From the Guidelines
Fungal endocarditis should be treated with a combination of antifungal therapy and surgical intervention, with valve replacement being strongly recommended in most cases, as it has been shown to reduce mortality rates 1. The recommended approach is long-term systemic antifungal therapy, often with an amphotericin B–containing product, for initial therapy, followed by oral azole therapy for susceptible organisms as step-down therapy.
- Treatment duration is typically 6 weeks to lifelong suppression depending on whether valve replacement surgery is performed.
- Surgical intervention involves debridement of infected tissue and valve replacement, with removal of the infected prosthesis and extensive debridement of the annulus and abscesses to remove all infected and non-viable tissue 1.
- Blood cultures should be monitored to ensure clearance of infection, and echocardiography is essential for diagnosis and monitoring treatment response. The rationale for aggressive treatment is the high mortality rate associated with fungal endocarditis and the poor penetration of antifungals into vegetations.
- Candida and Aspergillus species are the most common causative organisms, with risk factors including intravenous drug use, prosthetic valves, indwelling catheters, and immunosuppression.
- Early diagnosis and prompt initiation of appropriate therapy are crucial for improving outcomes, with a meta-analysis demonstrating a marked reduction in death among those who underwent adjunctive valve surgery 1. The use of oral azole therapy as lifelong suppressive therapy is reasonable, particularly in patients who respond clinically to induction medical therapy but are not deemed appropriate surgical candidates for valve replacement 1.
From the FDA Drug Label
Digitalis glycosides: amphotericin B-induced hypokalemia may potentiate digitalis toxicity. Flucytosine: while a synergistic relationship with amphotericin B has been reported, concomitant use may increase the toxicity of flucytosine by possibly increasing its cellular uptake and/or impairing its renal excretion. Imidazoles (e.g., ketoconazole, miconazole, clotrimazole, fluconazole, etc.) : in vitro and animal studies with the combination of amphotericin B and imidazoles suggest that imidazoles may induce fungal resistance to amphotericin B.
The diagnosis and treatment for fungal endocarditis (infective endocarditis) is not directly addressed in the provided drug label.
- Diagnosis: Not mentioned
- Treatment: The label discusses potential interactions and precautions for using amphotericin B, but does not provide direct guidance on the diagnosis and treatment of fungal endocarditis. 2
From the Research
Diagnosis and Treatment of Fungal Endocarditis
There are no research papers provided to directly answer the question about the diagnosis and treatment of fungal endocarditis. The studies provided focus on bacterial endocarditis, discussing diagnosis, treatment, and management strategies for bacterial infections.
Bacterial Endocarditis Treatment
- The choice of antibiotic therapy for bacterial endocarditis is determined by the identity and antibiotic susceptibility of the infecting organism, the type of cardiac valve involved, and characteristics of the patient 3.
- Treatment with aqueous penicillin or ceftriaxone is effective for most infections caused by streptococci 3.
- A combination of penicillin or ampicillin with gentamicin is appropriate for endocarditis caused by enterococci that are not highly resistant to penicillin 3.
- Vancomycin should be substituted for penicillin when high-level resistance is present 3.
- Native valve infection by methicillin-susceptible staphylococci is treated with nafcillin, oxacillin, or cefazolin 3.
- Infection of a prosthetic valve by a staphylococcal organism should be treated with three antibiotics: oral rifampin and gentamicin and either nafcillin, oxacillin, cefazolin, or vancomycin, depending on susceptibility to methicillin 3.
Comparison of Antibiotic Regimens
- A comparison of different antibiotic regimens for the treatment of infective endocarditis found limited and very low-quality evidence suggesting no conclusive differences between antibiotic regimens in terms of cure rates or other relevant clinical outcomes 4.
- The included trials compared various antibiotic schedules, including quinolone plus standard treatment, daptomycin versus low-dose gentamicin plus an anti-staphylococcal penicillin or vancomycin, and cloxacillin plus gentamicin with a glycopeptide plus gentamicin 4.
- The trials reported adverse events, need for cardiac surgical interventions, uncontrolled infection, and relapse of endocarditis, but found no conclusive differences between comparison groups 4.