Endocarditis: Difference between revisions
 
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==Background==
==Background==
*Defined as an infection of the endocardial surface of the heart, affecting native (or prosthetic) heart valves as well as in-dwelling cardiac devices
*Consider in patients with known risk factors and unexplained fever
*Consider in patients with known risk factors and unexplained fever
*Mitral valve most commonly affected overall; tricuspid valve most common in IVDA
*Mitral valve most commonly affected overall; tricuspid valve most common in IVDA
*Noninfectious vegetations can arise in patients with malignancy/SLE/ Hypercoagulable state
*Noninfectious vegetations can arise in patients with malignancy/[[SLE]]/Hypercoagulable state ("Marantic" endocarditis)
*[[S. aureus]] is single most common cause
*[[S. aureus]] is single most common cause (accounts for 1/3 of all cases)<ref>Selton-Suty C, Célard M, Le Moing V, et al. Preeminence of Staphylococcus aureus in infective endocarditis: a 1-year population-based survey. Clin Infect Dis. 2012;54(9):1230-1239. doi:10.1093/cid/cis199</ref>
*[[Strep viridans]] is the most common cause of native valve endocarditis, excluding risk factors below
*[[Blood cultures]] are falsely negative ~5% (think HACEK organisms)
*[[Blood cultures]] are falsely negative ~5% (think HACEK organisms)
*Only 20% have an increase in a known murmur and only 48% have a new murmur<ref name="Hoen">Hoen, B. et al. Infective Endocarditis. NEJM. 2013. 368;15. 1425-1433 [http://www.cardioaragon.es/web/pdf/InfectiveEndocarditisNEJM2013.pdf PDF]</ref>
*Only 20% have an increase in a known murmur and only 48% have a new murmur<ref name="Hoen">Hoen, B. et al. Infective Endocarditis. NEJM. 2013. 368;15. 1425-1433 [http://www.cardioaragon.es/web/pdf/InfectiveEndocarditisNEJM2013.pdf PDF]</ref>
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**Tricuspid valve most commonly affected
**Tricuspid valve most commonly affected
*Prosthetic heart valve
*Prosthetic heart valve
**Coagulase negative staphylcocci are substantial etiologies in this patient population<ref>Lalani T et al. Prosthetic valve endocarditis due to coagulase-negative staphylococci: findings from the International Collaboration on Endocarditis Merged Database. Eur J Clin Microbiol Infect Dis. 2006 Jun;25(6):365-8.</ref>
**Coagulase negative [[staph]]ylcocci are substantial etiologies in this patient population<ref>Lalani T et al. Prosthetic valve endocarditis due to coagulase-negative staphylococci: findings from the International Collaboration on Endocarditis Merged Database. Eur J Clin Microbiol Infect Dis. 2006 Jun;25(6):365-8.</ref>
*Structural heart disease
*Structural heart disease
**Rheumatic heart disease
**Rheumatic heart disease (biggest risk factor in low-income countries)
**Mitral valve prolapse
**Mitral valve prolapse
**Bicuspid aortic valve
**Bicuspid aortic valve
*Hemodialysis
*[[Hemodialysis]]
*[[HIV]] infection
*[[HIV]] infection
*Fungal endocarditis risk factors, with Candida most common
*[[Fungal infections|Fungal]] endocarditis risk factors, with [[Candida]] most common
**Prolonged antibiotics
**Prolonged antibiotics
**TPN through central line
**TPN through central line
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==Clinical Features==
==Clinical Features==
[[File:Splinter hemorrhage.jpg|thumb|Splinter hemorrhage]]
[[File:Splinter hemorrhage.jpg|thumb|Splinter hemorrhage]]
===Fever===
[[File:Osler Nodules Hand.jpg|thumb|Osler's nodes.]]
*Present in 80% of cases
[[File:PMC5072319 12879 2016 1912 Fig2 HTML.png|thumb|Janeway lesions]]
 
