Right-sided endocarditis caused by Staphylococcus aureus in drug abusers

Abstract

A prospective, open, and randomized study of right-sided endocarditis caused by Staphylococcus aureus in drug abuse patients is reported. The following parenteral treatments were compared. Group A patients were treated with 2 g of cloxacillin every 4 h and 1.5 mg of gentamicin per kg of body weight every 8 h for 2 weeks. Group B patients were treated with teicoplanin at 10 mg/kg/12 h on the 1st to 3rd days, 6 mg/kg/12 h on the 4th to 7th days, and 7 mg/kg/24 h on the 8th to 28th days. Drug abusers with bacteremia caused by S. aureus and suggestive signs of endocarditis were included. Clinical failures were observed in one patient in group A and in four of six patients in group B. Three patients in group B developed breakthrough bacteremia with teicoplanin-susceptible strains on days ؉6, ؉14, and ؉19. Serum teicoplanin levels and serum bactericidal titers showed a decrease in the 2nd week, when dosages received were 7 mg/kg/day. In conclusion, in treatment of right-sided endocarditis caused by S. aureus in drug abusers with teicoplanin, the use of dosages of 7 mg/kg/day is not recommended even if patients have received dosages of 12 mg/kg/day during the 1st week.Right-sided endocarditis caused by Staphylococcus aureus in parenteral drug abusers is more amenable to a benign treatment than left-sided endocarditis, particularly in the absence of extensive pulmonary embolization (4, 15).Results after 2 weeks of treatment with a combination of isoxazolyl penicillins and aminoglycosides are satisfactory in more than 90% of patients (6).Nonintravenous therapy of right-sided endocarditis in drug abusers will be a help in the management of these patients. Preliminary studies with an oral combination of ciprofloxacin and rifampin are encouraging (9); however, in vitro studies have found that this combination can be antagonistic (23).The more usual alternative is the use of glycopeptides: vancomycin and teicoplanin. Experience with vancomycin in endocarditis caused by S. aureus is unfavorable (22). On the other hand, two characteristics of teicoplanin are relevant in these patients: its special pharmacokinetics and its proven efficiency in endocarditis caused by gram-positive organisms (8,11,17,18,20).To evaluate the efficiency of teicoplanin in right-sided endocarditis caused by S. aureus in parenteral drug abusers, a comparative study was conducted with the following two parenteral treatments: cloxacillin-gentamicin for 2 weeks (group A) and teicoplanin for 4 weeks (group B). MATERIALS AND METHODSThis was a prospective, open, randomized (1 of group A:1 of group B), and parallel study.Parenteral drug abusers with the following findings were included: (i) two or more blood cultures with isolation of methicillin-susceptible S. aureus, (ii) community-acquired infection, (iii) tricuspid regurgitation murmur, and (iv) clinical or radiological findings of septic pulmonary embolization or evidence of rightsided vegetations in transthoracic ecocardiography.Patients were excluded from enrollment if any of the following criteria was...

2015 ESC Guidelines for the management of infective endocarditis

“…Standardowy 4-6-tygodniowy schemat terapii należy wdrożyć w następujących sytuacjach: -powolna odpowiedź kliniczna lub mikrobiologiczna (> 96 h) na leczenie antybiotykami [426]; -IZW prawej części serca powikłane niewydolnością prawej komory, wegetacjami > 20 mm, ostrą niewydolnością oddechową, przerzutowymi ogniskami septycznymi poza płucami (w tym ropniakiem opłucnej) lub powikłaniami pozasercowymi, np. ostrą niewydolnością nerek [426]; -leczenie antybiotykami innymi niż benzylopenicyliny odporne na penicylinazy [437]; -IVDA z ciężką immunosupresją (liczba limfocytów CD4 < 200 komórek/μl) z objawami lub bez objawów AIDS [438]; -obecność dodatkowo IZW lewej części serca.…”

Infective endocarditis in intravenous drug abusers

“…Ninety-four percent of the 50 patients treated were cured with this regimen. Table 3 summarizes the studies published between 1988 and 2001 [26,[34][35][36][37]38••] with a 2-week course of nafcillin or cloxacillin plus an aminoglycoside (usually gentamicin) for the therapy of noncomplicated right-sided MSSA endocarditis in IVDAs. Overall, 209 patients have been treated, with an overall cure rate of greater than 90%.…”

“…The standard 4-week regimen must be used in the following situations: 1) slow clinical or microbiologic response (> 96 hours) to the initial antibiotic therapy [28•,44]; [34] Clo + Gen 12 12 0/0 0 Torres-Tortosa et al [35] Clo + Amk 72 67 4/0 1 Miró [26] Clo + Gen 20 19 0/1 0 Fortún et al [36] Clo + Gen 8 7 1/0 0 Ribera et al [37] Clo + Gen 36 31 [46] demonstrated that oral antibiotic treatment with ciprofloxacin plus rifampin during 4 weeks was as effective as the recommended 4-week regimen with oxacillin plus gentamicin. This oral regimen may be a reasonable alternative to parenteral therapy in some patients.…”

Staphylococcus aureus Infections: Epidemiology, Pathophysiology, Clinical Manifestations, and Management

“…There is evidence that ␤-lactam therapy is better than glycopeptides for MSSA bacteremia from both randomized controlled trials (RCTs) (104,105,107) and observational studies (108)(109)(110)(111)(112)(113)(114)(115)(116)(117)(118). Vancomycin and daptomycin are currently the only antibiotics that are approved by the U.S. Food and Drug Administration (FDA) for MRSA bacteremia and right-sided IE.…”