Assessing the Infectious Process

This step is critical in achieving optimal control of an active infection. Failure of infection control and active infection at the time of surgery is a risk factor in all surgery. It may result in residual infected tissue after surgery and increased risk of recurrence. First, any predisposing local factors such as anatomic or functional valve abnormalities, or factors related to general patient condition (immunosuppression, history of cancer, etc.) should be identified and managed to evaluate risks and prevent recurrence. Next, a possible primary source of infection, either obvious or latent, such as soft tissue abscess or poor dental hygiene, must be identified and eradicated prior to heart surgery. Septic dissemination may also result in non-cardiac infectious localization, including metastatic abscesses (e.g., splenic abscess), mycotic aneurysms, and cerebral emboli, which should be addressed, as they may significantly complicate the surgical strategy.

Finally, the causative microorganism should be identified and treated as per culture results. In culture-negative IE, the most probable organisms should be determined based on epidemio-logical and demographic characteristics of the individual case. The identified or probable causative organism determines the specific or empiric antibiotic therapy pre- and periopera-tively. Determining the causative microorgan ism is significant in decision-making, in that it has a direct impact on the course, pathophysiology, and complications of IE, and hence on its management. Staphylococcus aureus IE, for instance, causes more serious valvular damage and is associated with a higher embolization and mortality rates [4]. Fungal IE generally does not respond well to medical therapy, and surgery is eventually needed; thus earlier intervention is usually warranted. In streptococcal IE, vegetation size is an independent risk factor for embolic events [5]. Q Fever IE is a leading cause of negative blood-culture IE and should be investigated through specific immunological testing [6,7].

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