Scand J Infect Dis 24: 797-800, 1992
CASE REPORT
Scand J Infect Dis Downloaded from informahealthcare.com by Karolinska Institutet University Library on 01/28/15 For personal use only.
Long-Term Oral Ciprofloxacin in the Treatment of Prosthetic Valve Endocarditis due to Pseudomonas Aeruginosa OMRUM UZUN', H. ERDAL AKALIN'. SERHAT UNAL'. METIN DEMIRCIN', A. CEM YORGANCIOCLU' and BARAN
UGURLU' From rhe Departments of 'Medicine, Section of Infecriouv Diseaser. and 'Thoracic and Cardiovascular Surgery, Hacettepe Unwersity School of Medicine. Ankara. liwke\
Prosthetic valve endocarditis caused by Pseudomonas aeruginosa is refractory to medical treatment alone and early valve replacement is necessary. We describe a 40-year-old patient in whom endocarditis developed in the early postoperative period, and reoperation was not considered feasible. Ciprofloxacinwas administered orally in order to suppress hacteremia for 36 months. Long-term oral ciprofloxacin may provide an opportunity in the treatment of prosthetic valve endocarditis caused by Ps. aeruginosa in patients who are unfavorable candidates for reoperation. H . E . Akalm, MD, Hacettepe University School of Medicine, Department of Medicine, Section of
Infectious Diseases, Hacettepe, Ankara 06100, Turkey
INTRODUCTION Prosthetic valve endocarditis is a life-threatening complication in the early postoperative period (1-3). Gram-negative bacilli constitute approximately 20% of infecting organisms with a mortality of 87% (4).Early, aggressive surgical intervention is an essential part of treatment ( 5 ) , as well as appropriate antimicrobial therapy. Patients who are poor candidates for reoperation pose a great challenge. Antimicrobials alone do not cure the infection; therefore, suppressive therapy with an orally administered and effective agent with minimal side-effects may be an alternative in such cases. We report a patient with early prosthetic valve endocarditis due to Pseudomonas aeruginosa who received long-term ciprofloxacin therapy. CASE REPORT A 40-year-old man was admitted to Hacettepe University Hospitals for aortic and mitral valve replacement in December 1989. H e experienced acute rheumatic fever when he was 12 years old. Rheumatic valvular heart disease with aortic stenosis and insufficiency and mitral insufficiency was first diagnosed in 1076. Behcet's disease was considered because of recurrent oral and genital aphthous lesions. thrombophlebitis and a positive pathergy reaction at another hospital In 1984. and he was placed o n corticosteroid (prednisolone 5 mg/day) and colchicine (0.5 mg/day) therapy. Before the operation. he was in class I11 of the New York Heart Association's (NYHA) classification of cardiac functional capacity. Antibiotic prophylaxis with cefazolin and gentamicin was administered at the induction of anesthesia. The mitral and aortic valves were replaced with mechanical prostheses (both monostrut Bjiirk-Shiley). He required no positive inotropic support in the immediate postoperative period, and antibiotics were discontinued at 72 h. The patient had fever exceeding 39°C on the seventh postoperative day. Physical examination revealed no source of infection. His white blood cell count (WBC) was 17.5 X IOy/l with a left shift on
Scand J Infect Dis Downloaded from informahealthcare.com by Karolinska Institutet University Library on 01/28/15 For personal use only.
798 0. Vzun et al.
