From the Guidelines
Fungal endocarditis should be treated with a combination of antifungal therapy and surgical intervention, with the recommended approach being early surgical valve replacement or repair, along with long-term antifungal therapy, as this approach has been shown to reduce mortality and improve outcomes 1.
Diagnosis and Treatment
The diagnosis of fungal endocarditis is typically made through a combination of clinical presentation, blood cultures, and echocardiography.
- Blood cultures should be monitored regularly during treatment to assess the effectiveness of antifungal therapy.
- Echocardiography is essential for diagnosis and follow-up, as it can help identify the presence of vegetations and assess the severity of valve damage.
Antifungal Therapy
For Candida endocarditis, the initial treatment should include an echinocandin (such as caspofungin 150 mg daily, micafungin 150 mg daily, or anidulafungin 200 mg daily) or lipid formulation of amphotericin B (3-5 mg/kg/day), with or without flucytosine (25 mg/kg 4 times daily) 1.
- Step-down therapy to fluconazole (400-800 mg daily) is recommended for patients who have fluconazole-susceptible Candida isolates, have demonstrated clinical stability, and have cleared Candida from the bloodstream 1.
Surgical Intervention
Valve replacement is recommended, and treatment should continue for at least 6 weeks after surgery and for a longer duration in patients with perivalvular abscesses and other complications 1.
- For patients who cannot undergo valve replacement, long-term suppression with fluconazole (400-800 mg daily) is recommended if the isolate is susceptible 1.
Outcome and Prognosis
Fungal endocarditis carries a high mortality rate (30-80%) due to its propensity for large vegetations, invasive growth, and embolic complications 1.
- Risk factors include prosthetic heart valves, intravenous drug use, indwelling catheters, immunosuppression, and prior cardiac surgery.
- Early diagnosis and aggressive management are crucial for improving outcomes in this challenging infection.
Key Considerations
- The treatment of fungal endocarditis requires a multidisciplinary approach, involving cardiologists, infectious disease specialists, and cardiothoracic surgeons.
- The choice of antifungal therapy and the decision to proceed with surgical intervention should be individualized based on the patient's specific circumstances and the characteristics of the infecting organism.
From the Research
Diagnosis of Fungal Endocarditis
- Fungal endocarditis is a rare disease that mostly occurs in patients with predisposing host conditions, such as immunosuppression and intravenous drug use 2, 3.
- Diagnosis is challenging and requires a high index of suspicion, as clinical presentation is often indistinguishable from bacterial endocarditis 2, 3, 4.
- Diagnosis can be pursued using echocardiography and multiple blood cultures or surgical specimens 2.
- Molecular diagnostic techniques are also being used to improve diagnosis 4.
Treatment of Fungal Endocarditis
- Treatment of fungal endocarditis requires an aggressive approach, combining medical and surgical therapy 2, 5, 3, 4.
- For Candida endocarditis, treatment includes surgical treatment in combination with liposomal amphotericin B or caspofungin, with optional addition of flucytosine 2.
- For Aspergillus endocarditis, treatment requires rapid surgery and voriconazole 2, 5.
- Fluconazole can be used as chronic suppressive therapy, especially in patients with native valve infection, and has been shown to be effective in combination with other antifungal agents 6.
- The combination of antifungal therapy and surgical debridement is essential to improve outcomes in fungal endocarditis 5, 4.