ENDOCARDITISENDOCARDITIS

CLASSIFICATION OF CLASSIFICATION OF ENDOCARDITISENDOCARDITIS

Acute Subacute

Organism S. aureus ViridansStreptococci

Heart valve Normal Damaged

Metastaticfoci

Yes No

Fatal < 6 weeks 6 wks - 1 yr

CATEGORIES OF CATEGORIES OF ENDOCARDITISENDOCARDITIS

Native valveNative valve

Prosthetic valveProsthetic valve

IVDAIVDA

AETIOLOGY OF NATIVE AETIOLOGY OF NATIVE VALVE ENDOCARDITISVALVE ENDOCARDITIS

StreptococciStreptococci 55%55% StaphylococciStaphylococci 30%30% EnterococciEnterococci 6%6% Gram negative bacilliGram negative bacilli rarerare FungiFungi rarerare

EPIDEMIOLOGY OF NATIVE EPIDEMIOLOGY OF NATIVE VALVE ENDOCARDITISVALVE ENDOCARDITIS

MaleMale Age > 50 yrsAge > 50 yrs Mitral valve > aortic valve >>> Mitral valve > aortic valve >>>

tricuspidtricuspid Predisposing FactorsPredisposing Factors

– mitral valve prolapsemitral valve prolapse– congential heart diseasecongential heart disease

PROSTHETIC VALVE PROSTHETIC VALVE ENDOCARDITISENDOCARDITIS

Early onset - symptoms within 60 days Early onset - symptoms within 60 days of surgeryof surgery– usually valve contaminated during surgeryusually valve contaminated during surgery– S. epidermidisS. epidermidis– S. aureusS. aureus– Gram-negative bacilliGram-negative bacilli

Late onset - symptoms occur > 60 days Late onset - symptoms occur > 60 days after surgeryafter surgery– usually due to Streptococciusually due to Streptococci

INTRAVENOUS DRUG INTRAVENOUS DRUG ABUSERSABUSERS

Tricupsid (50%) > aortic (25%) > mitral Tricupsid (50%) > aortic (25%) > mitral (20%)(20%)

S. aureusS. aureus >50%>50% StreptococciStreptococci 20%20% EnterococciEnterococci 20%20% Gram negative bacilli Gram negative bacilli 5% 5% FungiFungi 5% 5%

CLINICAL CLINICAL MANIFESTATIONS OF MANIFESTATIONS OF

ENDOCARDITISENDOCARDITISSymptomsSymptoms PercentagePercentage

FeverFever 8080

Chills/Weakness/DyspnoeaChills/Weakness/Dyspnoea 4040

Cough/Anorexia/Wt lossCough/Anorexia/Wt loss 2525

Skin lesions/Stroke/N/V/HASkin lesions/Stroke/N/V/HA 2020

Myalgia/Arthralgia/Oedema/CPMyalgia/Arthralgia/Oedema/CP 1515

Delirium/Haemoptysis/Back painDelirium/Haemoptysis/Back pain 1010

CLINICAL CLINICAL MANIFESTATIONS OF MANIFESTATIONS OF

ENDOCARDITISENDOCARDITISPhysical FindingsPhysical Findings PercentagePercentage

FeverFever 9090

Heart murmurHeart murmur 8585

Embolic phemomenomEmbolic phemomenom >50>50

Skin manifestationsSkin manifestations 18-5018-50

SplenomegalySplenomegaly 20-5720-57

Septic complicationsSeptic complications 2020

ClubbingClubbing 12-5212-52

CLINICAL INVESTIGATIONSCLINICAL INVESTIGATIONS

FBC U+E Cr LFTFBC U+E Cr LFT Multiple Blood Cultures (At least 3 Multiple Blood Cultures (At least 3

from 2 different sites)from 2 different sites) ESR CRPESR CRP TTE TTE TOE TOE CT/MRI (embolic phenomena) CT/MRI (embolic phenomena)

CRITERIA FOR DIAGNOSIS CRITERIA FOR DIAGNOSIS OF ENDOCARDITISOF ENDOCARDITIS

DefiniteDefinite– Pathologic criteriaPathologic criteria– Clinical criteriaClinical criteria

2 major or 1 major and 3 minor or 5 minor 2 major or 1 major and 3 minor or 5 minor

Possible if not definite or rejectedPossible if not definite or rejected RejectedRejected

– Alternate diagnosisAlternate diagnosis– No evidence at surgery or resolution of No evidence at surgery or resolution of

endocarditis with < 4 days of abx therapyendocarditis with < 4 days of abx therapy

MAJOR CRITERIA FOR IEMAJOR CRITERIA FOR IE

Positive blood culture for IEPositive blood culture for IE– Typical organism from 2 separate Typical organism from 2 separate

blood cultures orblood cultures or– Persistently positive blood culturesPersistently positive blood cultures

Evidence of endocardial Evidence of endocardial involvementinvolvement– Positive echocardiogramPositive echocardiogram– New valvular regurgitationNew valvular regurgitation

