Endocarditis

Endocarditis is a disease of the internal connective tissue membrane of the heart, known since antiquity, caused by an infectious or autoimmune agent. To date, endocarditis is poorly cured and grows into serious complications. Even after using the newest methods of treatment, the frequency of recurrence of endocarditis is close to 10%.Often, complications bring more trouble than the disease itself. Heart defects, which are formed later, are incurable and constantly make themselves felt, thus depriving them of the opportunity to work and lower their standard of living. The localization of the endocardial lesion is different: the valve apparatus and the parietal membrane suffer. The cunning of endocarditis is the absence of subjective manifestations, and in case of untimely diagnosis, the disease passes into a complicated form.

Endocarditis causes

The occurrence of endocarditis is provoked by infectious and non-infectious agents, which determines the type of the disease.

Infective endocarditis can be bacterial, viral, fungal. The vast majority of endocarditis is bacterial in nature. Bacteria enter the blood from pustular eruptions, tonsils, carious teeth, respiratory, urinary and reproductive systems, as well as with valve replacement.

Noninfectious endocarditis develops most often when exposed to antibodies to its own tissues. Autoimmune antibodies formed in the body as a result of rheumatic attacks, as well as in autoimmune diseases, cause in the overwhelming majority of cases the formation of aseptic endocarditis and subsequently valvular heart disease. Sometimes trauma of the heart provokes the appearance of endocarditis.

Rheumatism is a disease of the connective tissue of an allergic nature that occurs after a sore throat caused by a green streptococcus, and can cause inflammation of the endocardium. Angina in 0.3-3% of cases result in a rheumatic attack. Streptococcus produces M-protein, which causes an autoimmune reaction of the body to the connective tissue. Direct involvement of streptococcus in inflammation does not take, the symptoms of the disease develop after the treatment of angina.

Endocarditis in children deserves special attention. He is congenital and acquired. Congenital endocarditis is caused due to infections that during pregnancy the mother was ill. The causes of acquired endocarditis in children correspond to those of adults.

Endocarditis symptoms

Non-specific signs of endocarditis include fever, chills, fatigue, fever over 38 ° C, joint pain, weight loss. Sometimes these symptoms can be worn out and not manifest in the elderly. Characteristic signs can be - a warm dry skin, an increase in the spleen.

Specific symptoms of infective endocarditis include heart sounds and heart failure, as well as signs of embolism. The nature of the noise depends on the affected valve. The presence of neurologic symptoms speaks of cerebral embolism. Ischemia of limbs and abdominal organs may occur. Hemorrhages in the skin give a hemorrhagic rash in the form of a petechia, hemopoiesis hemorrhages, Osler's knots( knots on the palmar side of the fingers), Janevei's sores( painful sores on the palms and soles).

As a result of infective endocarditis heart defects are formed. Aortic stenosis can occur with the growth of vegetation in the valve area. It appears in the late stages of endocarditis, since the left ventricle compensates well for the inadequacy of its function. The patient complains of shortness of breath and intolerance to physical exertion, on contracting pain behind the sternum. Sometimes, during exercise, there is a loss of consciousness. The skin of this patient is pale, the pulse is slow, blood pressure is reduced.

Aortic insufficiency is more often associated with infective endocarditis. The patient complains of the heartbeat, especially in the prone position on the left side, rapid fatigue, dyspnea. Later, edema on the legs begins to appear, the liver is enlarged, which indicates the formation of heart failure. The pulse is fast. The diastolic pressure is sharply reduced, sometimes even to zero.

Mitral stenosis with infective endocarditis is not formed. Mitral insufficiency manifests itself by dyspnoea at a load and at rest, hoarseness of a voice as a result of compression of a nerve responsible for a voice, a left atrium, a cough, hemoptysis, edema, cyanotic lips.

The defeat of the tricuspid valve is typical for drug addicts with an injectable method of drug injection. Insufficiency is manifested by shortness of breath, fatigue, a feeling of pulsation of the neck vessels, a feeling of heaviness in the liver, jaundice of the skin and mucous membranes, cyanosis( cyanosis) of the extremities. Stenosis is characterized by arrhythmia, cyanosis of the extremities, and jaundice of the skin. The liver is enlarged, the cervical veins swell.

