Transcript 8.25.09 Cammarata Endocarditis

Fingernails
Conjunctiva
Skin
CT ABDOMEN
MRI BRAIN
Duke Criteria
Definative: 2 major, 1 major and 3 minor,
5 minor
 Possible: 1 major and 1 minor OR 3
minor crieria met

Duke Criteria

Major:
 Positive Blood culture:
 Evidence of endocardial involvement
Duke Criteria – Major

Positive Blood culture:
○ Typical microorganism for infective
endocarditis from two separate blood cultures
 Viridans Streptococci, streptococcus bovis, HACEK
group, staph aureas, Community acquired
enterococcus in absence of a primary focus OR
○ Persistently positive blood culture (3/4
cultures or 2 cultures >12 hours apart)
○ Single positive for coxiella bunetti, or phase I
IgG titer of >1:800
Duke Criteria – Major

Endocardial Involvement
 Positive Echo:
 Oscillating intracardiac mass on valve or supporting
structures in the path of regurgitant jet or in implanted
material in the absence of an alternative anatomic
explanation
 Abscess
 New partial dehiscence of prosthetic valve
 New Valvular Regurgitation
 Increase or change in previous murmur not sufficient
Duke Criteria – Minor
 Predisposing condition
 Abnormal valve (prior endocarditis, rheumatic
valvular disease, Aortic Valvular disease, complex
cyanotic lesions, prosthesis
 Abnormal risk (IVDU, indwelling catheters, poor
dentition, hemodialysis, DM
 Fever ≥38.0 C
 Vascular Phenomena:
 Major arterial emboli, septic pulmonary infarctions,
mycotic aneurism, intracranial hemorrhage,
conjunctival hemorrhages, Janeway lesions
Duke Criteria – Minor
Immunologic Phenomena:
Glomerulonephritis, Osler;s nodes,
Roth’s sports, rheumatoid factor
 Microbiologic evidence:

 Positive blood culture but not meeting major criteria
- Usu: gnr’s
 Serologic evidence of active infection with organism
consistent with infective endocarditis
IE - Acute vs. Subacute

Acute
 More virulent pathogen
 Rapid valvular damage
 Rapid hematogenous seeding of
extracardiac sites
 Untreated leads to death in days to weeks
 Typical exam findings of vascular
phenomenon: Janeway lesions, emboli,
mycotic aneurisms
IE - Acute vs. Subacute

Acute Organisms
 Staphylococcus Aureas (MRSA and MSSA)
 Beta Hemolytic Streptococcus
 Pneumococcus
 Enterococcus, Coag negative Staph (less
commonly)
IE - Acute vs. Subacute

Subacute
 Indolent course.
 gradual valvular damage
 Rarely has seeding of extracardiac sites
 Generally has more signs of rhematologic
activation: roth spots, RF+, osler’s nodes,
GN
IE - Acute vs. Subacute

Subacute Organisms
 Viridan’s Streptococcus
 Enterococci
 Coagulase negative Staph
 HACEK
 haemophilus ssp.,
 actinobaciullus actinomycetemcomitans,
 cadiobacterium hominis,
 eikenella corrodens,
 kingella ssp.
 Strep Bovis with colon cancer.
Age old Debate - TTE vs. TEE
Cardiac Complications

CHF – 30-40%
 Consequence of valvular disease

Perivalvular Abscess
 Perivalvular fistula
 Pericarditis
 Varying degrees of heart block
- Mitral: may interrupt the AV node, or bundle of his
- Aortic: non-cardiac or right sinus: upper
interventricular system.
Extra-cardiac Findings

Musculoskeletal
 Septic and reative arthritis, bone infarctions, back pain,

Skin
 Subungual hemorrhages, janeway lesions, osler’s nodes,

Eyes:
 Roth’s spots, conjunctival petichiae,

Neuro:
 CVA in up to 40%, aseptic and purulent meningitis, intracranial
hemorrhage, seizures, encephalopathy, microabscesses in brain
and meninges,

Renal:
 Immune complex deposition in GBM, embolic infarcts, abscesses

Embolic:
 Any organ can be involved but most often are skin, kidneys,
spleen, skeletal system, brain and meninges
Treatment

Medical Management:
 Difficult to eradicate bacteria from the valve.
 Should use long course of IV bacteriocidal
antibiotics and static antibiotics should be
avoided.
 Antibiotic management should be held for
cultures to be drawn.
- Either 4 over the course of an hour, or 2 and 2 12
hours apart.
 Even with appropriate management some
may continue to spike fevers and have + BC
Treatment – Medical Mgmt.