MINOR CRITERIA FOR IEMINOR CRITERIA FOR IE

PredispositionPredisposition FeverFever Vascular phenomenaVascular phenomena Immunologic phenomenaImmunologic phenomena EchocardiogramEchocardiogram Microbiologic evidenceMicrobiologic evidence

INDICATIONS FOR SURGERYINDICATIONS FOR SURGERYHeart Failure – Severe

- Moderate- Mild

531

552

Fungal etiology 5 5Persistent bacteremia 5 5Organism other than S strep. 1 2Relapse 2 31 major embolus 2 22 or more emboli 4 4Vegetation on echo 1 1Right-sided disease -2 NAHeart block 3 3Unstable prosthesis NA 5Early PVE (< 60 days) NA 2Prior prosthetic valve replace NA -2

NVE PVE

5 or more pointssuggest the needfor valve replacement

VIRIDANS STREPTOCOCCIVIRIDANS STREPTOCOCCI

S. sanguisS. sanguis S. mutansS. mutans S. mitisS. mitis S. milleriS. milleri S. bovisS. bovis Normal inhabitants of the Normal inhabitants of the

oropharynxoropharynx

RARE ORGANISMSRARE ORGANISMS

CorynebacteriumCorynebacterium Listeria Listeria Bartonella SpeciesBartonella Species Coxiella Burnetti (Q fever)Coxiella Burnetti (Q fever)

NATIVE VALVE ENDOCARDITIS DUE TO NATIVE VALVE ENDOCARDITIS DUE TO PENICILLIN SUSCEPTIBLE VIRIDANS PENICILLIN SUSCEPTIBLE VIRIDANS

STREPTOCOCCI (MIC 0.1 µg/ml)STREPTOCOCCI (MIC 0.1 µg/ml)

Antibiotic Dosage &Route

Duration, wk

PCN G 12-18 mu/d 4

Ceftriaxone 2 g qd 4

PCN G +Gentamicin

12-18 mu/d1 mg/kg q8h

22

Vancomycin 30 mg/kg/d 4

JAMA 1995;274:1706-1713.

NATIVE VALVE ENDOCARDITIS DUE TO NATIVE VALVE ENDOCARDITIS DUE TO VIRIDANS STREPTOCOCCI (MIC 0.1 VIRIDANS STREPTOCOCCI (MIC 0.1

AND < 0.5 µg/ml)AND < 0.5 µg/ml)Antibiotic Dosage &

RouteDuration, wk

PCN G +Gentamicin

18 mu/day1 mg/kg q8h

42

Cefazolin +Gentamicin

2 g q8h1 mg/kg q8h

42

Vancomycin 30 mg/kg/d 4

JAMA 1995;274:1706-1713.

ENTEROCOCCI ENTEROCOCCI ENDOCARDITISENDOCARDITIS

Antibiotic Dosage &Route

Duration, wk

PCN G +Gentamicin

18-30 mu/d1 mg/kg q8h

4-64-6

Ampicillin +Gentamicin

12 g/day1 mg/kg q8h

4-64-6

Vancomycin+ Gentamicin

30 mg/kg/d1 mg/kg q8h

4-64-6

JAMA 1995;274:1706-1713.

STAPHYLOCOCCUS ENDOCARDITIS STAPHYLOCOCCUS ENDOCARDITIS IN THE ABSENCE OF PROSTHETIC IN THE ABSENCE OF PROSTHETIC

VALVEVALVE

Antibiotic Dosage &Route

Duration

Nafcillin ±Gentamicin

2 g q4h1 mg/kg q8h

4-6 wk3-5 d

Cefazolin ±Gentamicin

2 g q8h1 mg/kg q8h

4-6 wk3-5 d

Vancomycin 30 mg/kg/d 4-6 wk

JAMA 1995;274:1706-1713.

STAPHYLOCOCCAL ENDOCARDITIS STAPHYLOCOCCAL ENDOCARDITIS IN THE PRESENCE OF A IN THE PRESENCE OF A

PROSTHETIC VALVEPROSTHETIC VALVEAntibiotic Dosage &

RouteDuration, wk

Nafcillin +Rifampin +Gentamicin

2 g IV q4h300 mg q8h1 mg/kg q8h

662

Vancomycin+ Rifampin +Gentamicin

30 mg/kg/d300 mg q8h1 mg/kg q8h

662

JAMA 1995;274:1706-1713.

HACEK ORGANISMSHACEK ORGANISMS

Haemophilus parainfluenzaeHaemophilus parainfluenzae Haemophilis aphrophilusHaemophilis aphrophilus Actinobacillus Actinobacillus

actinomycetemcomitansactinomycetemcomitans Cardiobacterium hominisCardiobacterium hominis Eikenella corrodensEikenella corrodens Kingella kingaeKingella kingae

ENDOCARDITIS DUE TO ENDOCARDITIS DUE TO HACEK ORGANISMSHACEK ORGANISMS

Antibiotic Dosage &Route

Duration, wk

Ceftriaxone 2 g qd 4

Ampicillin +Gentamicin

12 g/day1 mg/kg q8h

44

JAMA 1995;274:1706-1713.