The pathology of the pulmonary artery valve manifests itself as a relative deficiency and often remains asymptomatic.

Rheumatic endocarditis is preceded by streptococcal angina. Systemic manifestations of rheumatism may accompany rheumatic carditis, and may be absent. At the same time, heart murmurs, cardiac enlargement, arrhythmias, congestive heart failure are noted.

Rheumatic heart diseases are formed in the following sequence: mitral valve insufficiency, mitral stenosis, aortic insufficiency, aortic stenosis. The tricuspid valve suffers extremely seldom. Throughout life, there is a progression of valvular defects, regardless of exacerbation or remission. Heart failure develops and progresses, which can be manifested by attacks of suffocation and hemoptysis.

Deposits on damaged valves eventually break away and lead to embolic complications. As a result, ischemia and myocardial infarction of the spleen, lower extremities, and intestines are formed, which leads to an emergency surgical intervention.

Symptoms of pediatric endocarditis: marked general intoxication in the form of chills, night sweats, fevers, aches in the body, joint pain. A rapid transition to a generalized process is characteristic. Otherwise, the symptomatology is similar to the adult.

Infectious endocarditis

Infective endocarditis is an inflammatory disease of the endocardium of an infectious nature, in which the valvular heart apparatus is affected, less often - the parietal endocardium and prosthetic valves.

Infective endocarditis is diagnosed in every thousand hospitalized patients. The "modern" infectious endocarditis has a number of peculiarities: more often this disease affects people over 50 and injecting drug users. In view of the frequent use of catheters for large vessels, the infectious agent belongs to the group of nosocomial infections. The incidence of complications remains high even with adequate treatment;Less infectious endocarditis occurs on rheumatically changed valves.

The old classification divided infectious endocarditis into acute and subacute. According to this classification, acute endocarditis accompanies the septic process and proceeds rapidly, more often affects intact valves. Subacute endocarditis has a more protracted character as a result of a prolonged infectious process and weakening of the immune system.

The current classification includes the following criteria:

1) Active / healed;

2) recurrence: recurrent( repeated within a year after treatment) / persistent;

3) the reliability of the diagnosis: specific / suspect / possible;

4) Exciter;

5) area of ​​involvement: aortic, mitral valve, etc.;

6) special circumstances: endocarditis of the prosthesis, pacemaker.

The onset of infective endocarditis begins with damage to the valvular or parietal endocardium. Attached to the damaged area are blood components, which create a substrate for the propagation of bacteria that circulate in the blood. After that, they multiply and form the so-called vegetation. Vegetations are an education consisting of platelets, fibrin, bacteria, leukocytes and scraps of endocardium tissue. Their size can vary. Naturally, such formation interferes with the blood flow or prevents the complete closing of the valve. Thus, vice is formed. Infectious agent in addition to vegetation, can directly damage the endocardium, forming ulcers and abscesses.

A large risk of infectious endocarditis is caused by valve replacement, pacemaker installation and cardiac catheterization. In the field of seams and contact of the endocardium with a foreign body, suitable conditions for the formation of vegetation are created.

A serious complication is the detachment of vegetation and its entry into the bloodstream. This will lead to embolism of vessels, the caliber of which depends on the size of the vegetation. Thus, a large number of bacteria or fungi enter other organs and form chronic sites of inflammation there.

Infectious endocarditis is caused by bacteria, protozoa( eg, rickettsia), viruses, fungi.

Special criteria are used for the diagnosis. Diagnosis of infective endocarditis is exposed in the presence of two large, one large and three small, or five small signs. Great signs: detection of the pathogen in the blood, the presence of vegetation in echocardiography, the formation of a defect. Small signs: predisposition, fever 38 ° C, embolic complications, positive seeding, serological signs.

The main method of endocarditis is EchoCG.With it, vegetation, valves, and the direction of the blood flow are visualized. Reverse blood flow, or regurgitation, is observed with a far-in-progress disease.

Separately, it should be noted the characteristics of infectious endocarditis in injecting drug users. Most often observed mixed infectious nature, reduced immunity and frequent infection with HIV.