[[File:PMC5059132 kjtcv-49-408f1.png|thumb|Roth spots on fundoscopy (A); 2 weeks after treatment (B); 6 weeks after treatment.]]
===Heart murmur===
*[[Fever]]
*Preexisting murmur found in 85% of cases; new murmur found in 48%
**Present in 80% of cases
 
*Heart [[murmur]]
===CHF===
**Preexisting murmur found in 85% of cases; new murmur found in 48%
*Acute or progressive (70%)
*[[CHF]]
===Embolic manifestations===
**Acute or progressive (70%)
====CNS====
*Derm
*65% of emboli involve the CNS<ref>Mylonakis. E, Calderwood S. Infective endocardidits in adults. NEJM. 2001;345(18):138-1330</ref>
**Osler nodes
*Central retinal artery occlusion
***Tender red/purple nodules on distal finger and toes
====Pulmonary====
**Splinter hemorrhages
*Pneumonia
***Nail bed hemorrhages not extending the length of the nail
*Empyema
**Janeway lesions
*Pulmonary emboli
***Non-tender, small erythematous or hemorrhagic macular, papular or nodular lesions on the palms or soles only a few millimeters in diameter
 
*CNS
====Cardiac====
**65% of emboli involve the CNS<ref>Mylonakis. E, Calderwood S. Infective endocardidits in adults. NEJM. 2001;345(18):138-1330</ref>
*MI
**[[Central retinal artery occlusion]]
*Myocarditis
*Pulmonary
 
**[[Pneumonia]]
====Abdominal Organs====
**[[Empyema]]
*Bowel, renal, splenic infarcts
**[[Pulmonary emboli]]
====Derm====
*Cardiac
*Osler nodes - tender red/purple nodules on distal finger and toes
**[[MI]]
*Splinter hemorrhages - nail bed hemorrhages not extending the length of the nail
**[[Myocarditis]]
*Janeway lesions - painless macules  on palms and soles due to microabscesses
*Abdominal  
**Bowel, renal, splenic infarcts
*Ophtho
**Roth spots
***White centered retinal hemorrhage
***Associated with multiple systemic illnesses, most commonly bacterial endocarditis


==Differential Diagnosis==
==Differential Diagnosis==
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==Evaluation==
==Evaluation==
[[File:PMC4497914 kjim-30-434-g003.png|thumb|Echocardiography showing typical vegetation on aortic valve (arrow).]]
[[File:PMC2649868 ymj-50-152-g001.png|thumb|Transthoracic echocardiography shows vegetations (arrows) on both mitral leaflets; (A) Diastole. (B) Systole. LA, left atrium; LV, left ventricle; Ao, aorta.]]
[[File:PMC5412748 JCE-27-33-g010.png|thumb|Vegetations in infective endocarditis (arrows). (a) Transthoracic echocardiogram parasternal long-axis view showing vegetation on native aortic valve; (b) transesophageal echocardiography long axis of endocarditis of native aortic valve; (c) transesophageal echocardiography visualization of vegetation on the atrial side of mechanical mitral valve; (d) transesophageal echocardiography showing endocarditis of bioprosthetic mitral valve. LA: Left atrium; LV: Left ventricle.]]
[[File:PMC5087261 JCHIMP-6-32827-g001.png|thumb|CT chest: Multiple cavitary (a) and pre-cavitary lesions (b) in both lung fields consistent septic emboli from pulmonary valve endocarditis.]]
===Work-Up===
===Work-Up===
*Blood culture (from 3 separate sites)<ref name="cultures">Lee A, Mirrett S, Reller LB, Weinstein MP. Detection of bloodstream infections in adults: how many blood cultures are needed? J Clin Microbiol 2007;45:
*[[Blood culture]] (from 3 separate sites)<ref name="cultures">Lee A, Mirrett S, Reller LB, Weinstein MP. Detection of bloodstream infections in adults: how many blood cultures are needed? J Clin Microbiol 2007;45:
3546 – 3548</ref>
3546 – 3548</ref>
*CBC
*CBC
**Staphylococcal endocarditis: Leukocytosis +/- thrombocytopenia
**Staphylococcal endocarditis: [[Leukocytosis]] +/- [[thrombocytopenia]]
**Subacute endocarditis: WBC may be normal or elevated
**Subacute endocarditis: WBC may be normal or elevated
*[[Urinalysis]]
*[[Urinalysis]]
**Hematuria
**[[Hematuria]]
*ESR
*ESR
**Elevated in >90% of cases
**Elevated in >90% of cases
*[[ECG]]
*[[ECG]]
**Ischemia, heart block
**Ischemia, [[heart block]]
*[[CXR]]
*[[CXR]]
**Pulmonary emboli, CHF
**Pulmonary emboli, [[CHF]]
*[[Cardiac ultrasound|Ultrasound]]
*[[Cardiac ultrasound|Ultrasound]]
**Obtain as soon as possible
**Obtain as soon as possible
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***High clinical probability of endocarditis
***High clinical probability of endocarditis


