Transcript Liu_Endocarditis Presentation-1

Endocarditis
Wei Liu, BSN
Penn State Nursing
N 870
Introduction
• Endocarditis is inflammation of the inside lining of the heart
chambers (endocardium) and heart valves
• It is commonly caused by bacteria infection, therefore we
refer it to infective endocarditis (IE)
• IE is an uncommon, but not rare, disease. The annual
incidence ranging from 3 to 7 per 100,000 person-years in the
most contemporary population surveys.
• IE continues to be characterized by increased morbidity and
mortality and is now the third or fourth most common lifethreatening infection syndrome, after sepsis, pneumonia, and
intra-abdominal abscess.
(AHA, 2015)
Diagenosis
• Infection of the endocardial surface of the heart, usually
involving heart valves or an intracardiac device
• Organisms: S. aureus, viridans streptococci, enterococci,
and pseudomonas aeruginosa
• Complications:
• congestive heart failure,
• arterial emboli,
• myocardial infarction,
• myocardial abscesses
• death
( Sexton, 2015)
Pathogenesis
• Congenital or acquired heart condition
• Alteration of the valvular endothelium leading to
depositions of platelets and fibrin
• Invasive procedures
• Microorganisms in the circulating blood stream colonize
on the damaged valvular surface or preexisting sterile
vegetation
• Microorganisms further propagate or enlarge the
vegetation or cause systemic emboli
• Further impeding blood flow and incite inflammation
that involves the vegetation and adjacent endothelium
( Sexton, 2015)
ROS
• PMH: prior endocarditis, prosthetic valve or cardiac
device, valvular or congenital heart disease, rheumatic
fever, IV drug use, IV lines, immunosuppression, recent
dental/surgical procedure
• fever and chills
• fatigue
• nausea and vomiting
• weight lost and anorexia
• aching muscles and joints
• night sweats
• headaches
• shortness of breath and cough
• skin lesions
• hematuria
(NHLBI, 2010)
Physical Exam
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General: chills, fatigue, and paleness
vital signs: fever
Eyes: Roth spots
peripheral vascular: edema, clubbing, Splinter
hemorrhages, Janeway lesions, and Osler's nodes
Cardiovascular: onset/changed heart murmur, pleuritic
pain
Pulmonary: dyspnea, cough
Gastrointestinal: splenomegaly, pain and fullness
Neurological: confusion, sensory dysfunction
Diagnostic Tests
• blood cultures and echocardiography(TEE/TTE)
• Sed rate, C-reactive-protein, urinalysis, WBC
• modified Duke diagnosis criteria
• definite endocarditis: 2 major criteria, 1 major
criterion and 3 minor criteria, or 5 minor criteria
• possible endocarditis: 1 major criterion and 1 minor
criterion, or 3 minor criteria
• The sensitivity of the Modified Duke Criteria is 98-100%,
and the specificity is 93%
• TEE has a substantially high sensitivity (76% to 100%) and
specificity (94%), which is higher than TTE
(Loeb et al, 2011 & Baddour, et al, 2015 )
Modified Duke Criteria
Differential Diagnosis
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Intravascular catheter infection
Skin and soft tissue infection
Cardiac device infection
Prosthetic joint infection
Sepsis
And many more…
This diagnosis of endocarditis (Red Flag) can be difficult to
make, or the signs misleading, and there is a wide
differential diagnosis to consider.
(Sexton, 2015)
Treatment
• Antibiotic Therapy 4 to 6 weeks: based on the causative
microorganism and its antibiotic susceptibility, and
whether the involved valve is native or prosthetic.
• Initial empiric therapy- Vancomycin or
Ampicillin/Sulbactam (Unasyn) plus an Aminoglycoside
(plus rifampin in patients with prosthetic valves)
• Native Valve Endocarditis associates with staphylococci
- Nafcillin and Gentamicin
• Prosthetic Valve Endocarditi associate MRSA or
coagulase-negative staphylococci - Vancomycin,
Rifampin and Gentamicin
• Vancomycin intolerance or resistant organisms Linezolid or Daptomycin
(Baddour, et al, 2015 )
Treatment Con't
• Surgical Therapy: patients with structural and functional
damaged cardiac valves.
• Anticoagulation: controversial
• American Heart Association endocarditis treatment
guidelines 2015:
http://circ.ahajournals.org/content/early/2015/09/15/CIR.000
0000000000296.full.pdf+html
Patient Education/Follow up
• intravenous catheters should be removed promptly after
antibiotic therapy
• Monitor recurrent IE among intravenous drug abusers
• echocardiography should be performed to establish a new
baseline
• monitored for complications such as valvular dysfunction,
congestive heart failure, renal failure, and embolic
phenomenon
• provide information about daily dental hygiene; regular visits
to the dentist; and the need for antibiotic prophylaxis for
certain procedures
(Pierce et, al, 2012)
Outcomes
• most of patients are able to recover with appropriate
antimicrobial therapy.
• The risk of embolization declines after institution of
appropriate treatment.
• in-hospital mortality rate is 18 to 23%; the six-month
mortality rate is 22 to 27%
• Complications: valvular dysfunction, congestive heart
failure, renal failure, and embolic phenomenon
(Spelman & Sexton, 2015) )
Reference:
•Baddour, L. M., Wilson, W. R., Bayer A. S., Fowler, V. G., Tleyjeh, I. M., Rybak M.J.,
et al. (2015). Infective endocarditis in adults: diagnosis, antimicrobial therapy, and
management of complications: a scientific statement for healthcare professionals
from the American Heart Association. Circulation. 132(15), P1435-86
•Goroll, A. H., & Mulley, A. G. (2006). Primary care medicine: office evaluation and
management of the adult patient. Philadelphia: Lippincott Williams & Wilkins.
•Loeb, M., Smaill, F., & Smieja, M. (2011). Evidence based infectious diseases. 2nd
ed. Chichester: Wiley-Blackwel.
•National heart lung and blood institute (NHLBI). (2010). What is endocarditis.
Retrieved from https://www.nhlbi.nih.gov/health/health-topics/topics/endo
•Pierce, D., Calkins, B. C., & Thornton, K. (2012). Infectious endocarditis: diagnosis
and treatment. American Family Physician, 85(10), p981-986
•Sexton, D. J. (2015) Pathogenesis of vegetation formation in infective endocarditis.
UpToDate. Retrieved from http://www.uptodate.com/contents/pathogenesis-ofvegetation-formation-in-infective-endocarditis
•Spelman, D., & Sexton, D. (2015). Complications and outcome of infective
endocarditis. UpToDate. Retrieved from
http://www.uptodate.com/contents/complications-and-outcome-of-infectiveendocarditis
Questions?