsy revealed vegetations of Serratia on a dysfunctioning prosthesis. Case 3.—A 29-year-old man had a history of rheumatic endocar¬ ditis at the age of 9 years. Because of severe aortic insufficiency, the aortic valve was replaced with a ball valve when the patient was 24 years of age. In March 1973, fever, anemia, and splenomeg¬ aly appeared, and an aortic dyastolic murmur was discovered. Blood cultures yielded Actinobacillus, and cure was achieved after a one-month treatment with penicillin G sodium (35 million units/ day) and streptomycin (1 gm/day). The patient was discharged and remained asymptomatic until July 1975, when fever, anemia, and splenomegaly reappeared. Blood cultures yielded Strepto¬ coccus viridans, and regimens of penicillin and streptomycin were man
Downloaded From: http://archsurg.jamanetwork.com/ by a West Virginia University Library User on 06/20/2015
on the eighth day after admission, detachment of the prosthesis resulted in acute aortic insufficiency and death. Case 4.—A 41-year-old woman was discharged from the hospital in good general health after undergoing an aortic valve replace¬ ment with a ball valve and replacement of the mitral and tricuspid valves with disc prostheses. Fifteen days after leaving the hospi¬ tal, mild fever appeared, and 30 days after discharge, the patient was readmitted with spiking fever and severe heart failure. She died shortly after of pulmonary edema. Necropsy findings included an almost total occlusion of the mitral and aortic pros¬ thesis by Candida. Case 5.-Because of double aortic and mitral valve lesions, a 22year-old man had received two Bjòrk prostheses in November 1973. Persistently high fever, intense sweating, anemia, spleno¬ megaly, and leukocytosis appeared one week after surgery; blood cultures, however, were negative. The patient was treated with penicillin G sodium (40 million units/day) and gentamicin sulfate (60 mg/8 hr), but on the 20th day of treatment, two blood cultures yielded Acinetobacter calcoaceticus and Bacteroides fragilis. Both being sensitive to carbenicillin disodium, therapy (24 gm/day) was started and maintained for 20 days. The patient was discharged in good health. Case 6.—A 9-year-old boy was treated for congenital mitral stenosis and ventricular septal defect in another center, under¬ going a banding of the pulmonary artery and receiving a Bjòrk mitral prosthesis at the same time. The patient's family related that fever had been present since the fourth postoperative day. Two months after surgery, the patient was admitted to our service with recurrent fever, malaise, anemia, and splenomegaly. No unusual auscultatory signs were heard, but eight of the ten blood cultures performed demonstrated Corynebacterium diphtheriae, and because of a history of previous penicillin hypersensitivity, treatment with cefazolin sodium (6 gm/day) and gentamicin sulfate (40 mg/8 hr) was initiated. On the 11th day of treatment, fever reappeared, and the treatment was changed to erythromycin (2 gm/day) and gentamicin sulfate (5 mg/kg of body weight), based on the antibiogram. New symptomatic improvement was obtained. Signs of nephrotoxicity were observed on the 21st day of gentamicin treatment, but they disappeared after administration of the drug was discontinued. All the following blood cultures were negative. The total duration of antibiotic therapy was 40 days, and the patient was discharged in good health.