CARDIAC CONDITIONS ENDOCARDITIS CARDIAC CONDITIONS ENDOCARDITIS PROPHYLAXIS RECOMMENDEDPROPHYLAXIS RECOMMENDED

High Risk ConditionsHigh Risk Conditions–Prosthetic valvesProsthetic valves–Previous bacterial endocarditisPrevious bacterial endocarditis–Complex congenital heart diseaseComplex congenital heart disease–Surgically constructed pulmonic shuntsSurgically constructed pulmonic shunts

Moderate Risk ConditionsModerate Risk Conditions–Most other Coronary Heart DiseasesMost other Coronary Heart Diseases–Mitral prolapse with regurgitationMitral prolapse with regurgitation–Hypertrophic cardiac myopathyHypertrophic cardiac myopathy

CARDIAC CONDITIONS ENDOCARDITIS CARDIAC CONDITIONS ENDOCARDITIS PROPHYLAXIS NOT RECOMMENDEDPROPHYLAXIS NOT RECOMMENDED

Cardiac pacemakers and implanted defibrillatorsCardiac pacemakers and implanted defibrillatorsRheumatic fever without valve dysfunctionRheumatic fever without valve dysfunctionPhysiologic, functional heart murmursPhysiologic, functional heart murmursMitral valve prolapse without MIMitral valve prolapse without MIPrevious CABGPrevious CABGAtrial septal defectAtrial septal defect

DENTAL AND OTHER PROCEDURES DENTAL AND OTHER PROCEDURES FOR ENDOCARDITIS PROPHYLAXISFOR ENDOCARDITIS PROPHYLAXIS

Dental - extractions, periodontal procedures, implants, Dental - extractions, periodontal procedures, implants, root canalroot canal

Respiratory - T&A, rigid bronchoscopyRespiratory - T&A, rigid bronchoscopyGI - ERCP with biliary obstruction, Sclerotherapy of GI - ERCP with biliary obstruction, Sclerotherapy of esophageal varices, dilation of esophagealesophageal varices, dilation of esophageal

Biliary tract surgery, surgery on/through intestinal Biliary tract surgery, surgery on/through intestinal mucosamucosa

GU - prostate surgery, cystoscopy, urethral dilatationGU - prostate surgery, cystoscopy, urethral dilatation

PROCEDURES ENDOCARDITIS PROCEDURES ENDOCARDITIS PROPHYLAXIS IS NOT RECOMMENDEDPROPHYLAXIS IS NOT RECOMMENDED

Dental - filling cavities, orthodontic adjustments, dental x-raysDental - filling cavities, orthodontic adjustments, dental x-raysRespiratory - Intubation, flexible bronchoscopyRespiratory - Intubation, flexible bronchoscopyGI - transoesophageal echoGI - transoesophageal echoGU - vaginal hysterectomy, vaginal delivery, C-section, GU - vaginal hysterectomy, vaginal delivery, C-section, insert/remove IUD, foley catheterinsert/remove IUD, foley catheter

Other - cardiac catheter, balloon angioplasty, implanted Other - cardiac catheter, balloon angioplasty, implanted pacemaker, defibrillators, circumcision, skin biopsy, coronary pacemaker, defibrillators, circumcision, skin biopsy, coronary stentsstents

PROPHYLACTIC REGIMENS PROPHYLACTIC REGIMENS FOR GU/GI PROCEDURESFOR GU/GI PROCEDURES

SITUATION AGENT REGIMEN

High-risk pts Ampicillin +Gentamicin

2 g IV or IM +1.5 mg/kg

High-risk ptsallergic to PCN

Vancomycin +Gentamicin

1 g IV over 1 hr +1.5 mg/kg

Moderate-risk pts Amoxycillin orAmpicillin

2 g po or2 g IV or IM

Moderate-risk ptsallergic to PCN

Vancomycin 1 g IV over 1 hr

PROPHYLACTIC FOR DENTAL, ORAL, PROPHYLACTIC FOR DENTAL, ORAL, RESPIRATORY OR OESOPHAGEALRESPIRATORY OR OESOPHAGEAL

SITUATION AGENT REGIMEN

Standard proph. Amoxicillin 2 g po

Unable to take po Ampicillin 2 g IM or IV

Allergic to PCN ClindamycinCephalexinAzi or clari

600 mg po2 g po500 mg po

Allergic to PCN &unable to take po

ClindamycinCefazolin

600 mg IV1 g IV

FAILURE TO RESPOND TO TREATMENTFAILURE TO RESPOND TO TREATMENTAbscess formationAbscess formation

- paravalvar- paravalvar

- metastatic- metastatic

Low cardiac outputLow cardiac output- flail mitral valve or perforation- flail mitral valve or perforation - coronary embolism - coronary embolism

- free aortic regurgitation- free aortic regurgitation

Wrong diagnosisWrong diagnosis- lymphoma- lymphoma - SLE- SLE - TB- TB

- sarcoidosis- sarcoidosis - AIDS- AIDS

Major Immune ActivationMajor Immune Activation- renal failure- renal failure - emboli- emboli

- vasulitis- vasulitis