Strep ssp.:
 Pen sensitive: Penicillin G, ceftriaxone, vanc for 4
wks, OR penicilin/ceftr plus gent for 2 weeks
 Pen resistant: Penicillin G plus gent for 4-6wks OR
Vanc 4 weeks

Enterococcus:
 Pen g plus gen for 4-6 weeks, OR Amp plus gent for
4-6 weeks, OR vank plus gent for 4-6 weeks

HACEK:
 Ceftriaxone for 4 weeks OR Amp/Sulbactam 4 weeks
Treatment – Medical Mgmt.
○ MRSA
 Native valve
- Vanc for 4-6 weeks
 Prosthetic valve
- Vanc plus gent plus rifampin for 6-8 weeks
○ MSSA
 Native valve
- Naf/oxacillin/cefazolin 4-6 wks plus gent for 4-5
days, OR vanc for 4-6 weeks
 Prosthetic valve
- Naf/oxacillin for 6-8 weeks plus gent for 2 weeks
plus rifampin for 6-8 weeks
Treatment – Surgical

When to consider surgical therapy
 Emergent (same day):
○ aortic reguritation and preclosure of mitral
valve
○ sinus of valsalva abscess rupture into right
heart
○ rupture into pericardial sac
Treatment – Surgical
 Urgent (1-2 days):
○ Valve obstruction by vegitation
○ Unstable prosthesis
○ Ao regurgitation with NYHA 3-4 CHF
○ Septal perforation
○ Perivalvular infection
○ Lack of effective antibiotic therapy
○ Major embolus plus persisting large
vegetation (evidence conflicting but
concensus opinion)
Treatment – Surgical
 Elective (earlier usually preferred):
○ Progressive paravalvular prothetic
regurgitation
○ Valve dysfuntion plus persistent infection after
7-10 days of Abx
○ Fungal endocarditis (specifically mold)
○ Prosthetic vave:
 With staph
 <2 moths after preplacement
 Fungal
 Antibiotic resistant
Treatment – Surgical
 Abx after surgery:
 If native valve and uncomplicated with negative valve
cultures:
- 2 weeks of post operative antibiotics OR a total full
duration of above regimen whichever is longer
 If complicated by perivalvular abscess, partially
treated prosthetic valve infection or cases with
culture positive valves:
- Full course of antibiotics after surgery
Complication rate:




Mortality with staph aureas: 70% with medical management decreases to 25% with surgical intervention
Splenic abscess 3-5%
○ Should be treated with drain placement
Mycotic aneurisms: 2-15%, 50% in cerebral vasculature
○ Some resolve with Abx so monitor with cerebral
angiography recommended
○ Persistent enlarging or periferal aneurisms should be
resected surgically if possible
Vegitations
○ 50% remain unchanged 3 months after cure is
achieved, and 25% have slight improvement
Prophylaxis:

Indications:
○ Prosthetic heart valves
○ Prior endocarditis
○ Unrepaired cyanotic congenital heart disease
○ Completely repaired congential heart disease
<6 months after repair)
○ Incompletely repaired congenital heart diease
with residual defects adjacent to prosthetic
material
○ Valvulopathy developing after cardiac
transplantation
Prophylaxis:

Regimens:
 Standard: amoxicillin 2.0 g PO 1 hour prior
to procedure
 If pen allergic:
- clarithromycin or azithro 500 mg prior to procedure
- Cefalexin 2.0 g PO prior to procedure
- Clindamycin 600 mg prior to procedure
Bibliography
Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of
infective endocarditis: utilization of specific echocardiographic
findings. Duke Endocarditis Service. American Journal of Medicine.
96(3):200-9, 1994.
 Jennifer S. Li, Daniel J. Sexton, Nathan Mick, Richard Nettles,
Vance G. Fowler, Jr., Thomas Ryan, Thomas Bashore, G. Ralph
Corey . Proposed Modifications to the Duke Criteria for the
Diagnosis of Infective Endocarditis. Clinical Infectious Diseases,
Vol. 30, No. 4 (Apr., 2000), pp. 633-638
 Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL,
Jameson JL, Loscalzo J. (2008). Harrison's principles of internal
medicine (17th ed.). Pp.789-798; New York: McGraw-Hill Medical
Publishing Division
 Fuster, O’rourke, Walsh, Poole-Wilson. (2008). Hurst’s The heart
Manual of Cardiology (12th ed.). 1975-2004. New York: McGrawHill Medical Publishing Division