===Evaluation===
===Diagnosis===
Inpatient diagnosis is based on the Duke's Criteria although many of the criteria are not filled in the ED.  Heightened clinical suspicion is necessary even if diagnosis does not meet the official criteria.<ref>Durack D, Lukes A, Bright D "New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service". Am J Med. 1994. 96 (3): 200–9</ref>
*Inpatient diagnosis is based on the Duke's Criteria although many of the criteria are not filled in the ED
**Heightened clinical suspicion is necessary even if diagnosis does not meet the official criteria.<ref>Durack D, Lukes A, Bright D "New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service". Am J Med. 1994. 96 (3): 200–9</ref>


====Modified Duke Criteria<ref>Li, JS et al. "Proposed Modifications to the Duke Criteria for the Diagnosis of Infective Endocarditis". Clinical Infectious Diseases. 2000. 30(4). 633.</ref>====
====Modified Duke Criteria<ref>Li, JS et al. "Proposed Modifications to the Duke Criteria for the Diagnosis of Infective Endocarditis". Clinical Infectious Diseases. 2000. 30(4). 633.</ref>====
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*Often due to mitral or aortic valve rupture causing severe regurgitation
*Often due to mitral or aortic valve rupture causing severe regurgitation
*Focus on after-load reduction
*Focus on after-load reduction
===Respiratory Failure (emboli)===
===[[Respiratory failure]] (emboli)===
*Often requires intubation with failure either due to [[CHF]] or [[Pneumonia]]
*Often requires [[intubation]] with failure either due to [[CHF]] or [[Pneumonia]]
*Multi-lobar pneumonia suggests a tricuspid or pulmonary valve lesion with emboli to lungs
*Multi-lobar [[pneumonia]] suggests a tricuspid or pulmonary valve lesion with emboli to lungs


==[[Antibiotics]]==
==[[Antibiotics]]==
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***IV [[amphotericin B]]
***IV [[amphotericin B]]
***Lifelong PO antifungal
***Lifelong PO antifungal
==Miscellaneous==
*No therapeutic anticoagulation necessary
**Anticoagulation carries higher risk of bleeding without delivering mortality benefit or reducing embolic complication<ref>Elkaryoni A et al. ANTICOAGULATION IN INFECTIVE ENDOCARDITIS: INSIGHTS FROM NATIONWIDE INPATIENT SAMPLE. Journal of the American College of Cardiology. Volume 73, Issue 9 Supplement 1, March 2019.</ref>
*[[Septic pulmonary embolism]]
**Most common culture growths are MSSA, MRSA, and candida<ref>Li Zhao RY et al. Clinical characteristics of septic pulmonary embolism in adults: A systematic review. Respiratory Medicine. Volume 108, Issue 1, January 2014, Pages 1-8.</ref>
**Furthermore, therapeutic anticoagulation not indicated for [[septic pulmonary embolism]]


==Complications==
==Complications==
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===Embolic===
===Embolic===
*[[CVA]]
*[[CVA]]
*Blindness
*[[Vision loss|Blindness]]
*Painful, ischemic extremities
*Painful, ischemic extremities
*Unusual pain sydromes (due to splenic or renal infarction)
*Unusual pain syndromes (due to splenic or renal infarction)
*Hypoxia
*[[Mycotic aneurysm]]
*MI
*[[Hypoxia]]
*[[MI]]
 