started; however,
COMMENT
Because of the indiscriminate
use
of
drugs such
as
antibiotics, steroids, and immunosuppressants, the increas¬
ing use of progressively more complex surgical techniques, and the prolonged survival of patients with severely debil¬ itating disease, an increasing number of clinical infections and potentially lethal diseases caused by a group of lowvirulence microorganisms is being observed. Nevertheless, postoperative antibiotic prophylaxis of at least one month's duration is essential for all recipients of prosthetic heart valves. The postoperative prophylactic program that we have carried out in all patients is as follows: cephalothin sodium (intravenously), 4 gm/day in divided doses every six hours, for four days and then orally for 26 additional days; and gentamicin sulfate intravenously, 2 to 3 mg/kg of body weight daily for seven days. The doses of gentami¬ cin were modified according to the creatinine clearance. In our opinion, the results obtained with this prophy-
lactic program have been quite good as the global incidence of endocarditis among patients with prosthetic valves has been 2.3%. For this reason we feel that it is not necessary to modify our program at the present time. For the further prevention of endocarditis after this period, we advocate the following prophylaxis: 600,000 units of a preparation of penicillin G and procaine penicil¬ lin, given intramuscularly several hours before and during the two days following any future otorhinolaryngological or odontological explorations or interventions. Infections of any kind (cutaneous, respiratory, urinary, or others) should receive prompt and energetic treatment with the appropriate antibiotics. In patients having a known history of hypersensitivity to penicillin, a wide-spectrum antibiotic, such as erythromycin (250 mg/6 hr) or tetracycline (250 mg/6 hr), should be given for days, beginning the morning of the day of any future surgical exploration or intervention. Even if the cure of an infected prosthesis is obtained with medical treatment, we believe that the risk of a new bacterial infection remains elevated; for this reason, we favor a prolonged antibiotic prophylaxis. The course of action to be followed once prosthesis reinfection occurs, however, has not been clearly established. In our opinion, if prosthesis function is normal, medical treatment should be tried initially; however, if dysfunction appears, we advo¬ cate early replacement in order to minimize the possibility of prosthesis detachment. Since the first description appeared in 1930,' a wide variety of infections by Serratia marcescens, especially of the respiratory and urinary tracts,-' have been reported, although Serratia endocarditis is rare. A review of the literature by Alexander et al" showed that four of the six cases reported had been diagnosed at autopsy. This was also the occurrence in our case 2, in whom, despite pre¬ senting clinical signs highly suggestive of endocarditis, the diagnosis could be verified only by a postmortem culture of the prosthesis. We therefore believe that, in cases similar to these, positive blood cultures are not necessary before instituting treatment, and we feel that endocarditis by Serratia should be suspected whenever this microorganism is repeatedly evidenced in the sputum or urine of patients with clinical signs of endocarditis.'' The initial treatment should be medical, given the sensitivity that this microor¬ ganism shows to gentamicin, kanamycin sulfate, and chlo¬ ramphenicol.1 It should be remembered, however, that the mortality associated with sepsis by Serratia is approxi¬ mately 40%,' and consequently, we advocate surgery when¬ ever resistance to antibiotics develops, clinical deteriora¬ tion occurs, or embolism appears. Numerous cases of endocarditis by Candida have been reported since the first description of this type of infection appeared in 1956,7 one of the most extensive reviews being done by Seeling et al.s Serological tests may be useful in establishing diagnosis in patients with negative blood cultures, since the titers of agglutinins and precipitins to Candida tend to rise very early in the course of infection and undergo a progressive decrease once medical treat¬ ment is begun." "
Downloaded From: http://archsurg.jamanetwork.com/ by a West Virginia University Library User on 06/20/2015
The detachment of endocarditic vegetations is frequent in Candida endocarditis, and embolisms may appear before the diagnosis of infection has been clearly estab¬ lished. We therefore recommend the careful culture of all the material extracted in the course of any eventual embolectomy performed in patients susceptible to this type of infection. Since the risk of contamination of the new prosthesis is present in those patients who have undergone prosthesis replacement because of Candida infection, a prophylactic treatment of one year's duration has been proposed." This is especially important in those patients where homografts have been used; in these subjects, the prophylaxis should be intensified, since the incidence of Candida infection on bioprostheses is increased/ Some authors recommend the use of laminar flow in the construction of these valves.'" In cases where Candida endocarditis is suspected, the use of flucytosine at a dosage of 150 mg/kg/day is recommended. Once the diagnosis has been confirmed, or if resistance to this drug appears, amphotericin should be given, beginning with 10 mg/day intravenously, in order to evaluate tolerance to this drug, and gradually increasing to 50 mg/day until a total of 2,500 mg have been given. Nevertheless, prosthesis replacement is frequently re¬ quired in this type of infection." Human infection by diphtheriform Corynebacterium organisms is extremely rare, and prosthetic valve infection is even more so. The prognosis of this type of endocarditis is uncertain, and all reviews have emphasized the fact that prophylactic antibiotic therapy currently used in cardiac surgery increases the possibility of bacteremia by diphtheroids."" The clinical picture of prosthetic valve infection by opportunistic microorganisms is frequently very insidious, and in many cases, only moderate fever is present. This relative clinical silence is partly due to the routine use of antibiotics, in addition to the differences in behavioral characteristics existing between these microorganisms and the usual pathogens. For these reasons, we believe that the possibility of endocarditis should be considered in all patients having persistent fever during the postoperative period, and that strict surveillance should be maintained and oriented toward its early diagnosis.
