What is the treatment for sacroileitis accompanied by endocarditis?

Treatment of Sacroileitis with Endocarditis

When sacroileitis occurs with endocarditis, this represents Brucella endocarditis until proven otherwise, requiring aggressive combination antimicrobial therapy with doxycycline, rifampin, cotrimoxazole, and streptomycin for at least 3-6 months, along with consideration for early cardiac surgery. 1, 2

Pathogen Identification and Clinical Context

The combination of sacroileitis and endocarditis is highly characteristic of Brucella species infection, which is endemic in certain regions and frequently causes both osteoarticular and cardiac complications. 2

• Sacroileitis is one of the most frequent complications of brucellosis, while endocarditis is among the rarer but more severe manifestations. 2
• This clinical presentation warrants immediate blood cultures (three sets at 30-minute intervals) before initiating antibiotics to confirm Brucella infection. 1, 3
• Brucella tube agglutination test should be performed, with titers ≥1:160 considered diagnostic in the appropriate clinical context. 2
• Patients typically have a history of consuming raw milk or dairy products and present with fever, night sweats, fatigue, weight loss, and joint pain. 2

Antimicrobial Treatment Regimen

For confirmed Brucella endocarditis with sacroileitis, the European Society of Cardiology recommends:

• Doxycycline 200 mg/24 hours orally 1
• PLUS Cotrimoxazole 960 mg/12 hours orally 1
• PLUS Rifampin 300-600 mg/24 hours orally 1
• Duration: ≥3-6 months 1

Additional streptomycin (1 g/day for 21 days) should be added when endocarditis is present, as demonstrated in successful case management. 2

• Treatment success is defined as antibody titer falling below 1:60. 1, 4
• The addition of streptomycin (15 mg/kg/24 hours in 2 doses) for the first few weeks is optional but recommended for severe cases with cardiac involvement. 1

Surgical Considerations

Early cardiac surgery combined with prolonged antimicrobial therapy is the recommended approach for Brucella endocarditis, though successful outcomes have been achieved with aggressive medical management alone when patients refuse surgery. 2

• Approximately 50% of endocarditis patients require surgical intervention. 3
• Indications for surgery include heart failure due to valve dysfunction, uncontrolled infection with abscess formation, persistent positive blood cultures despite appropriate therapy, and prevention of systemic embolism. 3
• Early consultation with cardiac surgery is essential to determine optimal timing of intervention. 3
• In the documented case of Brucella endocarditis with sacroileitis, the patient achieved significant improvement with medical treatment alone after refusing valve replacement surgery. 2

Multidisciplinary Management

Consultation with an infectious disease specialist from the Endocarditis Team is mandatory for this rare and severe presentation. 1, 3

• These cases should be discussed by the Endocarditis Team, which includes infectious disease specialists, cardiologists, cardiac surgeons, and microbiologists. 3
• Because of the rarity and severity of Brucella endocarditis, expert consultation is essential for optimizing treatment outcomes. 1

Monitoring and Follow-up

Close monitoring is essential throughout the prolonged treatment course:

• Serial Brucella agglutination titers should be followed to document treatment response, with success defined as titers <1:60. 1, 4
• Repeat echocardiography to assess vegetation size and valve function. 2
• Monitor inflammatory markers (ESR, CRP) for treatment response. 2
• Clinical assessment for resolution of fever, night sweats, and joint pain. 2
• Blood cultures should be obtained if persistent fever or bacteremia is suspected, though routine surveillance cultures after starting therapy are not necessary. 5

Critical Pitfalls to Avoid

The most dangerous pitfall is delayed diagnosis, as brucellosis can resemble many other diseases and is often not considered in non-endemic areas. 2

• In the documented case, diagnosis was delayed by 12 months due to failure to consider brucellosis during clinical follow-up. 2
• Always obtain a detailed dietary history regarding consumption of raw milk and dairy products in patients with fever of unknown origin and multisystem involvement. 2
• Do not use trimethoprim alone, as it is not active against certain endocarditis pathogens; cotrimoxazole (which contains both trimethoprim and sulfamethoxazole) is required. 1
• Ensure adequate duration of therapy (minimum 3-6 months) to prevent relapse, as shorter courses are associated with treatment failure. 1, 6