===Neurologic===
===Neurologic===
*[[CVA|Embolic stroke]]
*[[CVA|Embolic stroke]]
*Acute encephalopathy
*Acute [[encephalopathy]]
*[[Meningitis|Meningoencephalitis]]
*[[Meningitis|Meningoencephalitis]]
*Purulent or aseptic meningitis
*Purulent or aseptic [[meningitis]]
*Cerebral hemorrhage
*[[ICH|Cerebral hemorrhage]]
*[[Seizure]]
*[[Seizure]]
*Spinal Abscess
*[[Epidural abscess|Spinal abscess]]
===Renal===
===Renal===
*Infarction
*[[Renal infarction]]
*[[Glomerulonephritis]]
*[[Glomerulonephritis]]
===Musculoskeletal===
===Musculoskeletal===
*[[Osteomyelitis|Vertebral osteomyelitis]]
*[[Vertebral osteomyelitis]]
 
==See Also==
*[[Fever]]
*[[In-training exam review]]


==External Links==
==External Links==
*[http://www.mdcalc.com/duke-criteria-for-infective-endocarditis/ MDCalc - Duke Criteria]
*[http://www.mdcalc.com/duke-criteria-for-infective-endocarditis/ MDCalc - Duke Criteria]
*[https://emcrit.org/ibcc/endo/ EMCrit - Endocarditis]


==References==
==References==

Latest revision as of 17:29, 4 January 2023

Background

  • Defined as an infection of the endocardial surface of the heart, affecting native (or prosthetic) heart valves as well as in-dwelling cardiac devices
  • Consider in patients with known risk factors and unexplained fever
  • Mitral valve most commonly affected overall; tricuspid valve most common in IVDA
  • Noninfectious vegetations can arise in patients with malignancy/SLE/Hypercoagulable state ("Marantic" endocarditis)
  • S. aureus is single most common cause (accounts for 1/3 of all cases)[1]
  • Strep viridans is the most common cause of native valve endocarditis, excluding risk factors below
  • Blood cultures are falsely negative ~5% (think HACEK organisms)
  • Only 20% have an increase in a known murmur and only 48% have a new murmur[2]

Prophylaxis

  • No longer recommended at all in the United Kingdom[3]
  • In United States, only recommended for invasive dental procedures (not routine cleanings) and invasive respiratory procedures in setting of: [4][5]
  1. Prosthetic valves
  2. Prior endocarditis
  3. Un-repaired congenital cyanotic heart disease
  4. Repaired congenital heart disease/valvulopathy with prosthetic material

Risk Factors

  • IVDA
    • Tricuspid valve most commonly affected
  • Prosthetic heart valve
    • Coagulase negative staphylcocci are substantial etiologies in this patient population[6]
  • Structural heart disease
    • Rheumatic heart disease (biggest risk factor in low-income countries)
    • Mitral valve prolapse
    • Bicuspid aortic valve
  • Hemodialysis
  • HIV infection
  • Fungal endocarditis risk factors, with Candida most common
    • Prolonged antibiotics
    • TPN through central line

Clinical Features

Splinter hemorrhage
Osler's nodes.
Janeway lesions
Roth spots on fundoscopy (A); 2 weeks after treatment (B); 6 weeks after treatment.
  • Fever
    • Present in 80% of cases
  • Heart murmur
    • Preexisting murmur found in 85% of cases; new murmur found in 48%
  • CHF
    • Acute or progressive (70%)
  • Derm
    • Osler nodes
      • Tender red/purple nodules on distal finger and toes
    • Splinter hemorrhages
      • Nail bed hemorrhages not extending the length of the nail
    • Janeway lesions
      • Non-tender, small erythematous or hemorrhagic macular, papular or nodular lesions on the palms or soles only a few millimeters in diameter
  • CNS
  • Pulmonary
  • Cardiac
  • Abdominal
    • Bowel, renal, splenic infarcts
  • Ophtho
    • Roth spots
      • White centered retinal hemorrhage
      • Associated with multiple systemic illnesses, most commonly bacterial endocarditis

