Transcript Endocarditis_SA - Hatzalah of Miami-Dade

Infective Endocarditis
Suhail Allaqaband
Sinai Samaritan Medical Center
Milwaukee, WI
EPIDEMIOLOGY
• An estimated 10,000 to 15,000 new cases of IE are
diagnosed in the United States each year
• IE has increasingly become a disease of the elderly
• More than one-half of all IE cases in the United States
now occur in patients over the age of 60
• This trend is probably due to two factors
– the decline in the incidence of rheumatic heart disease
– the increasing proportion of elderly subjects in the general
population
RISK FACTORS
• Injection drug use
– Highest risk factor in patients < 40 years of age
• Prosthetic heart valves
– Prosthetic valve endocarditis comprises a small
but important segment of IE cases
– More than 100,000 heart valves are implanted
annually in the United States
– IE develops in 1 to 4 % of valve recipients during
the 1st year following valve replacement, and in
approximately 1 percent per year thereafter
RISK FACTORS
• Nosocomial endocarditis
– Usually a complication of bacteremia induced by an
invasive procedure or a vascular device
• Structural heart disease
– Approximately three-fourths of all patients with IE
have a preexisting structural cardiac abnormality
– Congenital heart disease is present in 10-20% cases
– The most common predisposing congenital heart
lesions are bicuspid aortic valves, PDA, VSD,
coarctation of the aorta, and tetralogy of Fallot
RISK FACTORS
• Degenerative valvular lesions
– The risk of IE in patients with MVP and
associated regurgitation is estimated to be 5 to 8
times higher than that in the normal population
– Aortic valve disease(stenosis or/and
regurgitation) is present in 12 to 30 percent of
cases
RISK FACTORS
• History of infective endocarditis
– Recurrent endocarditis occurred in 4.5 percent of
one large cohort of non-addicts
– Other studies have reported rates of IE recurrence
ranging from 2.5 to 9 percent
• HIV infection
– A number of cases of IE have been reported in
patients with HIV infection
– It has been suggested that HIV infection is an
independent risk factor for IE in IV drug abusers
• A number of other, less common
predisposing factors for IE include
–
–
–
–
–
Pregnancy
AV fistulas used for hemodialysis
Central venous and pulmonary artery catheters
Peritoneovenous shunts for the control of ascites
Ventriculoatrial shunts for the management of
hydrocephalus
• In addition, patients with ulcerative lesions of the
colon due to carcinoma or inflammatory bowel
disease have a poorly understood predilection to
develop endocarditis secondary to Strep.bovis
Case Definition
• Duke criteria
– In 1994 investigators from Duke University
modified the previous criteria to include the
role of echocardiography in diagnosis
– They also expanded the category of
predisposing heart conditions to include
intravenous drug use
Duke Criteria
• Definitive infective endocarditis
– pathologic criteria
• microorganisms : demonstrated by culture or
histology in a vegetation, or in a vegetation that has
embolized, or in an intracardiac abscess or
• Pathologic Lesions : vegetation or intracardiac
abscess, confirmed by histology
– clinical criteria
• two major criteria, or
• one major and three minor criteria, or
• five minor criteria
Duke Criteria
• Possible infective endocarditis
– findings consistent of IE that fall short of “definite”, but
not “rejected”
• Rejected
– firm alternate Dx for manifestation of IE
– resolution of manifestations of IE, with antibiotic
therapy for  4 days
– no pathologic evidence of IE at surgery or autopsy, after
antibiotic therapy for  4 days
Duke Criteria
• Major criteria
– positive blood culture for IE
– evidence of endocardial involvement
• Minor criteria
–
–
–
–
predisposition (heart condition or IV drug use)
fever of 100.40F or higher
vascular or immunologic phenomena
microbiologic or echocardiographic evidence not
meeting major criteria
Major Criteria
• Positive blood culture for IE
– typical microorganism for IE from two separate blood
cultures in the absence of a primary focus
• strep viridans, strep bovis, HACEK group, staph
aureus or enterococci
• Persistently positive blood culture
– blood cultures drawn more than 12 hr apart, or
– all of 3 or a majority of 4 or more separate blood
cultures, with first and last drqwn at least 1 hr apart
Major Criteria
• Evidence of endocardial involvement
