Infective endocarditis staphylococcal

Severe staphylococcal Infections - Severe staphylococcal infections (including methicillin-resistant staphylococci) in patients who cannot receive or who have failed to respond to penicillins and cephalosporins, or who have infections with resistant staphylococci. Infections may include endocarditis, bone infections, lower respiratory tract infections, septicemia, and skin and skin structure infections. 

Streptococcal infections Pharyngitis, rheumatic fever, otitis media and even for subacute bacterial endocarditis. Staphylococcal infections Penicillinase resistant penicillin can be used. Meningococcal infections Meningitis other infections caused by meningococci. 

Staphylococcal septicaemia may be suspected where there is an abscess, e.g. of bone or lung, or with acute infective endocarditis or infection of intravenous catheters high dose flucloxacillin is indicated (vancomycin). 

Used in combination with other antibiotics to treat staphylococcal infections, endocarditis, tuberculosis, pelvic inflammatory disease... 

Duration - Duration of therapy varies with the type and severity of infection as well as the overall condition of the patient therefore, determine duration by the clinical and bacteriological response of the patient. In severe staphylococcal infections, continue nafcillin therapy for at least 14 days. Continue therapy for at least 48 hours after the patient has become afebrile and asymptomatic and cultures are negative. The treatment of endocarditis and osteomyelitis may require a longer duration of therapy. 

The minimally required duration of treatment is only known for a limited number of infections. Clinical trials have shown the effectiveness of a single dose in the treatment of gonorrhoea or uncomplicated urinary tract infection in women and in surgical prophylaxis. The more precise duration of treatment has been studied for endocarditis, meningitis and staphylococcal bacteraemia. More often, guidelines for duration of treatment have been based on clinical experience with similar infections and on the parameters of response mentioned above. Failure of treatment should be recognised early. It can be due to a variety of reasons (Table 2). 

For parenteral therapy, nafciUin and oxacillin offer comparable efficacy and antimicrobial spectra of activity. Although both drugs undergo hepatic metabolism, only nafcillin requires dose adjustment in patients with combined hepatic and renal insufficiency. Other pharmacokinetic data for nafcillin and oxacillin appear in Table 45.1. Indications for nafcillin or oxacillin include severe staphylococcal infections like cellulitis, empyema, endocarditis, osteomyelitis, pneumonia, septic arthritis, and toxic shock syndrome. 

Teicoplanin, although not available in the United States, has been used to treat a wide range of gram-positive infections, including endocarditis and peritonitis. It is not as effective as the (3-lactams, but its actions are similar to those of vancomycin against staphylococcal infections. 

Rifampin is a first-line antitubercular drug used in the treatment of all forms of pulmonary and extrapul-monary tuberculosis. Rifampin is an alternative to isoniazid in the treatment of latent tuberculosis infection. Rifampin also may be combined with an antileprosy agent for the treatment of leprosy and to protect those in close contact with patients having H. influenza type b and N. meningitidis infection rifampin is also used in methicillin-resistant staphylococcal infections, such as osteomyelitis and prosthetic valve endocarditis. 

Rifampin combined with a second agent is used to eradicate staphylococcal carriage. Rifampin combination therapy is also indicated for treatment of serious staphylococcal infections such as osteomyelitis and prosthetic valve endocarditis. 

Rifampin is used in a variety of other clinical situations. An oral dosage of 600 mg twice daily for 2 days can eliminate meningococcal carriage. Rifampin, 20 mg/kg/d for 4 days, is used as prophylaxis in contacts of children with Haemophilus influenzae type b disease. Rifampin combined with a second agent is used to eradicate staphylococcal carriage. Rifampin combination therapy is also indicated for treatment of serious staphylococcal infections such as osteomyelitis and prosthetic valve endocarditis. Rifampin has been recommended also for use in combination with ceftriaxone or vancomycin in treatment of meningitis caused by highly penicillin-resistant strains of pneumococci. 

Bacterial endocarditis. An aminoglycoside, usually gentamicin, should comprise part of the antimicrobial combination for enterococcal, streptococcal or staphylococcal infection of the heart valves, and for the therapy of clinical endocarditis which fails to yield a positive blood culture. 

Staphylococcal endocarditis is not a homogeneous disease appropriate management requires consideration of several questions, such as. Is the organism methicillin resistant Should combination therapy be used Is the infection on a native or prosthetic valve Does the patient have a history of IVDA Is the infection on the left or right side of the heart Another consideration in staphylococcal endocarditis is that some organisms may exhibit tolerance to antibiotics. However, similar to streptococci, the concern for tolerance among staphylococci should not affect antibiotic selection. ... 

