Earlier operation for left-sided Pseudomonas endocarditis in drug addicts

Three consecutive patients with Pseudomonas endocarditis were treated by early operation with no deaths. The indications for operation were severe failure, systemic embolization, and infection refractory to antibiotics. The organism is aggressive, characterized by early invasion of the myocardium. Wide débridement of the anulus is necessary to remove any vegetations or intramyocardial abscessed wall. Because multiple valve infection is common, it is important to evaluate all four cardiac valves at the time of operation. Removing a second rim of the mitral anulus for separate culture at the time of mitral valve replacement may demonstrate the degree to which the valve resection has removed all infection. Early operation is necessary for reinfection of the prosthetic valve; however, metastatic abscess should also be considered in the face of continued signs of infection postoperatively. Patients should receive a 6 week postoperative course of antibiotics which have been shown by in vitro testing to be serum bactericidal in at least a 1:8 dilution. The operative findings of invasion of the myocardium by the organism and the surgical success in this small series have resulted in our recommending earlier operation in patients with these indications.