Endocarditis.ppt - Georgetown University - Department of Medicine

Endocarditis: Prophylaxis and Infection

Deborah Goldstein

ID Fellow

Georgetown University Hospital

October, 2008

Let’s talk about endocarditis…

• 1997 AHA Guideline for prevention

• 2007 Revised AHA Guideline

• Infective Endocarditis (IE): – Pathogenesis– Diagnosis– Treatment

• Cases, questions

1997 American Heart Assoc. Guidelines:Endocarditis Prophylaxis Recommended: High-risk category

Prosthetic cardiac valves, including bioprosthetic and homograft valves Previous bacterial endocarditis Complex cyanotic congenital heart disease (eg, single ventricle states, transposition of the great arteries, tetralogy of

Fallot) Surgically constructed systemic pulmonary shunts or conduits

Moderate-risk category Most other congenital cardiac malformations (other than above and below) Acquired valvar dysfunction (eg, rheumatic heart disease) Hypertrophic cardiomyopathy Mitral valve prolapse with valvar regurgitation and/or thickened leaflets

Endocarditis Prophylaxis Not Recommended: Negligible-risk category (no greater risk than the general population)

Isolated secundum atrial septal defect Surgical repair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus (without residua beyond 6 mo) Previous coronary artery bypass graft surgery Mitral valve prolapse without valvar regurgitation1 Physiologic, functional, or innocent heart murmurs1 Previous Kawasaki disease without valvar dysfunction Previous rheumatic fever without valvar dysfunction Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators

1997 AHA Guidelines

• Assumptions:– Bacteremia w/organisms known to cause IE occurs in assoc.

w/invasive dental/GI/GU procedures– Abx ppx was proven effective in animals– Abx ppx thought to be effective in human

• Class IIb, Level of Evidence C– Usefulness/efficacy is less well established by evidence/opinion– Only consensus opinion of experts, case studies, or standard of

care

• Complicated, ambiguous, inconsistent—per the guideline authors!

Reasons for 2007 Revision

• IE more likely due to frequent exposure to random bacteremias from daily activities than from bacteremia during dental/GI/GU procedure

• Prophylaxis may prevent an exceedingly small # of cases of IE, if any

• Risk of antibiotic-assoc. adverse events exceeds the benefit, if any, from ppx

• To reduce the risk of bacteremia from dental procedure: maintaining good oral health and hygiene is more important than Abx ppx

Frequency of Transient Bacteremia

• Tooth extraction 10-100%

• Periodontal surgery 36-88%

• Teeth cleaning 40%

• Tooth brushing, flossing 20-68%

• Using wooden toothpicks 20-40%

• Chewing food 7-51%

Risk of IE from dental procedures?

• No prospective, randomized, placebo-controlled studies exist on efficacy of Abx ppx in preventing IE after dental procedure

• The evidence linking bacteremia from dental procedures with IE is largely circumstantial– Case reports used time periods as long as 3-

6mos from dental procedure to onset of IE overestimation of cases

Circulation. 2007 Oct 9;116(15):1736-54.

2007: Who gets prophylaxis?

Only patients with the highest risk of adverse outcomes (heart failure, surgery, death) from endocarditis:

1. Prosthetic cardiac valve2. Previous IE3. Cardiac transplant recipients who develop

cardiac valvulopathy4. Congenital Heart Disease

Which categories of Congenital Heart Disease?

• Unrepaired cyanotic CHD – Tetralogy of Fallot, Transposition of Great Arteries,

including palliative shunts and conduits

• Completely repaired congenital heart defect with prosthetic material or device during 1st 6 months after surgery

• Repaired CHD with residual defects at or near a prosthetic patch/device (which inhibit endothelialization)

What about “Moderate-Risk” Pts?

1997’s “Moderate Risk” Category NO LONGER gets prophylaxis:

• MVP with regurg and/or thickened leaflets

• Hypertrophic cardiomyopathy

• Acquired Valvular Dysfunction (eg rheumatic heart disease)

Dental Procedures

• “If it bleeds, give prophylaxis”• High-risk pts undergoing all dental procedures that

involve manipulation of gingival tissues OR periapical region of teeth OR perforation of oral mucosa– i.e. biopsies, suture removal, placing orthodontic bands

• NO PROPHYLAXIS:– Xray, anesthetic injections, fluoride treatments– Shedding of deciduous teeth– Placement/adjustment of removable prosthodontic or

orthodontic appliances

Where is the periapical region of teeth?

