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36.6 Right-sided infective endocarditis
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Published:July 2018
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Abstract
Right-sided infective endocarditis (RSIE) can be classified into three epidemiological groups: intravenous drug users (IDUs), intravascular device carriers, and the ‘three noes’ group (no left-sided, no device, no IDUs). RSIE represents 5–10% of all infective endocarditis episodes in adults. The most common clinical manifestations of RSIE are fever and respiratory symptoms. The microbiological profile is dominated by Staphylococcus species, especially methicillin-sensitive Staphylococcus aureus. The modified Duke criteria should be used for the diagnosis of this entity, although their sensitivity and specificity are lower than in left-sided infective endocarditis. Regarding imaging in RSIE, the diagnostic yield of transthoracic echocardiography (TTE) is comparable with transoesophageal echocardiography, so TTE should be the initial imaging technique when RSIE is clinically suspected. The empirical antibiotic treatment should include antibiotics against staphylococci, such as vancomycin or daptomycin in combination with gentamicin and then adapted to the antibiogram. In non-complicated episodes of isolated tricuspid endocarditis caused by methicillin-sensitive Staphylococcus aureus, a 2-week regimen with cloxacillin can be safely used. In other cases, a standard 4–6 weeks is mandatory. Careful selection of patients for surgery is needed and surgery is only indicated in cases of microorganisms difficult to eradicate, or bacteraemia for more than 7 days despite adequate antimicrobial therapy, persistent tricuspid valve vegetations larger than 20 mm after recurrent pulmonary emboli with or without concomitant right heart failure, or right heart failure secondary to severe tricuspid regurgitation with poor response to diuretic therapy. Mortality of RSIE in IDUs is about 7%.
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