Endocarditis.Diagnosis.and.Management-184628452X.pdf

Endocarditis

Kwan-Leung Chan and John M. Embil (Eds)

Endocarditis

Diagnosis and Management

With 62 Figures

including 43 Color Plates

Kwan-Leung Chan, BSc, MSc, MD, FRCPC, FACC

University of Ottawa Heart Institute

Ottawa

Ontario

Canada

John M. Embil, BSc (Hon), MD, FRCPC, FACP

University of Manitoba

Winnipeg

Manitoba

Canada

British Library Cataloguing in Publication Data

Endocarditis : diagnosis and management

1. Endocarditis

I. Chan, Kwan-Leung II.Embil, John M.

616.1′1

Library of Congress Control Number: 2006924374

ISBN-10: 1-84628-452-X

e-ISBN 1-84628-453-8

Printed on acid-free paper

ISBN-13: 978-1-84628-452-6

Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the

Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by

any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance

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that such names are exempt from the relevant laws and regulations and therefore free for general use.

Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained

in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical

literature.

987654321

Springer Science+Business Media

springer.com

Foreword

Infection remains the number one killer worldwide. Nevertheless, it is the expectation that bacter-

ial infections can be eliminated with antibiotics. Unfortunately, there remain infections due to bac-

teria that are difficult to detect and difficult to reach, because of minimal blood supply, with even

the most potent of antibiotics. One of the diseases in this category is infections that initiate on the

inner lining of a vital organ, the heart. These infections are referred to as endocarditis since they

involve the endocardium, the inner lining of the heart and valves. The initial site of infection is gen-

erally in areas exposed to mechanical trauma or prosthetic device. Unfortunately the damage to the

heart if not treated can be fatal and often survival requires surgical replacement of one of the valves.

Despite the tremendous array of antibiotics and the marked increase in potency of these drugs to

eradicate bacterial infection, the efficacy of treating the relatively avascular lining of the heart or its

valvular apparatus often eludes the desired effect. This is further complicated by the changing sub-

strate for bacterial endocarditis, namely, artificial valves and devices and the increasing number of

individuals who are imuno-suppressed because of drug use, human immuno deficiency virus infec-

tions or other debilitating conditions. Endocarditis due to bacteria and other agents remains a

continuing threat as well as a challenge in terms of diagnosis, management and treatment.

Drs Chan and Embil have brought together the expertise of pathologists, infectious disease

experts, cardiologists, pharmacologists and surgeons to provide a comprehensive approach to the

problem of endocarditis. The book is organized to include a chapter on the pertinent pathology fol-

lowed by population studies. The diagnostic section is extensive, comprehensive and very clearly

written so that both medical and paramedical personnel can appreciate the armamentarium and its

application. The management section is broad based to include treatment of the acute and chronic

forms as well as potential sequelae that may occur. Echocardiography has become a major tool in

the management of endocarditis and transesophageal echocardiography is now essential in the

diagnosis and management of suspected prosthetic valve endocarditis. The role of echocardiogra-

phy is critically assessed in several chapters dealing with specific clinical situations. The chapters

reflect the authors’ first-hand experience in dealing with endocarditis. The book in essence brings

together the most current and evidence-based approaches as practiced by a group of experts who

are intimately involved in the management of this disease.

In a world in which longevity is sought by all and lifespan has doubled just in the past century, it

is expected that bacterial infections will not rob us of this expanding lifespan. The fact that they can

and do in today’s world of modern technology and ever revolving therapies remains a sobering

thought. This book is an example of the thoughtful analysis that is required if we are to prevail in

our long battle with serious infections such as endocarditis. It is a gem for the student, the teacher

and the practitioner.

Robert Roberts MD, FRCPC, FACC

President

Chief Executive Officer and Chief Scientific Officer

University of Ottawa Heart Institute

Ottawa, Ontario, Canada

Preface

Despite advances in medical and surgical treatments, infective endocarditis continues to be an

important clinical problem. It has an in-hospital mortality of 10–20%, and many patients will

require valve surgery during long-term follow-up. The diagnosis is difficult since it is based on a

constellation of findings and none of the clinical findings alone is pathognomonic. Unequivocal

diagnosis is often made only at surgery or autopsy.

Our aim is to provide an up-to-date approach to the diagnosis and management of endocarditis

based on a critical analysis of recent studies. The book is structured in a format that is easy to fol-

low, clinically relevant, and evidence-based. Key points are listed at the end of each chapter for

quick review. It is divided into three sections. The first section provides a comprehensive review of

the basic principles underlying the management of endocarditis. In addition to chapters on etiologic

agents and pathologic findings, the changing epidemiology and the vexing issue of antibiotic pro-

phylaxis are discussed. The second section presents the clinical principles underlying the diagnosis

and treatment approaches, both medical and surgical. The role of transthoracic and transesophageal

echocardiography is discussed in detail, particularly in relation to false-positive and false-negative

test results. The third section focuses on difficult clinical scenarios frequently encountered in

patients with this disease, including culture-negative endocarditis, prosthetic valve endocarditis,

natural history and management of perivalvular abscess, systemic embolism, and etiologies and

treatments of neurologic events. The practical clinical approach of this section is underscored by the

inclusion of an illustrative case in each of the clinical chapters in the book.

We sincerely hope that this book will serve as an important source of clinical information on

diagnosis and management of endocarditis that is useful to all practitioners involved in the care of

these critically ill patients.

We would like to thank all the authors for their thoughtful and erudite contributions covering

the protean facets of this challenging disease. We are indebted to our colleagues, past and pres-

ent, for their support and inspiration. Finally, we would like to express our sincere appreciation

to our families for their understanding, patience and encouragement without which this text

would not have become a reality.

Kwan-Leung Chan

John M. Embil

vii

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