• Periapical: the area that surrounds the root tip of a tooth

Prophylaxis for Dental Procedures• Goal: cover Strep Viridans• Single dose, 30-60 min prior to procedure

PO Amoxicillin 2g

PO, PCN-allergic

Cephalexin 2g OR Clinda 600mg OR Azithro 500mg**Don’t use Cephalexin if anaphylaxis, angioedema, or urticaria w/PCNs or ampicillin

IV: Ampicillin 2gm IV/IM OR Cefazolin 1g IV/IM OR Ceftriaxone 1g IV/IM

IV, PCN-allergic

Cefazolin 1g IV/IM OR Ceftriaxone 1g IV/IM OR Clinda 600mg IV/IM

What about resistant Strep Viridans?

Increasing resistance of Strep Viridans IE since 1990s• PCN-Resistance: 13%• Macrolide-Resistance: 26%• Clindamycin-Resistance: 4%• Impact of this resistance on antibiotic prophylaxis is

unknown• Quinolones or IV Vancomycin not recommended

for prophylaxis due to concern of creating new drug resistance

Respiratory Tract Procedures

• No published data linking resp tract procedures and IE....

• Consider prophylaxis for High-risk pts undergoing Invasive Procedure in resp tract with incision or biopsy of resp mucosa:

• Tonsillectomy• Adenoidectomy• Bronchoscopy WITH biopsy (not for BAL alone)• Resp tract procedure to drain abscess or empyema

GI/GU Procedures

• No published data linking GI/GU procedures and IE....

• NO prophylaxis for GI/GU procedures

Procedures on Infected Skin/Skin Structure, or Msk Tissue

In patients who are HIGH-risk for IE:

• The antibiotic regimen given to treat the skin or musculoskeletal infection should contain an Anti-staphylococcal PCN or cephalosporin

• If unable to take PO or PCN-allergic: Clindamycin or Vancomycin

Summary: IE prophylaxis

• Need high-risk pt PLUS high-risk procedure• High-risk pts:

1. Prosthetic cardiac valve2. Previous IE3. Cardiac transplants w/ valvulopathy4. Congenital Heart Disease

• High-risk procedures:1. Dental: “If it bleeds, give prophylaxis”2. Respiratory: Consider if pt will be cut or biopsied3. GI/GU: never

No Prophylaxis

• Endotracheal intubation• Cardiac cath/stent• Pacer/ICD implantation• EGD, Colonoscopy• Barium Enema• TEE• Incision/Bx of surgically scrubbed skin• Circumcision• Vaginal delivery• Hysterectomy

Question #1

Which of the following patients would definitely need endocarditis prophylaxis?

A. Patient w/MVP going for banding for esophageal varices

B. Patient w/VSD going for colonoscopy

C. Patient w/ 3 coronary stents going for TEE

D. Patient w/ASD going for C-section

E. Patient w/prosthetic valve going for dental extraction





What regimen would you give? If he was PCN-allergic?

A. Amoxicillin 2 g PO 1 hr before procedure

B. Vancomycin 1 g IV 30min before procedure

C. Cefazolin/Ancef 1g IM before and after procedure

D. Clindamycin 600mg PO 1h before procedure


PO Amoxicillin 2g

PO, PCN-allergic



IV, PCN-allergic


Question #2

Endocarditis Prophylaxis is indicated in a patient with…

A. Ostium secundum defect undergoing vaginal hysterectomy

B. Bioprosthetic valve undergoing TEE

C. Completely repaired congenital heart defect in 2004, now undergoing cystoscopy

D. Repaired Congenital Heart Disease 3 months ago, now undergoing tonsillectomy

High-Risk Categories of Congenital Heart Disease

• Unrepaired cyanotic CHD (Tetralogy of Fallot, Transposition of Great Arteries), including palliative shunts and conduits

• Completely repaired congenital heart defect with prosthetic material or device during 1st 6 months after surgery

• Repaired CHD with residual defects at or near a prosthetic patch/device (which inhibit endothelialization)

Respiratory Tract Procedures

• No published data linking resp tract procedures and IE....

• Consider prophylaxis for High-risk pts undergoing Invasive Procedure in resp tract with incision or biopsy of resp mucosa:

• Tonsillectomy• Adenoidectomy• Rigid Bronchoscopy + biopsy (not for BAL alone)• Resp tract procedure to drain abscess or empyema

Question #3

A 42 yo man s/p cardiac transplant 2 years ago with mitral regurgitation makes his first visit to your office. He reports that he has not been to the dentist for a while.

He is allergic to Penicillin.

You URGE him to go to a dentist for regular cleanings….