Bacterial endocarditis

The most common form of infective endocarditis is bacterial. The most common pathogens are streptococci - up to 80% of the crops. Staphylococci accounts for 25%, including 23% of Staphylococcus aureus. Enterococci are detected up to 18% of cases. Gram-negative aerobes are found in crops in less than 5% of cases.

The peculiarities of bacterial endocarditis are the entrance gates, which represent a focus of inflammation. Often the disease accompanies sepsis, especially this is characteristic of an acute course.

Septic endocarditis

The most dangerous and fast-flowing variant of endocarditis is septic. In the old classification, it was called acute endocarditis. Most often, the cause of its occurrence are surgical interventions on the heart, catheterization of the heart chambers, prosthetics.10% of all cardiac operations is complicated by endocarditis. The period of complication occurrence is 14-30 days. In this case, pathogens are nosocomial strains. In the overwhelming majority of cases, staphylococci, Pseudomonas aeruginosa and fungi are found in the crop.

The main concomitant phenomenon of septic endocarditis is the circulation of the pathogen in the blood. It is cyclical, so a negative seeding result does not indicate the absence of bacteremia. It is necessary to take blood for sowing many times, and best before the initiation of therapy with antibiotics and at least five times.

But getting microorganisms into the surgical wound is not enough for the occurrence of endocarditis. An integral factor is the decrease in the reactive properties of the organism.

Local tissue damage is of great importance in the development of endocarditis. Platelet and fibrin are attached to the damaged area, and subsequently microorganisms.

Very severe course in patients with Pseudomonas aeruginosa caused by Pseudomonas aeruginosa. Such patients have a high percentage of mortality. The destruction of the valve apparatus takes place very quickly and is difficult to treat. Endocarditis caused by E. coli, more favorable, is better susceptible to antibiotic therapy.

Fungal sepsis occurs with oppressed reactivity of the body and with prolonged use of antibiotics. Defects of the valvular apparatus with this type of pathology are more coarse. Frequency of occurrence is 2-4% of all cases of endocarditis.

Septic endocarditis may appear on rheumatically changed valves. In this case, endocarditis is preceded by bacteremia. Sepsis and rheumatic heart disease often have similar symptoms.

The peculiarity of clinical manifestations of septic endocarditis is that cardiac murmurs progress against sepsis with pronounced general intoxication. In the general analysis of blood, leukocytosis is observed, the shift of the leukocyte formula to the left, the sedimentation rate of erythrocytes is 20-25 mm per hour. In the urine there are hyaline and granular cylinders, a protein. With ineffective treatment, all organs are involved in the pathological process. Develop kidney, respiratory, heart failure.

Subacute endocarditis has a more flattened symptomatology and a favorable course. Postoperative complications occur gradually. The most common pathogen is streptococcus, which lives in the mouth and throat. Population of the pathogen occurs on the already changed valves as a result of rheumatic carditis, syphilitic damage, congenital malformations.

Symptomatics is wavy in nature and appears 2-3 days after surgery. The temperature is up to 39 ° C, chills, muscle aches, raspryanie behind the breastbone, enlarged spleen, profuse sweating. There is such a variant of the disease without purulent metastases in other tissues.

Depending on the nature of the course of subacute endocarditis, several variants can be distinguished: the first one - with prolonged fever and embolic complications, which will lead to death in a few months, the second - an outpatient type that proceeds without fever. Depending on the leading symptom, anemic, splenomegalic, hepato-splenomegalic, nephritic and other variants are isolated.

Endocarditis treatment

Principles of treatment. The first place in the therapeutic treatment of infective endocarditis is antibiotic. Before appointing an antibiotic, it is necessary to conduct a bacteriological study of blood. But it must be remembered that in 10% of cases the crop comes with a negative result. In this case, antibiotic therapy is prescribed empirically.

Gentamicin is used at a dose of 1 mg / kg IV every 8 hours, while constantly monitoring the concentration of the drug in the blood. Streptomycin 7.5 mg / kg IV every 12 hours. The use of aminoglycosides is associated with a certain risk for the liver and kidneys, therefore, in the presence of hepatic, renal failure, these drugs should be limited.

