Lynlw and I had a back-and-forth about the benefits of (and the use of) an aggressive "shoot first and ask questions later" approach to treating Bacterial Endocarditis among tissue-valve recipients. At the end of it, I think we agreed to disagree about (1) how quickly Toronto General Hospital's Cardiac Centre generally operates on such BE patients and (2) whether operating (to excise/debride/replace the infected tissue) might be beneficial, rather than waiting for one or more weeks of intravenous antibiotics.
I just tripped over a newer article that may shed some light on that scary-but-important issue: "Surgery ups survival in infective endocarditis with HF of any severity: International study", at
http://www.theheart.org/article/131...medium=email&utm_source=20111124_EN_Heartwire .
Looking at 4075 BE patients with symptoms (HF = Heart Failure), but including the most minor category = NYHA class 1-2, they found that surgery was associated with a 50% drop in mortality at 1 year, compared to antibiotics without surgery.
This was a retroactive survey, so the patients weren't randomly streamed into surgical and non-surgical groups (and I don't ever expect to see that kind of a study done!). So the differences may well NOT be purely caused by the difference in treatments -- e.g., younger patients were more likely to get surgery, and were also more likely to survive.
But the authors suggest -- like the Toronto/TGH authors of the "Gold Standard" study I quoted above -- that fewer BE patients would die if surgery were more widely used.
There's another aspect of this survey that seems counter-intuitive to me. If BE patients in some surveyed hospitals were put on IV antibiotics, and some responded/recovered and some didn't, I'd expect the hospitals to operate primarily on the more critical patients -- those that were not getting cured by the IV antibiotics alone. With that kind of non-random selection, I'd expect to see close to 100% survival rate among the non-surgical patients, and much worse among the surgical ones -- but the results were the opposite, and strongly so. Either there are a lot of uninsured patients going without surgery because they can't afford it, or some of the surveyed hospitals are joining TGH in operating before waiting for the antibiotics to finish their work, or something else is going on, IMHO.
It's also worth noting that the survey sample included many patients who had NOT had any valves replaced. My impression is that BE is even scarier for us than for them -- hence (e.g.) the prescription for us to pre-dose with antibiotics before dental procedures. . . If that's right, then it would probably suggest that an even higher rate of surgery for BE would save our lives.
First it is always good to read results from different studies and treating BE in different cases or groups of patients, like this one on people in heart failure. Its helps to know what they found worked best in these groups with heart failure. Luckily many people aren't in HF when their BE is diagnosed
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To be clear I never said BE shouldn't be treated "aggressively" or that surgery wouldn't/isn't beneficial for valve patients, what I've said all along, is there is a huge difference between JUST antibiotics or "don't bother" waiting for antibiotics to work, operate right away on all patients -and my opinion is most people fall in between, usually starting with antibiotics and then IF NEEDED have surgery. I've also questioned if you knew that for a fact or just your interpritation from that mention in the hancock study, that toronto operates on all the BE patients right away or even operate much sooner than other hospitals
I've also said that i would NOT take from that couple sentences in the 'gold standard' that Toronto "doesn't start with antibiotics, but go right to surgery" when they talk about treating BE "aggresively" but aggressive includes a broad range of treatment, depending on the patients, as I quoted from CCF on treating BE aggresively. BE treatment depends on SOO many things its hard to look at it as black or white, antibiotics ALONE or surgery right away for everyone, it depends on the comorbitities, how much growth, the bacteria or fungus etc. and many people who have it bad spend weeks or months in the hospital, so even if they do have surgery the frst admission, it Could mean after weeks of antibiotics in many cases.
