Main description:

The most important example of intravascular infection is infective endocarditis (IE), a common and serious disorder in man. In the past, these infections were uniformly fatal, but since the development of potent antimicrobial agents, bac teriological cure has become practical and predictable. So, for a while, it seemed that intravascular infection would diminish in importance and be relegated to the stockpile of illnesses which physicians, one or two generations earlier, used to see frequently. In recent years, however, spectacular technological advances (cardiac surgery, intravascular devices, hemodialysis), accompanied by profound social deterioration (intravenous drug usage), have provided new breeding grounds for the development of these infections. So it is that a large percentage of intravascular infections may be looked upon today as one of the diseases of medical progress and social evolution. This "progress," however, has not only contributed to the encouragement of the disease; there is another side to the coin: the same technological advances that have served to increase the frequency of infection (e. g. , intravascular plastic catheters) have also led to the first simple, easily reproducible laboratory animal model for the study of the disease, thus advancing our understanding of the prophylaxis, treatment, and general biology of these infections (Figures 1 and 2). Similarly, whereas the insertion of prosthetic heart valves has created a new group of patients with endocarditis, these same surgical techniques are lifesaving to patients with endocarditis whose aortic valves have perforated.

Contents:

1. Introduction.- 1.1. Terminology.- Reference.- 2. The Pathogenesis of Intravascular Infection.- 3. The Nonbacterial Thrombotic Vegetation.- 3.1. Endothelial Damage.- 3.2. Hypercoagulability.- 3.3. Cancer.- 3.4. Infection.- 3.5. Immune Complexes.- 3.6. Limitation of Growth of Vegetations.- 3.6.1. Embolization.- 3.6.2. Fibrinolysis, Organization, and Endothelialization.- 3.7. Fibroblastic Parietal Endocarditis with Eosinophilia (Loeffler's Endocarditis).- 3.8. Arteriosclerosis.- 3.9. Nonbacterial Thrombotic Vegetation in the Venous System.- References.- 4. Establishment of Intravascular Infection.- 4.1. Bacteremia-The Capacity to Induce Infection.- 4.2. Types and Source of Bacteria Responsible for Intravascular Infection.- 4.2.1. Infective Endocarditis.- 4.2.2. Mycotic Aneurysm.- 4.2.3. Vascular-Graft Infections.- 4.3. Susceptibility of Nonbacterial Thrombotic Vegetation to Infection.- 4.3.1. Size of Nonbacterial Thrombotic Vegetation.- 4.3.2. Localization and Frequency within the Vascular System.- 4.3.3. Pathology of Thrombotic Vegetation.- References.- 5. Prophylaxis of Intravascular Infection.- 5.1. Infective Endocarditis.- 5.1.1. Anticoagulants.- 5.1.2. Bacterial Sticking.- 5.1.3. Microorganisms.- 5.1.4. Choice of Antibiotics.- 5.1.5. Choice of Subjects.- 5.2. Prosthetic-Valve Surgery.- 5.3. Vascular Grafts.- References.- 6. Consequences of Intravascular Infection.- 6.1. Establishing the Diagnosis.- 6.1.1. Clinical Presentation of Infective Endocarditis.- 6.1.2. Mycotic Aneurysm (Primary).- 6.1.3. Infection in Peripheral Veins.- 6.1.4. Clinical Diagnosis.- 6.2. Prolonged Bacteremia.- 6.2.1. Blood Culture.- 6.2.2. Fever and Constitutional Symptoms.- 6.2.3. Hematological Findings.- 6.2.4. Splenomegaly.- 6.2.5. Metastatic Infection.- 6.3. Host Responses to Bacteremia.- 6.3.1. Intravascular Coagulation.- 6.3.2. Anticoagulants.- 6.3.3. Specific Circulating Antibody.- 6.3.4. Circulating Immune Complexes.- 6.4. Local Invasion.- 6.4.1. Valve Destruction.- 6.4.2. Congestive Heart Failure.- 6.4.3. Valve-Ring Abscess.- 6.4.4. Valve Obstruction.- 6.5. Peripheral Emboli.- 6.5.1. Nervous System.- 6.5.2. Spleen, Gallbladder, and Liver.- 6.5.3. Kidney.- 6.5.4. Bone.- 6.5.5. Major Arteries.- 6.5.6. Mycotic Aneurysms.- 6.5.7. Heart.- 6.6. Mortality and Factors Affecting Prognosis.- References.- 7. Host Defense Mechanisms.- 7.1. Location within the Vascular System.- 7.2. Polymorphonuclear Leukocytes.- 7.3. Healing-Endothelialization.- 7.4. Role of Foreign Body.- 7.5. Aging of Bacteria.- 7.6. Serum Bactericidal Activity.- References.- 8. Treatment.- 8.1. Decision to Treat.- 8.2. Negative Blood Cultures.- 8.3. Positive Blood Cultures.- 8.4. Antibiotics.- 8.4.1. Principles.- 8.4.2. Recommended Treatment Programs.- 8.5. Special Problems of Microbial Infection.- 8.5.1. Gram-Negative Bacilli.- 8.5.2. Gram-Positive Bacilli ("Diphtheroids").- 8.5.3. Anaerobic Bacteria.- 8.5.4. Chlamydiae.- 8.5.5. Mycobacteria.- 8.5.6. Q Fever.- 8.5.7. Viruses.- 8.5.8. Fungi.- 8.5.9. Pneumococci.- 8.5.10. Neisseria Species.- 8.5.11. Staphylococcus epidermidis, Coagulase-Negative Staphylococci, and Micrococci Species.- 8.5.12. Streptococci.- 8.6. Surgery.- 8.6.1. Valve Destruction-Congestive Heart Failure.- 8.6.2. Antibiotic Failure.- 8.6.3. Peripheral Embolization.- 8.6.4. Cardiac Conduction Abnormalities.- 8.6.5. Peripheral Arterial Grafts.- 8.6.6. Purulent Thrombophlebitis.- 8.6.7. Cardiac Catheterization and Endocardial Pacemakers.- 8.6.8. Miscellaneous.- 8.7. Treatment of Septic Arthritis and Osteomyelitis.- 8.8. Treatment of Glomerulonephritis.- 8.9. Special Aspects of Patient Care.- References.- 9. Indices of Effectiveness of Treatment.- 9.1. Clinical.- 9.2. Laboratory.- 9.2.1. Serum Bactericidal Activity.- 9.2.2. Other Studies.- 9.3. Bacteriology of Surgically Removed Vegetations.- References.- 10. Outcome of Treatment.- 10.1. Medical.- 10.2. Surgical.- References.- 11. Complications of Treatment.- Appendix. AHA Committee Report: Prevention of Bacterial Endocarditis.- Dental Procedures and Upper Respiratory Tract Surgical Procedures.- Regimens for Dental Procedures and Surgery of the Upper Respiratory Tract.- Regimen A-Penicillin.- Regimen B-Penicillin plus Streptomycin.- Genitourinary Tract and Gastrointestinal Tract Surgery or Instrumentation.- Regimens for Gastrointestinal and Genitourinary Tract Surgery and Instrumentation.- Cardiac Surgery.- Status Following Cardiac Surgery.- Other Indications for Antibiotic Prophylaxis to Prevent Endocarditis.- Warning.- Selected References.- Books.