Scientific editor: Strokina OA, therapist, doctor of functional diagnostics. Practical experience since 2015.
October, 2018.
Infective endocarditis - an inflammation of the inner lining of the heart: endocarditis, involving in the process in the first place of the heart valves, rarely affects the walls of the chambers and baffles defects. Synonymous with this disease is bacterial endocarditis.
The symptoms of infective endocarditis
Symptoms of bacterial endocarditis usually begin to appear after 2 weeks from the moment of introduction of the infectious agent. The clinic can be erased, and can be pronounced.
Fever, usually high up to 38-39 ° C, can be worn wavy or permanent. It is important that from the outset it is accompanied by chills or chilling and sweating.
In some patients during the day can be normal or moderately elevated temperature, and only at a certain time and characteristic rises. It is therefore suspected infective endocarditis must be repeated, every 3 hours the temperature measurement.
The early clinical manifestations include impaired consciousness, decreased blood pressure, vomiting, diarrhea.
As a rule, patients concerned about chronic intoxication symptoms: weakness, headaches; patients reported muscle and joint pain, loss of appetite, weight loss.
Petechial hemorrhages in about half of patients are determined on the skin.
With the development of the pathological process of joining of heart failure symptoms that occur as a result of dysfunction of the affected valves. It mainly shortness of breath, the position of the patient sitting, swelling in the legs, swelling of the neck veins, heaviness in the right upper quadrant and others.
If the pathological process has gone so far that there thromboembolic complications (as a result of the separation of the bacterial growths on the valves), it appears appropriate additional symptoms characteristic of stroke, pulmonary embolism and other authorities.
The most severe disease development for this is septic shock. it significantly complicates the course of the disease and is associated with high mortality.
Diagnostics
First suspected diagnosis doctor may in the analysis of the patient's complaints. After thorough discussions with the patient goes to the doctor necessarily examination. When listening to the heart doctor can detect noises that may indicate structural heart damage. as a result all the collected data are appointed laboratory and instrumental methods of examination.
Changes in the overall analysis of unspecific blood: leukocytosis, anemia, elevated erythrocyte sedimentation rate.
Most of the diagnostic value with endocarditis has multiple research blood culture to a sterile environment. The probability of seeding the pathogen increased by drawing blood at the height of the fever.
Biochemical parameters of blood can also be changed within wide limits depending on the defeat of certain internal organs. It can be increased C-reactive protein, rheumatoid factor. Should pay attention to changes in the protein spectrum of blood with an early increase in alpha-1 and alpha-2 globulins and later increase of gamma globulins.
Of great importance is determination of the immune status, especially the increase in the CEC level reaction and leukocyte blast transformation with bacterial antigens, increased IgM; reduction in total hemolytic complement activity; protivotkanevyh level increase antibodies. Certain diagnostic importance is the preservation of normal credits and antigialuronidazy antistreptolisin-O (At nestreptokokkovoy nature IE).
The most valuable tool of research is ultrasound of the heart. Direct indication infective endocarditis - detection vegetations (bacterial growths) of the heart valves.
Treatment of infective endocarditis
In the complex therapeutic measures in infective endocarditis, of course, is adequate antimicrobial therapy in the first place.
Given that the most common pathogens are gram-positive, treatment can begin with penicillin at a dose of 12-30 IU / day. The course is an average of 4 weeks. Good effect, especially in infectious endocarditis caused by viridans streptococcus has penicillin combination with an aminoglycoside, in particular gentamycin at a dose of 1 mg / kg of patient weight every 8 hours. Other antibiotics used semisynthetic penicillins, vancomycin 30 mg / day. in 2 divided doses intravenously; ceftriaxone at a dose of 2 g / day.
When enterococcal endocarditis, develops, usually after surgery on the gastrointestinal tract and urogenital tract, due to the inefficiency of cephalosporins increasingly using ampicillin (12 g / d.), or in combination with vancomycin aminoglycosides.
Great difficulties are associated with the treatment of patients with infective endocarditis, which is a Gram-negative pathogens, flora, E. coli, Proteus, Pseudomonas aeruginosa, and others. In such cases administered cephalosporins second and third generation (cefotaxime, ceftriaxone), ampicillin (8.12 g / d.), Carbenicillin (30 g / d.), In combination with aminoglycosides. Use large dosages for long term (4-6 weeks) intravenous or intramuscular administration.
In the treatment using other means with antibacterial properties, for example 60-100 ml dioxidine intravenously. Introduced by indications antistaphylococcal plasma, globulin, etc. antistaphylococcal.
Should be aware of the possibility and the need for surgical treatment of infective endocarditis. Indications for surgical treatment:
increasing heart failure valve defects at coarse, resistant to drug therapy;
progressive heart failure with prolonged infection is not controlled (typically at Gram flora and fungi);
recurrent thromboembolic syndrome;
large and very mobile vegetation on the valves (on the conclusion ultrasound of the heart);
abscesses infarction and the valve ring;
repeated early recurrence of infective endocarditis.
As a rule, carried out excision of lesions with simultaneous prosthetic valves destroyed.
prevention
Any foci of infection requires a thorough and complete cure. This applies especially to patients with prosthetic heart valves, acquired and congenital heart disease; patients who have had previous infective endocarditis.
It recommended holding cardiac ultrasound (echocardiography) at 3, 6, 12 months after surgery.
Forecast
The prognosis of infective endocarditis depends on many factors (the previous valve lesions, timely and appropriate therapy initiated, etc.).
Yet, with the active antibiotic cure (usually with the formation of defects) observed in more than half of the patients. In 10-15% of patients have a transition into a chronic disease with recurrent exacerbations.
Death at an early stage in progressive infection or complications occur in about 20% of patients.
sources:
- Infective endocarditis. Klichineskie recommendations. - Association of Cardiovascular Surgeons of Russia; The American Association of Thoracic Surgeons; European Society of Cardiology 2016.
