Ambulatory treatment of streptococcal bacterial endocarditis

Abstracts

A endocardite bacteriana é uma grave doença infecciosa cujo tratamento é tradicionalmente feito com o paciente internado. recebendo medicação intravenosa. A possibilidade de tratamento domiciliar ou ambulatorial. em casos estritamente selecionados. é atraente tanto do ponto de vista social quanto do econômico. Apresentamos o relato de 6 pacientes com diagnóstico de endocardite bacteriana por Streptococcus. tratados parcial ou integralmente em regime ambulatorial. Todos evoluíram sem complicações e com resolução completa do quadro infeccioso.

Endocardite bacteriana; Streptococcus; pacientes ambulatoriais

La endocarditis bacteriana es una severa enfermedad infecciosa cuyo tratamiento se hace tradicionalmente con el paciente internado, recibiendo medicación intravenosa. La posibilidad de tratamiento domiciliar o clínico, en casos estrictamente seleccionados, es atractivo desde el punto de vista social como del económico. Presentamos el caso clínico de 6 pacientes con diagnóstico de endocarditis bacteriana por streptococcus, tratados parcial o integralmente en régimen ambulatorio. Todos evolucionaron sin complicaciones y con resolución completa del cuadro infeccioso.

Endocarditis bacteriana; Streptococcus; pacientes ambulatorios

CASE REPORT

Ambulatory treatment of streptococcal bacterial endocarditis

Sirio Hassem Sobrinho; Carlos Henrique de Marchi; Ulisses Alexandre Croti; Cristiane Girotto de Souza; Érico Vinícius Campos Moreira da Silva; Moacir Fernandes de Godoy

Faculdade de Medicina de São José do Rio Preto - Famerp - São José do Rio Preto, SP - Brazil

Mailing address

ABSTRACT

Bacterial endocarditis is a severe infectious disease, of which treatment is traditionally carried out in hospitalized patients through intravenous medication. The possibility of at-home or ambulatory treatment, for stringently selected cases, is attractive from the social as well as from the economic point of view. We report 6 patients with a diagnosis of bacterial endocarditis caused by Streptococcus, treated partially or completely on an outpatient basis. All of them evolved without complications and presented complete resolution of the infection.

Key words: Endocarditis, bacterial/therapy; Streptococcus; outpatients.

Introduction

Endocarditis is a severe bacterial disease that involves the mural endocardium and one or more cardiac valves or septal defects and can course with important cardiac and systemic complications during the treatment¹.

Traditionally, the treatment is carried out for a long period in hospitalized patients. Several studies, however, have demonstrated the possibility of conducting part of the treatment on an outpatient basis, resulting in the decrease of hospital costs and a higher degree of comfort for patients^2-3.

The aim of the present study was to show that the ambulatory treatment of streptococcal bacterial endocarditis, in well-selected patients, is safe and effective.

Patients

Six patients with streptococcal bacterial endocarditis, diagnosed through the Modified Duke Infective Endocarditis Criteria⁴, were included in the study from January 2006 to November 2008. The patients were required to present a hemodynamically stable condition, without the need for drugs. The study was approved by the Ethics Committee for Research with Human Subjects and the Free and Informed Consent Form was signed by all patients.

The demographic data of all six patients and illustrative aspects of two cases are shown in Chart 1 and Figure 1, respectively.

All of them presented fever and heart murmur before the drug therapy. The blood culture was carried out only before the patient´s inclusion. Four patients presented increased CRP levels, which normalized at the end of the treatment. Regarding the complete blood count, 3 patients presented leukocytosis and anemia at the start of the treatment and one of them still presented a slight anemia at the end of the treatment. Creatinine levels were within normal range in all patients, both pre and post-treatment. The electrocardiogram showed average frequency atrial fibrillation rhythm, intercalated with pacemaker rhythm in one patient and first-degree atrioventricular block in another patient. Such alterations did not suffer any changes during treatment.

The echocardiogram was carried out at the start and at the end of the treatment in all patients. It was necessary to perform a transesophageal echocardiogram in three of them, to adequately assess the intracardiac structures. Four patients presented typical vegetation images. In one patient, the vegetation image disappeared at the end of the treatment.