– positive echocardiogram for endocarditis
• oscillating intracardiac mass on valve or supporting
structure, or in the path of regurgitant jets, or on
implanted material, in the absence of an alternate
anatomic explanation
• abscess
• new partial dehiscence of prosthetic valve
– new valvular regurgitation (increase or change in
pre-existing murmur not sufficient)
Minor Criteria
• predisposition
– predisposing heart condition or iv drug use
• fever of 100.40F or higher
• vascular phenomena
–
–
–
–
–
–
major arterial emboli
septic pulmonary infarcts
mycotic aneurysm
intracranial hemorrhage
conjunctive hemorrhages
Janeway lesions
Duke’s Minor Criteria
• immunologic phenomena
– Glomerulonephritis
– Rheumatoid factor
– Osler’s nodes
– Roth spots
• microbiologic evidence
– positive blood culture not meeting major criteria or
serologic evidence of active infection with organism
consistent with IE
• echocardiogram
– consistent with IE but not meeting major criteria
Validity of Duke criteria
• 405 consecutive cases of suspected IE were studied
• 69 cases of IE were confirmed pathologically
• 55 (80 percent) were clinically classified as definite
using the Duke criteria, versus only 35 being
classified as probable by the von Reyn criteria
• 12 of the pathologically confirmed cases were
"rejected" by the von Reyn criteria whereas none by
the Duke criteria
New criteria for diagnosis of infective endocarditis:
Utilization of specific echocardiographic findings.
Duke Endocarditis Service Am J Med 1994; 96:200
Diagnostic approach to infective endocarditis
• History
– A careful history should be performed with special attention
given to a history of prior cardiac lesions and historical clues
pointing toward a recent source of bacteremia
• Physical examination
– A meticulous clinical examination should be performed
looking for clinical evidence of small and large emboli with
special attention to the fundi, conjunctivae, skin, and digits
– Cardiac examination may reveal signs of new regurgitant
murmurs and signs of CHF
– Neurologic evaluation may detect evidence of focal neurologic
impairment
Diagnostic approach to infective endocarditis
• Positive blood culture results
– A minimum of three blood cultures should be
obtained over a time period based upon the severity
of the illness
• Additional laboratory tests
– An elevated ESR and/or an elevated level of CRP
is usually present
– Most patients quickly develop a normochromic
normocytic anemia
– The WBC count may be normal or elevated
Diagnostic approach to infective endocarditis
• Additional laboratory tests
–
–
–
–
–
–
–
elevated levels of serum globulins
presence of cryoglobulins and circulating immune complexes
hypocomplementemia
false positive serologic tests for syphilis
abnormal urinalysis
microscopic or gross hematuria, proteinuria, or pyuria
the combination of RBC casts on urinalysis and a low serum
complement level may be an indicator of immune-mediated
glomerular disease
Diagnostic approach to infective endocarditis
• Electrocardiogram
– All patients with suspected IE should have an
EKG to determine whether there is evidence of
heart block or a conduction delay and to
establish a baseline should such a complication
develop later
Diagnostic approach to infective endocarditis
• Echocardiography
– Should be performed in all patients with suspected IE
– A TTE should initially be obtained in patients with
native heart valves, while those with prosthetic valves
should undergo TEE
– Detection of a vegetation by TTE is a positive test
– However, a negative study does not preclude the
diagnosis and should be followed by TEE, when there
is an intermediate or high suspicion of IE
Improved diagnostic value of echocardiography in patients
with infective endocarditis by transoesophageal approach
A prospective study.Eur Heart J 1988 Jan;9(1):43-53
• 96 patients were studied consecutively with TEE and
TTE
• TEE had a sensitivity for the detection of vegetations
of 100 percent as compared to 63 percent with TTE
• Both TTE and TEE had specificity of 98%
• Only 25% of vegetations less than 5 mm, 69% of
vegetations 6-10 mm, and 100% of vegetations
greater than 11 mm detected by TEE were also
observed with TTE
Major Pathogens
• Native Valve IE
– Strep.(55%), mostly Viridans
– Staph.(30%), mostly S.aureus
– Entrococci(5-10%)
• Prosthetic Valve IE
– Early (0-2 months)
• Staph(50%)- mostly S.epi.