Differential Diagnosis

Fever

Infectious

Non-infectious

Evaluation

Echocardiography showing typical vegetation on aortic valve (arrow).
Transthoracic echocardiography shows vegetations (arrows) on both mitral leaflets; (A) Diastole. (B) Systole. LA, left atrium; LV, left ventricle; Ao, aorta.
Vegetations in infective endocarditis (arrows). (a) Transthoracic echocardiogram parasternal long-axis view showing vegetation on native aortic valve; (b) transesophageal echocardiography long axis of endocarditis of native aortic valve; (c) transesophageal echocardiography visualization of vegetation on the atrial side of mechanical mitral valve; (d) transesophageal echocardiography showing endocarditis of bioprosthetic mitral valve. LA: Left atrium; LV: Left ventricle.
CT chest: Multiple cavitary (a) and pre-cavitary lesions (b) in both lung fields consistent septic emboli from pulmonary valve endocarditis.

Work-Up

Diagnosis

  • Inpatient diagnosis is based on the Duke's Criteria although many of the criteria are not filled in the ED
    • Heightened clinical suspicion is necessary even if diagnosis does not meet the official criteria.[9]

Modified Duke Criteria[10]

  • 2 major criteria OR
  • 1 major and 3 minor criteria OR
  • 5 minor criteria

Major Criteria

  • Positive blood culture with typical IE microorganism, defined as one of the following:
    • Typical microorganism consistent with IE from 2 separate blood cultures, as noted below:
    • Microorganisms consistent with IE from persistently positive blood cultures defined as:
      • Two positive cultures of blood samples drawn >12 hours apart, or
      • All of 3 or a majority of 4 separate cultures of blood (with first and last sample drawn 1 hour apart)
      • Coxiella burnetii detected by one positive blood culture or IgG
      • Staphylococus lugdunensis should raise concerns for endocarditis with a single positive blood culture[11]
  • Evidence of endocardial involvement with positive echocardiogram defined as:
    • Valvular mass or supporting structures or
    • Abscess, or
    • New disruption of a prosthetic valve or new valvular regurgitation

Minor Criteria

  • Predisposing factor: known cardiac lesion, recreational drug injection
  • Fever >38°C
  • Evidence of emboli: arterial emboli,pulmonary infarcts, Janeway lesions, conjunctival hemorrhage
  • Glomerulonephritis, Osler's nodes
  • Positive blood culture (that does not meet a major criterion) or serologic evidence of infection

Management

Initial management should focus on early blood cultures and antibiotics

CHF/Cardiogenic Shock

  • Often due to valve failure, rupture, or a new defect.

Pulmonary edema

  • Often due to mitral or aortic valve rupture causing severe regurgitation
  • Focus on after-load reduction

Respiratory failure (emboli)

  • Often requires intubation with failure either due to CHF or Pneumonia
  • Multi-lobar pneumonia suggests a tricuspid or pulmonary valve lesion with emboli to lungs

Antibiotics

Start after 3 sets of blood cultures are obtained (if possible)[8]

Therapy should be based on:

  • Whether the patient has received prior antibiotic therapy
  • Prosthetic valves
  • Local antibiotic resistance patterns or knowledge of prior endocarditis cultures
  • Prior hospitalizations and risk of MRSA

Native Valves

Options:[12]

Suspected MRSA:[12]

Prosthetic Valves (Early)

Early prosthetic valve endocarditis defined as < 12 months post surgery[12]

IV Drug User without Prosthetic Valve

Prosthetic Valve (Late)

Late prosthetic valve endocarditis defined as ≥ 12 months post surgery[12]
  • Same as native valve endocarditis empiric therapy

Dental Procedure Prophylaxis

All antibiotics options are given as a single dose 1 hour prior to the dental procedure

Options:[13]

Disposition

Admit all suspected cases and consult Cardiothoracic surgery for endocarditis complicated by:[2]

