Endocarditis 2

7/27/2019 Endocarditis 2

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Infective Endocarditis

Suhail Allaqaband

Sinai Samaritan Medical Center

Milwaukee, WI


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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


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RISK FACTORS

Injection drug use

Highest risk factor in patients < 40 years of age

Prosthetic heart valves

Prosthetic valve endocarditis comprises a smallbut important segment of IE cases

More than 100,000 heart valves are implanted

annually in the United StatesIE develops in 1 to 4 % of valve recipients during

the 1st year following valve replacement, and in

approximately 1 percent per year thereafter


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RISK FACTORS

Nosocomial endocarditisUsually a complication of bacteremia induced by an

invasive procedure or a vascular device

Structural heart diseaseApproximately 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


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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


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RISK FACTORS

History of infective endocarditisRecurrent 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


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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 boweldisease have a poorly understood predilection to

develop endocarditis secondary to Strep.bovis


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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


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Duke Criteria

Definitive infective endocarditispathologic 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


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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


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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


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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, staphaureus 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


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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 inpre-existing murmur not sufficient)


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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


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Dukes Minor Criteria

immunologic phenomena

Glomerulonephritis

Rheumatoid factor

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

Oslers nodes

Roth spots


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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 criteriaNew criteria for diagnosis of infective endocarditis:

Utilization of specific echocardiographic findings.

Duke Endocarditis Service Am J Med 1994; 96:200


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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 regurgitantmurmurs and signs of CHF

Neurologic evaluation may detect evidence of focal neurologic

impairment


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Positive blood culture resultsA 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 normochromicnormocytic anemia

The WBC count may be normal or elevated


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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 serumcomplement level may be an indicator of immune-mediated

glomerular disease


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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


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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 valvesshould 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


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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 vegetationsof 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 vegetationsgreater than 11 mm detected by TEE were also

observed with TTE


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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%)


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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 causeof the endocarditis should be performed in all

patients


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Treatment of infective endocarditis

GENERAL CONSIDERATIONS

The duration of therapy has to be sufficient to

eradicate microorganisms growing within thevalvular vegetations

The need for prolonged therapy in treating

endocarditis has stimulated interest in using

combination therapy to treat endocarditis


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VIRIDANS STREPTOCOCCI AND STREP. BOVIS

Antibiotic Dosage and route Duration Comments

Aqueous crystalline 12-18 million U/24 h 4 wks preferred in most patients older than 65 yrspenicillin G sodium IV either continuously and in those with impairment of the eighth

or in 6 = divided doses nerve or renal function

or

Ceftriaxone sodium 2g once daily IV or IM 2 wks

Aqueous crystalline 12-18 million U/24 h 2 wks when obtained 1h after a 20-30 min.

penicillin G sodium IV either continuously IV infusion or IM injection, serumor in six equally concentration of gentamicin of

divided doses approximately 3 mcg/mL is desirable;

with gentamicin 1 g IM or IV every 8 h 2 wks trough concentration should be < 1 pg/mL

sulfate

Vancomycin 30 mg/kg per 24 h IV 4 wks vancomycin therapy is recommended for

hydrochloride in two equally divided patients allergic to beta lactams; peak

doses, not to exceed 2 serum concentrations of vancomycin should

gram/24h unless serum be obtained one h after completion of the

levels are monitored infusion and should be in the range of

30-45 mcg/mL for twice-daily dosing

JAMA 1995; 274:1706

ENTEROCOCCI


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ENTEROCOCCI


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STAPH. ENDOCARDITIS IN NATIVE VALVES


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STAPH. ENDOCARDITIS IN PROSTHETIC VALVES


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HACEK ORGANISMS


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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, includingevidence of perivalvular extension

Recurrent emboli, particularly in the presence of

large vegetations


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Indications for surgery in IE

Relative indications for surgeryEvidence of perivalvular infection, such as

intracardiac abscess or fistula formation

Rupture of a sinus of Valsalva aneurysmFungal endocarditis

Endocarditis due to highly resistant microorganism

Relapse after a course of adequate antimicrobialtherapy, particularly in prosthetic valve endocarditis

Culture-negative IE with fever more than 10 days

after starting empirical therapy


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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


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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 earlymortality, 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, preoperativeacute renal failure, and staphylococcal infection

Operation for infective endocarditis: Results after implantation

of mechanical valves. Ann Thorac Surg 1998; 65:359.

recommen a on or surgery n pa en s w


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recommen a on or surgery n pa en s w

native valve endocarditis

ACC/AHA recommendation for surgery in patients with


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ACC/AHA recommendation for surgery in patients with

prosthetic valve endocarditis


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ACC/AHA recommendation for valve replacement with

mechanical prosthesis


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ACC/AHA recommendation for

valve replacement with bioprosthesis

Endocarditis 2

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