Any patient who develops staphylococcal bacteremia is at risk for endocarditis. Many investigators have attempted to develop criteria that identify the bacteremic patient likely to have IE. In hospitalized patients with S. aureus bacteremia and an identified focus of infection, such as a vascular catheter, the risk of concomitant IE is low, and treatment of the bacteremia can be reduced to 2 weeks. This approach applies only if the patient does not have a prosthetic valve or additional clinical evidence for endocarditis. On the other hand, the following parameters predict higher risk of IE in patients with S. aureus bacteremia (1) the absence of a primary site of infection, (2) community acquisition of infection, (3) metastatic signs of infection, and (4) valvular vegetations detected by echocardiography. ... 

Dodek P, Phillip P. Questionable history of immediate-type hypersensitivity to penicillin in staphylococcal endocarditis Treatment based on skin test results versus empirical alternative treatment—A decision analysis. Clin Infect Dis 1999 29 1251-1256. 

Vancomycin (500 mg IV q. 6 hours) is indicated for the treatment of severe staphylococcal infections, when other antibiotics are ineffective or contraindicated. Vancomycin (125 to 500 mg p.o. q. 6 hours for 7 to 10 days) is indicated for the treatment of antibiotic-associated pseudomembranous and staphylococcal enterocolitis and vancomycin (1 g IV given slowly over 1 hour, starting 1 hour before a procedure) is indicated for endocarditis prophylaxis for dental, Gl, biliary, and genitourinary instrumentation procedures and... 

The recommended dose is 10,000 to 20,000 units given intramuscularly every 6 hours and accompanied by careful studies of the renal function i " . In this way bacitracin is absorbed readily from the site of injection although pain and some injury may be observed there. It has been used in the treatment of staphylococcal bacteremias, osteomyelitis, bacterial endocarditis, and in the control of urinary tract infections either alone or in combination with other drugs . Local injection into circumscribed areas, such as furuncles and abscesses, has also been successful. Orally, bacitracin has been used either alone or in combination with other antibiotics as an intestinal antiseptic i, for example in the pre-operative sterilization of the bowel. Because of the poor absorption from the gastro-intestinal tract, no special precautions are necessary. 

An important characteristic of microbial biofilms is their innate resistance to immune system and antibiotic killing (89, 90). This has made microbial biofilms a common and difficult-to-treat cause of medical infections (87,91,92). It has recently been estimated that over 60% of the bacterial infections currently treated in hospitals are caused by bacterial biofilms (91). Several ehronic infections (e.g. respiratory infections caused by Pseudomonas aeruginosa in the cystic fibrosis lung. Staphylococcal lesions in endocarditis, and bacterial prostatitis, primarily caused by Escherichia coli) have been shown to be mediated by biofilms (93). More notably, biofilms (particularly of Staphylococcus aureus, P. aeruginosa, and E. coli) are also a major cause of infections associated with medical implants (94, 95). The number of implant-associated infections approaches 1 million per year in the United States alone, and their direct medical costs exceed 3 billion annually (96). Thus, there is an urgent need to find novel approaches to eradicate biofilms. 

Staphylococcus aureus causes a number of community- and hospital derived infections ranging from uncomplicated wound infections to severe diseases as septicemia or endocarditis. S. aureus expresses a large number of proteins that specifically impair the effectiveness of the innate immune system. " These include factors that modulate antimicrobial peptides and plu ocytic cells but also complement modulators (Table 1). The first anti-opsonic molecule identified in S. aureus was Staphylococcal protein A (SpA) (42 kDa), a surface protein that can also be released in the extracellular milieu. By binding the Fc part of G molecules, SpA covers the bacterial surface with G molecules in a manner that prevents recognition by Fc-receptors on phi ocytes. This way, SpA blocks Fc-receptor mediated ph ocytosis. Furthermore, since SpA interferes with C Iq binding it prevents classical pathway complement fixation as welL ... 

Sulfonamides - The synergistic combination of sulfamethoxazole with trimethoprim has emerged as a first choice drug in the treatment of sal-monenosis , chronic pyelonephritis , non-specific and chronic urinary tract infections , and upper respiratory tract infections, especially chronic bronchitis . Favorable results were also achieved in the treatment of purulent angina, bacterial skin infections , staphylococcal osteomyelitis , and endocarditis due to E. coli as well as a variety... 

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