• IE in IV drug abusers
– Staph. aureus(50-60%)
– Late (>60 days)
• Staph(30%)
Treatment of infective endocarditis
• GENERAL CONSIDERATIONS
– Antimicrobial therapy should be administered
in a dose designed to give sustained bactericidal
serum concentrations throughout much or all of
the dosing interval
– In vitro determination of the minimum
inhibitory concentration of the etiologic cause
of the endocarditis should be performed in all
patients
Treatment of infective endocarditis
• GENERAL CONSIDERATIONS
– The duration of therapy has to be sufficient to
eradicate microorganisms growing within the
valvular vegetations
– The need for prolonged therapy in treating
endocarditis has stimulated interest in using
combination therapy to treat endocarditis
VIRIDANS STREPTOCOCCI AND STREP. BOVIS
Antibiotic
Dosage and route
Aqueous crystalline
penicillin G sodium
12-18 million U/24 h
IV either continuously
or in 6 = divided doses
4 wks
2g once daily IV or IM
2 wks
12-18 million U/24 h
IV either continuously
or in six equally
divided doses
1 g IM or IV every 8 h
2 wks
or
Ceftriaxone sodium
Aqueous crystalline
penicillin G sodium
with gentamicin
sulfate
Vancomycin
hydrochloride
Duration
2 wks
30 mg/kg per 24 h IV
4 wks
in two equally divided
doses, not to exceed 2
gram/24h unless serum
levels are monitored
Comments
preferred in most patients older than 65 yrs
and in those with impairment of the eighth
nerve or renal function
when obtained 1h after a 20-30 min.
IV infusion or IM injection, serum
concentration of gentamicin of
approximately 3 mcg/mL is desirable;
trough concentration should be < 1 pg/mL
vancomycin therapy is recommended for
patients allergic to beta lactams; peak
serum concentrations of vancomycin should
be obtained one h after completion of the
infusion and should be in the range of
30-45 mcg/mL for twice-daily dosing
JAMA 1995; 274:1706
ENTEROCOCCI
STAPH. ENDOCARDITIS IN NATIVE VALVES
STAPH. ENDOCARDITIS IN PROSTHETIC VALVES
HACEK ORGANISMS
Indications for surgery in IE
• The indications for surgery in patients with native-valve
IE and prosthetic-valve IE are essentially the same
• Surgery is warranted for patients with active IE who
have one or more of the following complications:
– CHF that is directly related to valve dysfunction
– Persistent or uncontrolled infection while receiving
appropriate antimicrobial therapy, including evidence
of perivalvular extension
– Recurrent emboli, particularly in the presence of
large vegetations
Indications for surgery in IE
• Relative indications for surgery
– Evidence of perivalvular infection, such as
intracardiac abscess or fistula formation
– Rupture of a sinus of Valsalva aneurysm
– Fungal endocarditis
– Endocarditis due to highly resistant microorganism
– Relapse after a course of adequate antimicrobial
therapy, particularly in prosthetic valve endocarditis
– Culture-negative IE with fever more than 10 days
after starting empirical therapy
Indications for surgery in prosthetic
valve IE
• Same as native valve endocarditis
• Perivalvular infection
• Valve Dehiscence
– excessively mobile prosthesis on echo
– results in hemodynamic instability
OUTCOME OF SURGERY
• The outcome of surgery in patients with IE has been
good, particularly when surgical treatment is radical
with the removal of all infected and necrotic tissue
• In a recent study of 138 patients who underwent valve
surgery in the presence of active infection, the early
mortality, due to heart failure or septic multiorgan
failure, was 11.5 %
• Risk factors for early mortality were NYHA class IV
or cardiogenic shock, advanced age, preoperative
acute renal failure, and staphylococcal infection
Operation for infective endocarditis: Results after implantation
of mechanical valves. Ann Thorac Surg 1998; 65:359.
ACC/AHA recommendation for surgery in patients with native
valve endocarditis
ACC/AHA recommendation for surgery in patients with
prosthetic valve endocarditis
ACC/AHA recommendation for valve replacement with
mechanical prosthesis
ACC/AHA recommendation for
valve replacement with bioprosthesis