Scand J Infect Dis 24
peripheral blood smear, erythrocyte sedimentation rate (ESR) was 82 mm/h. Echocardiographic examination showed normal functioning prosthetic valves. Empiric antibiotic therapy consisting of amikacin 1 g/day (divided in 2 doses), ceftazidime 6 g/day (divided in 4 doses) and vancomycin 2 g/day (divided in 4 doses) was started for probable early prosthetic valve endocarditis. Ps. aeruginosa grew in 516 sets of blood cultures and vancomycin was abandoned. He was still febrile 5 days after the initiation of antibiotic therapy. The minimum inhibitory concentrations (MICs) were 16 mg/l for arnikacin, 2 mgA for ceftazidime and 0.125 mg/l for ciprofloxacin. Amikacin was discontinued and ciprofloxacin was added at a dose of 750 mg t.1.d. perorally. Fever subsided within 24 h. The subsequent blood cultures were negative, ESR and WBC returned to normal, and his clinical status improved. Serial echocardiograms revealed normal prosthetic valve function with an echo-dense appearance in the left ventricle. Reoperation was not considered, because the changes in the aortic root due to Behqet’s disease made it impossible for another valve replacement procedure. Ceftazidime and ciprofloxacinwere administered for 6 weeks, then ceftazidime was discontinued. The dose of ciprofloxacin was reduced to 500 mg twice daily after one more month at the initial dose. The patient is now in NYHA class 11, serial physical examinations and biochemistry profiles are normal, monthly blood cultures are negative. He is still receiving ciprofloxacin 500 mg twice daily with no side effects 36 months after the operation.
DISCUSSION Early prosthetic valve endocarditis is a rare but life-threatening complication. Gram-negative. especially pseudomonal endocarditis is difficult to treat and it requires reoperation for the cure of infection (4,6). Microorganisms embedded in small vegetations or thrombi rapidly proliferate after the antibiotic therapy resulting in the relapse of endocarditis. Those patients in whom reoperation is not feasible succumb to death. Ciprofloxacin has been studied in experimental models of endocarditis. Strunk et al. (7) compared the efficacy of ciprofloxacin with azlocillin plus tobramycin in a rabbit model of Ps. aeruginosa endocarditis, and showed that ciprofloxacin was as effective as the latter combination. Similar results were obtained by other investigators ( a l l ) . Ciprofloxacin was also found to be effective in the treatment of experimental endocarditis caused by methicillin-susceptible or methicillin-resistant strains of Staphylococcus aureus, alone or in combination with rifampin (12-15), and methicillin-resistant strains of S. epidermidis (16). A combination of ciprofloxacin and rifampin for the treatment of right-sided S. aureus endocarditis in intravenous drug users confirmed these experimental results (17). Since then, several case reports of successful treatment of endocarditis due to Eikenella corrodens (18), Erysipelothrix rhusiopathiae (19), Serratia (20), and Q fever (21) with ciprofloxacin have been reported. Long-term oral ciprofloxacin was administered to 2 patients with Ps. aeruginosa endocarditis with successful suppression of bacteremia and disappearance of symptoms (22). Immediate clinical and bacteriological responses were achieved in our patient by orally administered ciprofloxacin. However, ciprofloxacin may not cure the infection because of the prosthetic device. Cessation of antibiotic therapy is not planned because of high probability of relapse. It was reported that propagation in the size of the vegetations with the development of infected large intracardiac thrombi was the cause of death in 2 patients with Ps. aeruginosa endocarditis who experienced dose reduction or cessation of the treatment (22). Emergence of resistance may pose a problem during long-term treatment with ciprofloxacin. Experimental studies and clinical observations have revealed increases in MICs of this fluoroquinolone in S. aureus and Ps. aeruginosa strains (13,22-25). In the case of pseudomonal endocarditis, the decreased susceptibility of bacteria during treatment was encountered after reducing the dose or temporarily stopping treatment (22). In conclusion, the use of orally administered ciprofloxacin with no side effects on a long-term basis in early prosthetic valve endocarditis due to Ps. aeruginosa may provide new
Scand J Infect Dis 24
Ciprofloxacin for Ps. arruginosa endocarditis 799
opportunities in this special subset of patients who can not tolerate a second valve replacement procedure.
Scand J Infect Dis Downloaded from informahealthcare.com by Karolinska Institutet University Library on 01/28/15 For personal use only.