from post 18
I'm curiouss are you just taking from the statement "aggressive approach in the treatment of prosthetic valve endocarditis" that they "They no longer start with weeks of intravenous antibiotics before re-operating, because the mortality rate is much higher than among the patients where they operate promptly" or do you know that as a fact, were told by your doctors? Because I find that hard to believe, I'm pretty sure treating aggressively doesn't always mean operate right away, since many people (about 1/2 longterm,) never need surgery and IF possible it is often/usually? safer to operate after the bacteria have been killed for lack of a better word, instead of operating with an active infection that could bring about spreading of the bacteria during surgery. Sometimes of course you need to operate right away depending on a few things, but to me agressive probably falls somewhere between JUST antibiotics and surgery right away, in many patients weeks of IV followed by surgery can be aggresive. Most doctors I've talked to as well as studies I've read tend to go along with this article on CCF
http://my.clevelandclinic.org/heart/...besurgery.aspx as far as treatment and when to operate IF you need to. "
I did manged to read the 2007 study from toronto that you mentioned and I said Id read
"It's funny how different people can take different ideas away from reading the same thing, and I might be completely wrong, but In My opinion the word "alone", is important in this sentence "Survival was poor if patients were treated with antibiotics alone." and it doesn't say WHEN the 16 patients had their surgery, so I don't know that I personally would assume it was soon after diagnosises or when the infection was still active, especially since the results were so good,- even compared to the stats for their paper on surgery with ACTIVE infection, that you had quoted before
http://www.valvereplacement.org/for...-in-three-years-age-64&highlight=endocarditis and wonderred why the stats were much worse in the 07 paper."
but the intro says
"Appropriate antibiotic therapy is the most important component in the treatment of patients with infective endocarditis.1 Depending on how promptly the disease is diagnosed and appropriate antibiotics are started, on the virulence of the microorganism, and on whether the infected valve is native or prosthetic, surgery may become indispensable to save the patient’s life and eradicate the infection. Timing of surgery is crucial for patients for whom medical therapy fails. Delaying surgical treatment often increases the probability of complications and also operative mortality and morbidity."
Then under materials it has
.. review of the cardiac surgery database of Toronto General Hospital disclosed 383 patients who underwent surgery for active infective endocarditis from 1978 to 2004. Because the database did not contain all pertinent information for this disease, the hospital medical records were also reviewed to confirm the diagnosis and the indications for operation and to identify the microorganisms. The indications for surgery were one or more of the following factors: cardiogenic or septic shock in 53 patients (14%), congestive heart failure in 210 (55%), paravalvular abscess in 81 (21%), systemic or cerebral thromboembolism in 45 (12%), persistent sepsis in 72 (19%), and large vegetations in 39 (10%). ..."
which is basically the same list as CCF has listed for people who need immediate surgery. It would have been helpful to know the total number of cases of patients who were treated for BE in that 27 years so we'd know how many/if any patients were just treated medically or had surgery after the infection was cleared up..but since it is just about how complicated/high risk surgery is for ACTIVE BE, it makes sense they would only discuss those patients
Then under "discussion" it says
..Although cardiac surgery is necessary in fewer than a third of patients who have infective endocarditis of native valves and fewer than half of those with prosthetic valves,6-9 a multidisciplinary approach is necessary to treat these patients and must involve at least specialists in infectious disease, cardiology, and cardiac surgery.10 The indications for and timing of surgery are still controversial among internists who treat these patients, and the input of a cardiac surgeon is needed if mortality and morbidity are to be reduced.10,11 Close surveillance of these patients is indispensable to detect early failure of adequate antibiotic therapy to avoid cardiogenic or septic shock and multiorgan failure...
Also about your thoughts on this new study and
There's another aspect of this survey that seems counter-intuitive to me. If BE patients in some surveyed hospitals were put on IV antibiotics, and some responded/recovered and some didn't, I'd expect the hospitals to operate primarily on the more critical patients -- those that were not getting cured by the IV antibiotics alone. With that kind of non-random selection, I'd expect to see close to 100% survival rate among the non-surgical patients, and much worse among the surgical ones -- but the results were the opposite, and strongly so. Either there are a lot of uninsured patients going without surgery because they can't afford it, or some of the surveyed hospitals are joining TGH in operating before waiting for the antibiotics to finish their work, or something else is going on, IMHO''
My GUESS for the difference, is there are mainly 2 groups of people with BE that JUST are treated with antibiotics alone. Those who are diagnosed very early, before they are very sick and respond well to the antibiotics so dont have any perm damage or ongoing infection go home after a week or so with antibiotics and live happily ever after.
Then there is the other end of the spectrum, the patients who get hit very hard and fast or who by the time they are diagnosed with BE they are in such awful shape they are too sick for surgery, either because they already have a few medical problems making them high risk or several organs take a hit etc, so they start medical treatment in the hope to get them "healthy" enough to be able to survive a major surgery, many times they never get to that point and die before they can get to the OR so they fall under the just medical treatment deaths.