Question #3

What should be recommended to this patient before he undergoes dental cleaning?

A. No antibioticsB. Amoxicillin 2 g PO, 1 hr before each visitC. Azithromycin, 500mg PO, 1 hour before and 6

hours after each visitD. Clindamycin 600mg PO, 1 hour before each visitE. Vancomycin 1 g PO, 1 hour before each visit






PO Amoxicillin 2g

PO, PCN-allergic



IV, PCN-allergic


Question #4

You are asked to evaluate a 54 yo female with bloody diarrhea, prior to an elective colonoscopy to rule out for Inflammatory bowel disease.

She has a history of acute bacterial endocarditis related to prior IV drug use.

She reports an urticarial rash with penicillin.

Question #4

Which of the following is the most appropriate prophylaxis for this patient?

A. No antibiotics

B. Cefazolin 1 g IV

C. Vancomycin 1 g IV, plus Gent 1.5mg/kg IV

D. Clindamycin 600 mg IV





GI/GU Procedures

• No published data linking GI/GU procedures and IE....

• NO prophylaxis for GI/GU procedures

Infective Endocarditis

• Pathogenesis• Classification• Micro• Native, Prosthetic, IVDU, Culture-Negative• Clinical Findings• Diagnosis

– Duke’s Criteria– TTE vs TEE

• Therapy

IE Pathogenesis

• Turbulent blood flow (from congenital or acquired heart dz)Endothelial trauma

• Platelets and fibrin deposit on damaged endothelium Nonbacterial Thrombotic Endocarditis (NBTE)

• Bacteremia Colonization of NBTE Bacterial Vegetation

Endocarditis Classification

• Acute– Virulent! Staph aureus, GNR– Normal valves– Acute course with rapid valve destruction, HF

• Subacute (SBE)– Strep, Enterococcus, Staph epi– Underlying cardiac dz– More indolent presentation: low-grade fever, murmur

• Native valve, addict, prosthetic valve, culture-neg

Native Valve IE

1779 pts, 39 med centers, 16 countries:• 32% Staph aureus• 18% Strep Viridans • 11% Coag neg staph, 11% Enterococci• 8% Culture negative• 7% Strep bovis• 5% Other strep• 2% GNR, 2% Fungi, 2% HACEK

Fowler et al. JAMA 2005; 293:3012.

Why Staph, Strep, Enterococcus?

• They contain adhesins that attach to the fibrin platelet matrix of NBTE

• Adhesins also attach to the matrix proteins that coat implanted medical devices

• Bacterial extracellular structures form biofilm on surface of implancted devices

Cohen and Powderly, Infectious Diseases, 2nd Ed.

Prosthetic Valve Endocarditis• Risk of IE

– 1% at 12 mos, 2-3% at 60 mos post-op

• EARLY: < 2 months post-op– #1 cause: Staph aureus (used to be staph epi)– Usually acquired in the hospital: direct intra-op

contamination or post-op hematogenous spread– Anchoring sutures and valve ring are not yet

endothelialized, so more vulnerable

• LATE: > 12 months post-op– Endothelialization occurs over months, making it more

difficult for bugs to adhere. Community-acquired.

Mylonakis et al, NEJM 2001. Wang et al, JAMA 2007.

IVDU

• Classic teaching: IVDU Right-sided IE– But left-sided IE may actually be more

common

• 50% Staph Aureus• 15% Enterococcus• 8% each: Strep, GNR (Pseudomonas or

Serratia), Candida• May be polymicrobial

Culture Negative Endocarditis• #1 cause: Prior antibiotic use• HACEK group (Haemophillis, Actinobacillus,

Cardiobacteria, Eikenella, Kingella)• Legionella, Chlamydia• Bartonella, Brucella, Coxiella Burnetii (Q Fever)• Fungal

Dx: Serologies, holding blood cultures for 21 days, PCR of emboli or valve vegetation, use of special growth medium

If I say…

• Dental procedures Strep Viridans GI Malignancy Strep Bovis

• Prosthetic valve Staph aureus, staph epi

• Older men with prostate surgery Enterococcus

• IV drugs user Staph aureus, Gram negative rods

Diagnosis of IE

• Fever, new murmur or heart failure, bacteremia• Systemic findings of emboli• Neurologic impairment• EKG

– New AV block or BBB suggests perivalvular invasion

• CXR– Septic pulmonary emboli

Septic Emboli

Roth Spots

Pale retinal lesions surrounded by hemorrhage, usu near optic disk

Janeway LesionsNontender, erythematous, hemorrhagic or pustular lesions on palms, soles