REFERENCES 1. Dismukes WE, Karchmer AW, Buckley MJ. Austen WG. Swartz MN. Prosthetic valve endocarditis: an analysis of 38 cases. Circulation 48: 365-377, 1973. 2 . Masur H, Johnson WD Jr. Prosthetic valve endocarditis. J Thorac Cardiovasc Surg 80: 31-37. 1980. 3. Wilson WR, Jaumin PM, Danielson GK, Giuliani ER. Washington JA I I . Geraci JE. Prosthetic valve endocarditis. Ann Intern Med 82: 751-756. 1975. 4. Wilson WR, Danielson GK, Giuliani ER, Geraci JE. Prosthetic valve endocarditis. Mayo Clin Proc 57: 155-16l. 1982. 5 . Saffle J R , Gardner P, Schoenbaum SC, Wild W. Prosthetic valve endocarditis: the case for prompt valve replacement. J Thorac Cardiovasc Surg 73: 4 l M 2 0 . 1977. 6. Reyes MP. Palutke WA, Wylin RF, Lerner AM. Pseudomonas endocarditis i n the Detroit Medical center 1969-1972. Medicine (Baltimore) 52: 173-104. 1973. 7. Strunk RW, Gratz JC, Maserati R , Scheld WM. Comparison of ciprofloxacin with azlocillin plus tobramycin in the therapy of experimental Pseudomonas aeruginosa endocarditis. Antimicroh Agents Chemother 28: 428432, 1985. 8. Bayer AS, Lindsay P. Yih J, Hirano L, Lee D. Blomquist IK. Efficacv of ciprofloxacin in experimental aortic valve endocarditis caused hy a multiply betalactam-resistant variant of Pseudomonas aeruginosa stably derepressed for beta-lactamase production. Antimicrob Agents Chemother 30: 42W31, 1986. 9 , Bayer AS, Kim KS. In vivo efficacy of azlocillin and amikacin versus ciprofloxacin with and without amikacin in experimental right-sided endocarditis due t o Pseudomonas aeruginosa. Chemotherapy 32: 364-373, 1986. 10. Bayer AS, Blomquist IK, Kim KS. Ciprofloxacin in experimental aortic valve endocarditis due to Pseudomonas aeruginosa. J Antimicrob Chemother 17: 641449. 1986. 11. Thauvin C , Lecomte F, Le Boete 1, Grise G . Lemeland JF. Efficacy of ciprofloxacin alone and in combination with azlocillin in experimental endocarditis due to Pseudomonas aeruginosa. Infection 17: 31-34. 1989. 12. Carpenter TC, Hackbarth CJ, Chambers HF. Sande MA. Efficacy of ciprofloxacin for experimental endocarditis caused by methicillin-susceptible o r -resistant strains of Staphylococcus aureus. Antimicrob Agents Chemother 30: 382-384, 1Y86. 13. Kaatz GW, Barriere SL, Schaberg DR, Fekety R. Ciprofloxacin versus vancornycin in the therapy of experimental methicillin-resistant Staphylococcus aureus endocarditis. Antimicrob Agents Chemother 31: 527-530, 1987. 14. Fernandez-Guerrero M, Rouse M, Henry N . Wilson W. Ciprofloxacin therapy of experimental endocarditis caused by methicillin-susceptible o r methicillin-resistant Staphylococcus aureus. Antimicrob Agents Chemother 32: 747-751. 1988. 15. Kaatz GW, Seo SM. Barriere SL, Albrecht LM. Ryhak MJ. Ciprofloxacin and rifampin, alone and in combination, for therapy of experimental Staphylococcus aureus endocarditis. Antimicrob Agents Chemother 33: 1184-1187, 1989. 16. Rouse MS, Wilcox RM, Henry NK, Steckelberg JM. Wilson WR. Ciprotloxacin therapy of experimental endocarditis caused by methicillin-re~istant Staphylococcus epidermidis. Antimicrob Agents Chemother 34: 273-276, 1990. 17. Dworkin RJ, Lee BL, Sande MA, Chambers HF. Treatment of right-sided Staphylococcus aureus endocarditis in intravenous drug users with ciprofloxacin and rifampicin. Lancet 2: 1071-1073. 1989. 18. Santiago M. Chocarro A, Chaves F, Sanchez-Zaballos 1. Ciprofloxacin in the treatment of a case of endocarditis caused by Eikenella corrodens. Enferm lnfecc Microhiol Clin 8: IXfG189. 1990. 19. MacGowan AP. Reeves DS, Wright C, Glover SC. Tricuspid valve infective endocarditis and pulmonary sepsis due to Erysipelothrix rhusiopathiae successfully treated with high doses of ciprofloxacin but complicated by gynaecomastia. J Infect 22: IOc1-lOl. 1901 20. Ena J , Amador C, Parras F, Bouza E . Ciprofloxacin as an effective antibacterial agent in serratia endocarditis. J Infect 22: 103-105, 1991. 21. Levy PY, Drancourt M , Etienne J , Auvergnat JC, Beytout J . Sainty JM. Goldstein F, Raoult D. Comparison of different antibiotic regimens for therapy of 32 case\ of Q fever endocarditis. Antimicrob Agents Chemother 35: 533-537, 1991
Scand J Infect Dis Downloaded from informahealthcare.com by Karolinska Institutet University Library on 01/28/15 For personal use only.