Nonproprietary Names
and Trademarks of
Drugs
Flucytosine-A ncobon. Gentamicin sulfate—Garamycin. Cefazolin sodium—Ancef. Cephalothin sodium-Äe/iin. Amphotericin B-Fungizone.
References 1. Holloway WJ, Taylor WA: Clinical Antibiotic Solution. New Futura Publishing Company, 1973, vol 1, p 110.
York,
2. Dodson WH: Serratia marcescens septicemia. Arch Intern Med 121:145-150, 1968. 3. Wilfert JN, Barret FF, Kass EH: Bacteremia due to Serratia marcescens. N Engl J Med 279:286-289, 1968. 4. Altemeir WA, Culbertson WR, Fullen WD, et al: Serratia marcescens septicemia. Arch Surg 99:232-238, 1969. 5. Crowder JG, Gilkey GH, White AC: Serratia marcescens bacteriemia:
Clinical observations and studies of precipitin reactions. Arch Intern Med 128:247-253, 1971. 6. Alexander RH, Reichenbach DD, Meredino KA: Serratia marcescens endocarditis: A review of the literature and report of a case involving a homograft replacement of the aortic valve. Arch Surg 98:287-291, 1969. 7. Koelle WA, Pastor BH: Candida albicans endocarditis after valvulotomy. N Engl J Med 255:997-1,001, 1956. 8. Seeling MS, Speth CP, Kozinn PJ, et al: Patterns of Candida endocarditis following cardiac surgery. Prog Cardiovasc Dis 17:125-160, 1974. 9. Turner E, Kay JH, Bernstein S, et al: Surgical treatment of Candida endocarditis. Chest 67:262-268, 1975. 10. Juffe A, Perea JE, Castillo JL, et al: Reducci\l=o'\nde la contaminaci\l=o'\n microbiana por el uso de flujo laminar en la construcci\l=o'\nde v\l=a'\lvulas cardiacas. Pre Med Arg 62:109-111, 1975. 11. Kaplan K, Weinstein L: Diphtheroid infections of man. Ann Intern Med 70:919-929, 1969. 12. Reid JD, Green WL: Corynebacterial endocarditis. Arch Intern Med 119:106-110, 1967. 13. Johnson WD, Cobbs CG, Arditi LI, et al: Diphtheroid endocarditis after insertion of a prosthetic heart valve. JAMA 203:117-119, 1968.
Editorial Comment Serious infection after cardiac surgery is an important problem that has yet to be completely eradicated. The authors of this article contend that opportunistic postoperative infections on cardiac valves are in large part due to the inappropriate use of antibiotics. (They do, however, delineate a rather lengthy program of prophy¬ lactic antibiotics for their own patients.) The potential sources of postoperative infection after cardiac valve replacement are numerous and cannot often be identified in a patient who develops endocarditis. A preventive program for infection should include the following: high-dose short-term preventive cephalosporin ther¬ apy, careful operative technique with the electrocautery, air filtration and on-going environmental survey techniques. High-dose, short-term preventive antibiotic therapy begun prior to the incision and extending for two or three days postoperatively is necessary and appropriate coverage for the intraoperative period when the patient's blood is circulated through and over a variety of foreign materials, including oxygenators and long lengths of tubing. As the authors graphically demonstrate, infec¬ tion in a patient with prosthetic or bioprosthetic valve is, indeed, a catastrophic event justifying, for most surgeons, the use of preventive antibiotic therapy. Recent prospective studies testify to the efficacy of short-term, high-dose preventive antibiotics in a variety of surgical operations, provided the drugs are begun prior to the procedure. As the authors suggest, the indiscriminate and prolonged use of antibiotics, particularly in those patients most susceptible to infections (ie, immunosuppressed or extremely debilitated) should be avoided. Their re-emphasis on meticulous infection prophylaxis for any dental or minor surgical procedure in the late postopera¬ tive period in patients with prosthetic valves is to be commended. Lawrence H. Cohn, MD Boston
Downloaded From: http://archsurg.jamanetwork.com/ by a West Virginia University Library User on 06/20/2015