As for the drug treatment, four patients received 2.0 mg of Ceftriaxone, once a day. One patient received 1.0 mg Vancomycin every 12 hours and the other received 500 mg of Levofloxacin once a day. The standardized treatment duration was 4 weeks, due to the low pathogenicity of the infectious agent. The antibiotics were administered by intravenous route in all patients, using a salinized abbocath as the venous access. Three patients received the medication at the outpatient clinic of the health insurance facility, one received the medication at home, one received it at the public basic unit health and another received it in a private clinic.

The patients were examined by a physician once a week and were interviewed daily by the nurses in charge of the antibiotic infusion. No seriated blood cultures were carried out due to the good clinical evolution presented by all patients. There were no clinical complications throughout the outpatient treatment.

Discussion

Historically, patients with bacterial endocarditis remain hospitalized throughout their treatment, receiving antibiotics by parenteral route and undergoing daily medical evaluation.

Recently, the possibility of treating endocarditis with a shorter-duration treatment, the capacity to administrate parenteral drugs at home and economic pressures have made the ambulatory treatment more frequent, even though the outcomes are still limited due to the lack of large cohort studies using this type of approach^5,6.

This study reports 6 patients with streptococcal bacterial endocarditis that were treated on an outpatient basis and presented excellent evolution.

Four patients were treated with Ceftriaxone; one was treated with Levofloxacin due to the fact that he was allergic to Ceftriaxone and another patient was treated with Vancomycin, as he still presented fever 72 hours after the introduction of Ceftriaxone.

When the Streptococcus was sensitive to Ceftriaxone, the latter was the antibiotic of choice, due to its simple posological scheme and low rate of complications. The complete treatment plan lasted four weeks.

Two patients were treated entirely on an outpatient basis; two remained for three weeks on an outpatient basis and two were treated for two weeks on an outpatient basis. The latter two cases were treated longer on a hospital basis due to purely administrative issues, rather than infection-related problems.

The incidence of bacterial endocarditis is 1.7 to 6.2 cases per 100,000 patients-year⁷, which would represent an expected number of 7 to 24 cases per year in our city, which has approximately 400,000 inhabitants. As six patients were treated throughout a period of two years (one case every 5.5 months), that is equivalent to 12.5% and 42.8% of the incident cases, which does not seem negligible, considering the disease severity profile.

The patient that presented endocarditis at the endocardial pacemaker electrode was treated on an outpatient basis, as the good evolution of endocarditis when it affects the right side of heart is well known, even when the etiological agent is Staphylococcus aureus. The pacemaker electrode was removed 28 days after the antibiotic administration.

The patient with the biological aortic-valve prosthesis was included in the study, as the drug treatment started 5 days after the fever onset and the patient presented excellent general status.

Patients with uncomplicated endocarditis, of which etiology is due to Streptococcus viridans, have been considered candidates to home-based treatment⁸. We agree with the literature when it states that the endocarditis caused by Streptococcus is the most adequate one for ambulatory treatment, due to its lower aggressiveness when diagnosed at an early stage.

The larger prospective studies for the ambulatory treatment of endocarditis caused by Streptococcus viridans have kept the patients hospitalized, on average, for 8 days, before releasing them to continue the treatment at home⁸. However, we think that it is even possible to prevent the hospitalization phase, when the diagnosis of the endocarditis is attained at an early stage and the patient does not present risk factors.

Costa et al⁹, retrospectively assessing a noteworthy Brazilian series of 186 consecutive confirmed cases of endocarditis, detected, through multivariate analysis, 7 variables that were predictors of mortality: age > 40 years; functional class IV or presence of shock; presence of arrhythmias or conduction disorders; presence of extensive valvular destruction, abscess or prosthesis; sepsis that was unresponsive to antibiotic treatment; and large (> 10 mm) and mobile vegetations.

Other important criteria that must be considered when selecting patients for this type of approach are: presence or not of cardiac prosthesis; impaired kidney function; older age; and the presence of symptoms or signs of heart failure.

Conclusion

The ambulatory treatment of streptococcal bacterial endocarditis may be employed in well-selected cases that do not present concomitant aggravating factors, with consequent benefits for the patient and for the health system.

Potential Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Sources of Funding

There were no external funding sources for this study.

Study Association

This article is part of the thesis of master submitted by Sirio Hassem Sobrinho, from FAMERP.

References

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Publication Dates

• Publication in this collection
  22 Sept 2010
• Date of issue
  Apr 2010

History

• Received
  07 Feb 2009
• Accepted
  06 Aug 2009
• Reviewed
  11 July 2009