800 0.Uzun ef al.
Scand J Infect Dis 24
22. Daikos GL, Kathpalia SB, Lolans VT, Jackson G G , Fosslein E. Long-term oral ciprofloxacin: experience in the treatment of incurable infective endocarditis. Am J Med 84: 786-790. 1988. 23. Kaatz GW, Barriere SL, Schaberg DR, Fekety R. The emergence of resistance to ciprofloxacin during therapy of experimental methicillin-susceptible Staphylococcus aureus endocarditis. J Antimicrob Chemother 20: 753-758, 1987. 24. Tebas P, Martinez Ruiz R, Roman F, Mendaza P, Rodriguez Diaz JC, Daza R, de Letona JM. Early resistance to rifampin and ciprofloxacin in the treatment of right-sided Staphylococcus aureus endocarditis. J Infect Dis 163: 204-205, 1991. 25. Bayer AS, Hirano L, Yih J. Development of betalactam resistance and increased quinolone MICs during therapy of experimental Pseudomonas aeruginosa endocarditis. Antimicrob Agents Chemother 32: 231-235. 1988.
CASE REPORT
Scand J Infect Dis Downloaded from informahealthcare.com by Karolinska Institutet University Library on 01/28/15 For personal use only.
Long-Term Oral Ciprofloxacin in the Treatment of Prosthetic Valve Endocarditis due to Pseudomonas Aeruginosa OMRUM UZUN', H. ERDAL AKALIN'. SERHAT UNAL'. METIN DEMIRCIN', A. CEM YORGANCIOCLU' and BARAN
UGURLU' From rhe Departments of 'Medicine, Section of Infecriouv Diseaser. and 'Thoracic and Cardiovascular Surgery, Hacettepe Unwersity School of Medicine. Ankara. liwke\
Prosthetic valve endocarditis caused by Pseudomonas aeruginosa is refractory to medical treatment alone and early valve replacement is necessary. We describe a 40-year-old patient in whom endocarditis developed in the early postoperative period, and reoperation was not considered feasible. Ciprofloxacinwas administered orally in order to suppress hacteremia for 36 months. Long-term oral ciprofloxacin may provide an opportunity in the treatment of prosthetic valve endocarditis caused by Ps. aeruginosa in patients who are unfavorable candidates for reoperation. H . E . Akalm, MD, Hacettepe University School of Medicine, Department of Medicine, Section of
Infectious Diseases, Hacettepe, Ankara 06100, Turkey
INTRODUCTION Prosthetic valve endocarditis is a life-threatening complication in the early postoperative period (1-3). Gram-negative bacilli constitute approximately 20% of infecting organisms with a mortality of 87% (4).Early, aggressive surgical intervention is an essential part of treatment ( 5 ) , as well as appropriate antimicrobial therapy. Patients who are poor candidates for reoperation pose a great challenge. Antimicrobials alone do not cure the infection; therefore, suppressive therapy with an orally administered and effective agent with minimal side-effects may be an alternative in such cases. We report a patient with early prosthetic valve endocarditis due to Pseudomonas aeruginosa who received long-term ciprofloxacin therapy. CASE REPORT A 40-year-old man was admitted to Hacettepe University