  • New Heart failure suspected due to severe regurgitation
  • Cardiogenic Shock
  • Echocardiography demonstrating a new fistula
  • Surgery indicated for[14]:
    • Acute heart failure
    • Periannular extension
    • Recurrent emboli
    • Large mobile vegetations
    • Persistent bacteremia
    • Fungal endocarditis (penetration of antifungals into vegetation walls poor)[15]


Miscellaneous

  • No therapeutic anticoagulation necessary
    • Anticoagulation carries higher risk of bleeding without delivering mortality benefit or reducing embolic complication[16]
  • Septic pulmonary embolism

Complications

Cardiac

  • Heart Failure
    • Most common cause of death due to IE
  • Perivalvular Abscess

Embolic

Neurologic

Renal

Musculoskeletal

See Also

External Links

References

  1. ↑ Selton-Suty C, Célard M, Le Moing V, et al. Preeminence of Staphylococcus aureus in infective endocarditis: a 1-year population-based survey. Clin Infect Dis. 2012;54(9):1230-1239. doi:10.1093/cid/cis199
  2. ↑ 2.0 2.1 Hoen, B. et al. Infective Endocarditis. NEJM. 2013. 368;15. 1425-1433 PDF
  3. ↑ Wilson W. et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007;116(15):e376-e377.
  4. ↑ Richey R, Wray D, Stokes T. Prophylaxis against infective endocarditis: summary of NICE guidance. BMJ 2008;336: 770-1.
  5. ↑ Wilson W, et al. Prevention of Infective Endocarditis: Guidelines from the American Heart Association. Circulation. 2007;116:1736-1754
  6. ↑ Lalani T et al. Prosthetic valve endocarditis due to coagulase-negative staphylococci: findings from the International Collaboration on Endocarditis Merged Database. Eur J Clin Microbiol Infect Dis. 2006 Jun;25(6):365-8.
  7. ↑ Mylonakis. E, Calderwood S. Infective endocardidits in adults. NEJM. 2001;345(18):138-1330
  8. ↑ 8.0 8.1 Lee A, Mirrett S, Reller LB, Weinstein MP. Detection of bloodstream infections in adults: how many blood cultures are needed? J Clin Microbiol 2007;45: 3546 – 3548
  9. ↑ Durack D, Lukes A, Bright D "New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service". Am J Med. 1994. 96 (3): 200–9
  10. ↑ Li, JS et al. "Proposed Modifications to the Duke Criteria for the Diagnosis of Infective Endocarditis". Clinical Infectious Diseases. 2000. 30(4). 633.
  11. ↑ Liu Po-Yen et al. Staphylococcus lugdunensis Infective Endocarditis: A Literature Review and Analysis of Risk Factors. Journal of Microbiology, Immunology and Infection Volume 43, Issue 6, December 2010, Pages 478-484.
  12. ↑ 12.0 12.1 12.2 12.3 ESC Task Force Guidelines on the prevention, diagnosis, and treatment of infective endocarditis. European Heart Journal (2009) 30, 2369–2413 doi:10.1093/eurheartj/ehp285 PDF
  13. ↑ AHA Pocket Card Dental Prophylaxis Endocarditis
  14. ↑ Kosowsky JM, Takhar SS: Infective Endocarditis and Valvular Heart Disease in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2013, (Ch) 84: pp 1113-1123.
  15. ↑ British Society for Antimicrobial Chemotherapy. Guidelines for the antibiotic treatment of endocarditis in adults: report of the Working Party of the British Society for Antimicrobial Chemotherapy. J. Antimicrob. Chemother. (December 2004) 54 (6): 971-981.
  16. ↑ Elkaryoni A et al. ANTICOAGULATION IN INFECTIVE ENDOCARDITIS: INSIGHTS FROM NATIONWIDE INPATIENT SAMPLE. Journal of the American College of Cardiology. Volume 73, Issue 9 Supplement 1, March 2019.
  17. ↑ Li Zhao RY et al. Clinical characteristics of septic pulmonary embolism in adults: A systematic review. Respiratory Medicine. Volume 108, Issue 1, January 2014, Pages 1-8.
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