Vancomycin is a representative of glycopeptides. Its dosage, with normal liver function, is 1 g every 12 hours IV.Be sure to monitor the concentration of the drug in the blood. The level of content should not exceed 20 mg / l.

Teicoplanin is administered at a dose of 10 mg / kg every 12 hours. The concentration of the drug in the blood for the treatment period should be at least 20 mg / l.

Penicillin antibiotics such as Ampicillin and Amoxicillin should be administered iv every 2 hours every 6 hours, since the duration of their action is very short. With a reduced function of the kidneys, you need to adjust the dose.

It should be remembered that at present many people are allergic to the antibiotics of the penicillin line. In such cases, you should appoint Ceftriaxone 2 g / IV p / day.

When endocarditis rapidly progresses and wait for the results of sowing, there is no time, then they resort to empirical antibiotic therapy. If the patient is in serious condition, which is typical for sepsis, Flukloxacillin should be given 8-12 g per day for 6 divided doses and Gentamicin 1 mg / kg per day.

With less severe endocarditis, Penicillin and Gentamicin are recommended. In the presence of a prosthetic valve or pacemaker, Vancomycin is given at a dose of 1 g every 12 hours and Rifampicin is 300-600 mg every 12 hours inside.
The duration of antibiotic therapy should be at least 4 weeks, and with prolonged process - 6 weeks.

Staphylococcal endocarditis is treated after testing for sensitivity to the antibiotic. When detecting miticilin-sensitive strains Flukloxacillin-2g is prescribed every 6 hours IV.The use of Gentamicin in this case is not necessary. Miticillin-resistant strains require the appointment of Vancomycin in a dosage of 1 g every 12 hours and Rifampicin 300-600 mg every 12 hours inside.

If staphylococcal endocarditis develops against the background of a prosthetic valve, the scheme of its treatment is as follows: Flukloxacillin - 2 g every 6 hours IV( or Vancomycin - 1 g every 12 hours) and Rifampicin 300-600 mg every 12 hours. The following scheme is also possible: Gentamicin 1 mg / kg every 8 hours iv, or Sodium fuzidate - 500 mg every 8 hours inside.

Streptococcal endocarditis is often resistant to penicillin, therefore a test for sensitivity to this group of drugs is mandatory. It is best for the treatment of a combination of penicillins and aminoglycosides. Penicillin in a dose of 1.5 g every 6 hours for 4 weeks, combining it with Gentamycin 1 mg / kg every 8 hours for the first 2 weeks.

Pneumococcal endocarditis requires treatment with Vancomycin-1g every 12 hours or with ceftriaxone.

With valvular streptococcal endocarditis, a six-week course of penicillin is given with a two-week course of Gentamicin. In case of an allergic reaction to the penicillin series, a four-week course of Vancomycin with Gentamicin should be given within the first two weeks.

Enterococcal endocarditis with penicillin sensitivity is treated according to the following scheme: Apicillin 2g every 4 hours IV and Streptomycin 7.5 mg / kg every 12 hours IM.In case of an allergic reaction to penicillin, Vancomycin - 1 g every 12 hours IV and Streptomycin - 7.5 mg / kg every 12 hours IM is used. Alternative scheme: Teicoplanin 10 mg / kg every 24 hours IV and Streptomycin 7.5 mg / kg every 12 hours

Endocarditis caused by Gram-negative bacteria should be treated with Ampicilin 2g every 6 hours and Gentamycin -1 mg / kg every 8 hoursThe first two weeks. With resistance to ampicillin, appoint cephalosporins.

Fungal endocarditis is very difficult to treat. Therefore, often resort to surgical intervention. The use of drugs can sometimes be lifelong. Amphotericin B - 1 mg / kg per day and Flucytosine 100 mg / kg per day. Or Fluconazole - 400 g every 12 hours inside. Or Caspofungin - 70 mg as a loading dose, and then 50 mg 1 p.in a day. After treatment with medications, with fungal endocarditis, the operation is applied, since it is necessary to get rid of vegetations that reach large sizes.