Petechiae

• Not specific for IE but common

• Splinter Hemorrhages

–Linear, under nailbeds

• Conjunctival Petechiae

–Hemorrhages on eversion of eyelid

Osler Nodes

● Tender, subcutaneous nodules● Pulp of the digits or thenar eminence

4 P’s:PinkPainfulPea-sized Pulp of fingers/toes

TTE vs TEETTE:

• 98% Specificity for veg

• Sensitivity <60%; less in obesity, COPD

• Begin with TTE if pt is good candidate for imaging surface, has native valves, or has low probability of IE

TEE:

• Invasive, costly

• Sens 75-95%, Spec 85-98%. Neg TEE: NPV >92%

• Consider for pts w/prosthetic valves, high probability of endocarditis, and to evaluate myocardial abscess, perivalvular extension

Major Duke’s Criteria

Definite IE: 2 major, 1 major + 3 minor, or 5 minor

• (+) blood cultures with appropriate organism

• Evidence of Coxiella burnetii infection

• New Valvular regurgitation

• + Echo findings

Minor Duke’s Criteria

• High-risk for IE, or h/o IVDU• Temperature > 38oC• Vascular Phenomena

– Arterial embolism, septic pulm infarcts, mycotic aneurysm, intracranial hemorrhage, Janeway lesions

• Immunologic phenomena– Osler’s nodes, Roth spots, GN, Rheumatoid factor

• Serologic studies• Blood cultures or echo results not meeting the major

criteria

Therapy: General comments

• Prolonged IV administration of bactericidal agents(s) x 4-6 wks

• Culture-negative native-valve endocarditis should be individualized and generally includes penicillin, ampicillin, ceftriaxone, or vanc, +/- aminoglycoside

Indications for Surgery

• Refractory CHF, Severe valvular dysfunction• Uncontrolled infection• Valve perforation, dehiscence, fistula, abscess• 1 embolic event with persistent large vegetation,

or >1 episode of embolization• Prosthetic valve infection• Fungal IE• New heart block…

Questions?

Case 1

• 55yoF with Hepatitis C, cirrhosis admitted to OSH with enterococcal bacteremia. Suboptimally treated with oral antibiotics.

• Transferred to GUH. Bcx 4/4 bottles + Enterococcus faecalis.

• CT A/P: splenic infarcts• TTE: mild MV thickening with mild MR, mild AI• TEE 1.4cm aortic valve vegetation, no abscess• Treated with Ampicillin/Gent for 6 wks.

Case 2

• 45yo F with ESRD on HD had a St. Jude’s aortic valve placed for severe AI in 2005. In 2006, she was admitted to WHC with severe sepsis, found to have emboli to her brain and spleen. Blood cultures grew MSSA.

• TTE revealed prosthetic valve endocarditis. • TEE showed aortic valve annular abscess, and she

underwent replacement of her AV prosthetic valve.

• Treated with Vanc, Gent, and Rifampin.

Case 2, continued

• This same patient presented in 12/07 to GUH with hip pain. She developed a leukocytosis of 15K, afebrile. 1 set of blood cultures drawn prior to antibiotics were negative. Pt was started on empiric broad-spectrum antibiotics. ID service was consulted for leukocytosis.

• TTE: Mobile 4mm thrombus vs. veg in left ventricle.

• TEE: 0.6cm mobile vegetation on mitral valve, aortic valve negative.

Case 2, continued

• Subsequent blood cultures were all negative.

• Work-up for Culture-negative endocarditis: negative serologies for Coxiella, Bartonella, Brucella. Blood cultures negative after 21 d. Pt denied suspicious exposures.

• Treated with Cefepime, Vancomycin, Gentamycin x6 wks.

Case 3

• 69yo Female with ESRD on HD, AICD for ischemic cardiomyopathy, admitted with hypotension. Blood cultures grew coagulase negative staph (Staph epidermidis). After 2 wks of persistently positive blood cultures despite IV vancomycin therapy, pt had negative TTE.

• Sources of her ongoing bacteremia included her prosthetic hip (negative aspiration), her dialysis Quenton (removed twice), and her AICD leads.

Case 3, continued

• After another 2 wks of persistently positive blood cultures, she had a TEE.

• TEE: 3 small aortic valve vegetations, no perivalvular abscess.

• Gentamycin IV and Rifampin PO added to Vancomycin.

• Concern for infection of pacemaker leads. Transferred to GW for removal of AICD.

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Endocarditis.ppt - Georgetown University - Department of Medicine