Hospitals for aortic and mitral valve replacement in December 1989. H e experienced acute rheumatic fever when he was 12 years old. Rheumatic valvular heart disease with aortic stenosis and insufficiency and mitral insufficiency was first diagnosed in 1076. Behcet's disease was considered because of recurrent oral and genital aphthous lesions. thrombophlebitis and a positive pathergy reaction at another hospital In 1984. and he was placed o n corticosteroid (prednisolone 5 mg/day) and colchicine (0.5 mg/day) therapy. Before the operation. he was in class I11 of the New York Heart Association's (NYHA) classification of cardiac functional capacity. Antibiotic prophylaxis with cefazolin and gentamicin was administered at the induction of anesthesia. The mitral and aortic valves were replaced with mechanical prostheses (both monostrut Bjiirk-Shiley). He required no positive inotropic support in the immediate postoperative period, and antibiotics were discontinued at 72 h. The patient had fever exceeding 39°C on the seventh postoperative day. Physical examination revealed no source of infection. His white blood cell count (WBC) was 17.5 X IOy/l with a left shift on
Scand J Infect Dis Downloaded from informahealthcare.com by Karolinska Institutet University Library on 01/28/15 For personal use only.
798 0. Vzun et al.
Scand J Infect Dis 24
peripheral blood smear, erythrocyte sedimentation rate (ESR) was 82 mm/h. Echocardiographic examination showed normal functioning prosthetic valves. Empiric antibiotic therapy consisting of amikacin 1 g/day (divided in 2 doses), ceftazidime 6 g/day (divided in 4 doses) and vancomycin 2 g/day (divided in 4 doses) was started for probable early prosthetic valve endocarditis. Ps. aeruginosa grew in 516 sets of blood cultures and vancomycin was abandoned. He was still febrile 5 days after the initiation of antibiotic therapy. The minimum inhibitory concentrations (MICs) were 16 mg/l for arnikacin, 2 mgA for ceftazidime and 0.125 mg/l for ciprofloxacin. Amikacin was discontinued and ciprofloxacin was added at a dose of 750 mg t.1.d. perorally. Fever subsided within 24 h. The subsequent blood cultures were negative, ESR and WBC returned to normal, and his clinical status improved. Serial echocardiograms revealed normal prosthetic valve function with an echo-dense appearance in the left ventricle. Reoperation was not considered, because the changes in the aortic root due to Behqet’s disease made it impossible for another valve replacement procedure. Ceftazidime and ciprofloxacinwere administered for 6 weeks, then ceftazidime was discontinued. The dose of ciprofloxacin was reduced to 500 mg twice daily after one more month at the initial dose. The patient is now in NYHA class 11, serial physical examinations and biochemistry profiles are normal, monthly blood cultures are negative. He is still receiving ciprofloxacin 500 mg twice daily with no side effects 36 months after the operation.
