We have a challenging case who has had prosthetic Aortic valve replacement about 30 years previously and has been on warfarin. He presented with high grade fever, infective endocarditis was suspected, and blood cultures grew MRSA.
However, the problem is that he is bedridden, has contractures of the limbs due to associated vascular dementia and Cardiology team has deemed him unfit for TEE after a negative TTE. Even it was not possible to do FDG- PET scan because it would not be possible to position him properly during this study.
He is on antibiotics guided by culture sensitivity results. What are the chances that he will not relapse after stopping antibiotics for 6 weeks, while knowing that he is unfit for any possible surgery for replacement of the prosthetic valve.
What is the best possible approach in management of such a patient? For how long he should be continued on antibiotics considering that a recurrence of fever will mandate a surgical management.
Abbreviations:
TEE - Transesophageal Echocardiography, TTE - Transthoracic Echocardiography
FDG-PET - Fluorodeoxyglucose Positron Emission Tomography
It would be prudent to consult and involve the infectious disease consultant to manage this pt. Does he have a source of infection if he is bedridden, like bedsore/urinary tract. It would be wise to repeat transthoracic echocardiogram if TEE is rejected. If there are relapses or signs, involve the family and the cardiac surgery surgery team to reach a consensus on the final management plan.
Getting a TOE should not be difficult as IV sedation is required regardless.
A full course of IV antibiotics as per culture sensitivity and keeping a tab on the infection markers like CRP is a valid option.IF the markers remian stable even after stopping antibiotics that will be a good outcome.
However if he relapses a long term antibiotic treatment even life long can be continued.
A reoperation should be avoided considering the current morbidity..
However age of the patient and the families wishes have to considered.
I have to say that cases like yours are very difficult to treat. Furthermore, Dr. Sharma told everything about possible manage of that patient. Great problem could be additional respiratory complications, and risk of additional problems around prosthetic valve (new onset of paravalvular leaks, tissue damage of local structures). Consecutive TEEs' in sedated patient were the diagnostic choice and/or MSCT to follow and treat that patient. Finally, usage of procalcitonine is preferable as the better predictor than CRP in following septic or infective patients.
Best
Nikola
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Dear Zulfiqar Ali, Rajiv Sharma and Nikola Bradic. Thanks you all for valuable comments and insightful suggestions.
As a matter of fact Cardiology and Infectious disease were involved from the outset and Radiology was consulted as well for best possible imaging study. However, it was opined that this patient because of his late dementia, contactures, sarcopenia, Low BP (near 90-95 systolic), tachypnea and periods of Cheyne Stokes breathing and need for NGT feeding was high risk for general anesthesia that could be needed for doing TEE and he could not be put in proper position for FDG-PET scan. There was no obvious focus of infection. Therefore he was given Linezolid and Meropenem depending on the sensitivity of the organism for 4 weeks after initial Vancomycin and Meropenem 2 weeks. However, he developed significant secondary fungal UTI for which antifungal treatment was given. Trans thoracic Echo was repeated twice and was not conclusive. CRP is used for follow up. He had evidence of thromboemboli. He keeps on having fever off an on.
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