Surgical treatment is also very important with endocarditis. About 30% of cases of infective endocarditis require surgical treatment. Prosthetics and restorative treatment prolong life and improve its quality. To this type of treatment there are strict absolute indications: non-medicated heart failure, partial rupture of the framework ring, inefficiency of antibiotic therapy, endocarditis of the prosthetic valve after the full course of treatment, repeated embolism. Relative indications: abscess formation, endocarditis caused by Staphylococcus aureus, recurrence of the disease after a full course of treatment, endocarditis with negative results of crops and a fever lasting more than 10 days, the presence of large vegetation.

An important stage in the treatment of endocarditis is the drainage of existing foci of infection.

Treatment of rheumatic endocarditis is much reduced to symptomatic. With severe heart damage, Prednisolone is administered at a dosage of 1-2 mg / kg per day orally. Treatment should continue until the clinical manifestations or laboratory signs of the activity of the process cease. Antibacterial therapy - Penicillin 250,000 units IM in 5-6 times in the grid for 10 days with the subsequent mandatory transition to a preventive scheme. Antibiotics do not affect the course of the disease, but contribute to the sanation of foci of infection. Aspirin in a dose of 0.6-0.9 g every 4 hours is prescribed for polyarthritis, but also reduces cardiovascular inflammation. Patients with severe endocarditis for a long time take Delagil at 0.25 g per day or Plakvinil at 0.2 g per day.

To treat heart failure, which often accompanies endocarditis, an integrated approach is needed. Moderate physical activity has a beneficial effect on patients. Physical exercises are calculated for each individual, depending on the functional class of the patient. Signal to stop training is a change in health, increased blood pressure, excessive heart rate.

A diet for patients with endocarditis should limit the intake of table salt and liquid in the body. Food should be high in calories, with the obligatory inclusion of proteins and vitamins.

Cardiac failure requires medical treatment. Diuretics are prescribed in order to relieve the heart. Hypothiazide in an initial dose of 25-50 mg per day. In severe stages of the disease Furosemide is used - 20-40 mg initial dose and 400 mg maximum dose. Cardiac glycosides increase the power of the heart. Digoxin in the initial dose of 0.25-0.375 mg / day. For 5-7 days, then maintain a dose of 0.125-0.25 mg per day. Inhibitors of adenosine-converting enzyme are used according to the following scheme: Captopril in the initial dose of 6.25-12.5 mg, then every 3-7 days should double the dose to 150 mg. Beta-blockers: Bisoprolol - 1.25 mg per day initial dose, every 2-4 weeks to double until side effects occur.

Endocarditis prophylaxis

For the prevention of endocarditis requires a thorough sanitation of foci of infection, periodic examinations and treatment at the dentist, taking antibiotics after various surgical interventions, even a small amount. Especially important is antibiotic therapy in patients who underwent heart surgery. Untreated sore throats cause increased alertness and, if detected, require immediate treatment.

Risk groups need constant preventive examination, EchoCG, ECG.The risk group is formed from patients with weakened reactivity of the body, congenital and acquired heart defects, renal insufficiency, autoimmune diseases, HIV patients, injecting drug users.

Before any surgical intervention it is necessary to treat nasal staphylococcus, skin pustular eruptions. When using intravenous catheters, provide them with proper care.

Special attention should be paid to the prevention of rheumatic endocarditis. It is divided into primary and secondary. Primary prophylaxis of rheumatic endocarditis is the early treatment of nasopharyngeal streptococci. The primary prevention regimen includes a single intravenous injection of Bicillin-3 in a dose of 600,000 units for children, and Bicillin-5 at a dose of 1.5 million units for adults. In the course of prophylaxis with Phenoxymethylpenicillin, doses are prescribed as follows: children - 250,000 units 3 r. Per day, adults - 500,000 units 3 times a day for 10 days.
Secondary prophylaxis of rheumatic endocarditis is the use of Bicillin-5 after rheumatic attacks of 1.5 million units 1 p. Every 3 weeks in / m for 5 years. When allergic to beta-lactams, Erythromycin is administered at a dosage of 250 mg 2 r.