DISCUSSION Early prosthetic valve endocarditis is a rare but life-threatening complication. Gram-negative. especially pseudomonal endocarditis is difficult to treat and it requires reoperation for the cure of infection (4,6). Microorganisms embedded in small vegetations or thrombi rapidly proliferate after the antibiotic therapy resulting in the relapse of endocarditis. Those patients in whom reoperation is not feasible succumb to death. Ciprofloxacin has been studied in experimental models of endocarditis. Strunk et al. (7) compared the efficacy of ciprofloxacin with azlocillin plus tobramycin in a rabbit model of Ps. aeruginosa endocarditis, and showed that ciprofloxacin was as effective as the latter combination. Similar results were obtained by other investigators ( a l l ) . Ciprofloxacin was also found to be effective in the treatment of experimental endocarditis caused by methicillin-susceptible or methicillin-resistant strains of Staphylococcus aureus, alone or in combination with rifampin (12-15), and methicillin-resistant strains of S. epidermidis (16). A combination of ciprofloxacin and rifampin for the treatment of right-sided S. aureus endocarditis in intravenous drug users confirmed these experimental results (17). Since then, several case reports of successful treatment of endocarditis due to Eikenella corrodens (18), Erysipelothrix rhusiopathiae (19), Serratia (20), and Q fever (21) with ciprofloxacin have been reported. Long-term oral ciprofloxacin was administered to 2 patients with Ps. aeruginosa endocarditis with successful suppression of bacteremia and disappearance of symptoms (22). Immediate clinical and bacteriological responses were achieved in our patient by orally administered ciprofloxacin. However, ciprofloxacin may not cure the infection because of the prosthetic device. Cessation of antibiotic therapy is not planned because of high probability of relapse. It was reported that propagation in the size of the vegetations with the development of infected large intracardiac thrombi was the cause of death in 2 patients with Ps. aeruginosa endocarditis who experienced dose reduction or cessation of the treatment (22). Emergence of resistance may pose a problem during long-term treatment with ciprofloxacin. Experimental studies and clinical observations have revealed increases in MICs of this fluoroquinolone in S. aureus and Ps. aeruginosa strains (13,22-25). In the case of pseudomonal endocarditis, the decreased susceptibility of bacteria during treatment was encountered after reducing the dose or temporarily stopping treatment (22). In conclusion, the use of orally administered ciprofloxacin with no side effects on a long-term basis in early prosthetic valve endocarditis due to Ps. aeruginosa may provide new
Scand J Infect Dis 24
Ciprofloxacin for Ps. arruginosa endocarditis 799
opportunities in this special subset of patients who can not tolerate a second valve replacement procedure.
Scand J Infect Dis Downloaded from informahealthcare.com by Karolinska Institutet University Library on 01/28/15 For personal use only.
REFERENCES 1. Dismukes WE, Karchmer AW, Buckley MJ. Austen WG. Swartz MN. Prosthetic valve endocarditis: an analysis of 38 cases. Circulation 48: 365-377, 1973. 2 . Masur H, Johnson WD Jr. Prosthetic valve endocarditis. J Thorac Cardiovasc Surg 80: 31-37. 1980. 3. Wilson WR, Jaumin PM, Danielson GK, Giuliani ER. Washington JA I I . Geraci JE. Prosthetic valve endocarditis. Ann Intern Med 82: 751-756. 1975. 4. Wilson WR, Danielson GK, Giuliani ER, Geraci JE. Prosthetic valve endocarditis. Mayo Clin Proc 57: 155-16l. 1982. 5 . Saffle J R , Gardner P, Schoenbaum SC, Wild W. Prosthetic valve endocarditis: the case for prompt valve replacement. J Thorac Cardiovasc Surg 73: 4 l M 2 0 . 1977. 6. Reyes MP. Palutke WA, Wylin RF, Lerner AM. Pseudomonas endocarditis i n the Detroit Medical center 1969-1972. Medicine (Baltimore) 52: 173-104. 1973. 7. Strunk RW, Gratz JC, Maserati R , Scheld WM. Comparison of ciprofloxacin with azlocillin plus tobramycin in the therapy of experimental Pseudomonas aeruginosa endocarditis. Antimicroh Agents Chemother 28: 428432, 1985. 8. Bayer AS, Lindsay P. Yih J, Hirano L, Lee D. Blomquist IK. Efficacv of ciprofloxacin in experimental aortic valve endocarditis caused hy a multiply betalactam-resistant variant of Pseudomonas aeruginosa stably derepressed for beta-lactamase production. Antimicrob Agents Chemother 30: 42W31, 1986. 9 , Bayer AS, Kim KS. In vivo efficacy of azlocillin and amikacin versus ciprofloxacin with and without amikacin in experimental right-sided endocarditis due t o Pseudomonas aeruginosa. Chemotherapy 32: 364-373, 1986. 10. Bayer AS, Blomquist IK, Kim KS. Ciprofloxacin in experimental aortic valve endocarditis due to Pseudomonas aeruginosa. J Antimicrob Chemother 17: 641449. 1986. 11. Thauvin C , Lecomte F, Le Boete 1, Grise G . Lemeland JF. Efficacy of ciprofloxacin alone and in combination with azlocillin in experimental endocarditis due to Pseudomonas aeruginosa. Infection 17: 31-34. 1989. 12. Carpenter TC, Hackbarth CJ, Chambers HF. Sande MA. Efficacy of ciprofloxacin for experimental endocarditis caused by methicillin-susceptible o r -resistant strains of Staphylococcus aureus. Antimicrob Agents Chemother 30: 382-384, 1Y86. 13. Kaatz GW, Barriere SL, Schaberg DR, Fekety R. Ciprofloxacin versus vancornycin in the therapy of experimental methicillin-resistant Staphylococcus aureus endocarditis. Antimicrob Agents Chemother 31: 527-530, 1987. 14. Fernandez-Guerrero M, Rouse M, Henry N . Wilson W. Ciprofloxacin therapy of experimental endocarditis caused by methicillin-susceptible o r methicillin-resistant Staphylococcus aureus. Antimicrob Agents Chemother 32: 747-751. 1988. 15. Kaatz GW, Seo SM. Barriere SL, Albrecht LM. Ryhak MJ. Ciprofloxacin and rifampin, alone and in combination, for therapy of experimental Staphylococcus aureus endocarditis. Antimicrob Agents Chemother 33: 1184-1187, 1989. 16. Rouse MS, Wilcox RM, Henry NK, Steckelberg JM. Wilson WR. Ciprotloxacin therapy of experimental endocarditis caused by methicillin-re~istant Staphylococcus epidermidis. Antimicrob Agents Chemother 34: 273-276, 1990. 17. Dworkin RJ, Lee BL, Sande MA, Chambers HF. Treatment of right-sided Staphylococcus aureus endocarditis in intravenous drug users with ciprofloxacin and rifampicin. Lancet 2: 1071-1073. 1989. 18. Santiago M. Chocarro A, Chaves F, Sanchez-Zaballos 1. Ciprofloxacin in the treatment of a case of endocarditis caused by Eikenella corrodens. Enferm lnfecc Microhiol Clin 8: IXfG189. 1990. 19. MacGowan AP. Reeves DS, Wright C, Glover SC. Tricuspid valve infective endocarditis and pulmonary sepsis due to Erysipelothrix rhusiopathiae successfully treated with high doses of ciprofloxacin but complicated by gynaecomastia. J Infect 22: IOc1-lOl. 1901 20. Ena J , Amador C, Parras F, Bouza E . Ciprofloxacin as an effective antibacterial agent in serratia endocarditis. J Infect 22: 103-105, 1991. 21. Levy PY, Drancourt M , Etienne J , Auvergnat JC, Beytout J . Sainty JM. Goldstein F, Raoult D. Comparison of different antibiotic regimens for therapy of 32 case\ of Q fever endocarditis. Antimicrob Agents Chemother 35: 533-537, 1991
Scand J Infect Dis Downloaded from informahealthcare.com by Karolinska Institutet University Library on 01/28/15 For personal use only.
800 0.Uzun ef al.
Scand J Infect Dis 24
22. Daikos GL, Kathpalia SB, Lolans VT, Jackson G G , Fosslein E. Long-term oral ciprofloxacin: experience in the treatment of incurable infective endocarditis. Am J Med 84: 786-790. 1988. 23. Kaatz GW, Barriere SL, Schaberg DR, Fekety R. The emergence of resistance to ciprofloxacin during therapy of experimental methicillin-susceptible Staphylococcus aureus endocarditis. J Antimicrob Chemother 20: 753-758, 1987. 24. Tebas P, Martinez Ruiz R, Roman F, Mendaza P, Rodriguez Diaz JC, Daza R, de Letona JM. Early resistance to rifampin and ciprofloxacin in the treatment of right-sided Staphylococcus aureus endocarditis. J Infect Dis 163: 204-205, 1991. 25. Bayer AS, Hirano L, Yih J. Development of betalactam resistance and increased quinolone MICs during therapy of experimental Pseudomonas aeruginosa endocarditis. Antimicrob Agents Chemother 32: 231-235. 1988.
