Endocarditis: Difference between revisions
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==Risk Factors== | ==Risk Factors== | ||
*IVDA | |||
**Tricuspid valve most commonly affected | |||
*Prosthetic heart valve | |||
*Structural heart disease | |||
**Rheumatic heart disease | |||
**Mitral valve prolapse | |||
**Bicuspid aortic valve | |||
*Hemodialysis | |||
*HIV infection | |||
==Clinical Features== | ==Clinical Features== | ||
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*5 minor criteria | *5 minor criteria | ||
===Major 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: | |||
*** [[Streptococcus viridans|Viridans-group streptococci]], or | |||
*** ''[[Streptococcus bovis]]'' including nutritional variant strains, or | |||
*** [[HACEK]] group, or | |||
*** ''[[Staphylococcus aureus]]'', or | |||
*** Community-acquired ''[[Enterococci]]'', in the absence of a primary focus | |||
** 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 byone positive blood culture or IgG | |||
* 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=== | ===Minor Criteria=== | ||
* Predisposing factor: known cardiac lesion, recreational drug injection | |||
* Fever >38°C | |||
* Evidence of emboli: arterial emboli,pulmonary infarcts, [[Eponyms_(F-L)*Janeway_lesions|Janeway lesions]], conjunctival hemorrhage | |||
* [[Glomerulonephritis]], [[Eponyms_(M-P)*Osler.27s_nodes|Osler's nodes]] | |||
* Positive blood culture (that doesn't meet a major criterion) or serologic evidence of infection | |||
==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: | |||
3546 – 3548</ref> | 3546 – 3548</ref> | ||
*CBC | |||
**Staphylococcal endocarditis: Leukocytosis +/- thrombocytopenia | |||
**Subacute endocarditis: WBC may be normal or elevated | |||
*UA | |||
**Hematuria | |||
*ESR | |||
**Elevated in >90% of cases | |||
*ECG | |||
**Ischemia, heart block | |||
*CXR | |||
**Pulmonary emboli, CHF | |||
*[[Ultrasound: Cardiac|Ultrasound]] | |||
**Obtain as soon as possible | |||
**TEE may be required for: | |||
***Prosthetic valves | |||
***Difficulty obtaining clear TTE images (obesity, COPD) | |||
***High clinical probability of endocarditis | |||
==Management== | ==Management== | ||
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*Start after 3 sets of blood cultures are obtained (if possible)<ref name="cultures"></ref> | *Start after 3 sets of blood cultures are obtained (if possible)<ref name="cultures"></ref> | ||
''Therapy should be based on:'' | ''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'' | |||
{{Endocarditis_Empiric_Antibiotics}} | {{Endocarditis_Empiric_Antibiotics}} | ||
| Line 127: | Line 127: | ||
==Disposition== | ==Disposition== | ||
Admit all suspected cases and consult Cardiothoracic surgery for endocarditis complicated by:<ref name="Hoen"></ref> | Admit all suspected cases and consult Cardiothoracic surgery for endocarditis complicated by:<ref name="Hoen"></ref> | ||
*New Heart failure suspected due to severe regurgitation | |||
*Cardiogenic Shock | |||
*Echocardiography demonstrating a new fistula | |||
==Complications== | ==Complications== | ||
===Cardiac=== | ===Cardiac=== | ||
*[[Congestive Heart Failure (CHF)|Heart Failure]] | |||
**Most common cause of death due to IE | |||
* Perivalvular Abscess | |||
===Embolic=== | ===Embolic=== | ||
*[[CVA]] | |||
*Blindness | |||
*Painful, ischemic extremities | |||
*Unusual pain sydromes (due to splenic or renal infarction) | |||
*Hypoxia | |||
* MI | |||
===Neurologic=== | ===Neurologic=== | ||
*[[CVA|Embolic stroke]] | |||
*Acute encephalopathy | |||
*[[Meningitis|Meningoencephalitis]] | |||
*Purulent or aseptic meningitis | |||
*Cerebral hemorrhage | |||
*[[Seizure]] | |||
*Spinal Abscess | |||
===Renal=== | ===Renal=== | ||
*Infarction | |||
*[[Glomerulonephritis]] | |||
===Musculoskeletal=== | ===Musculoskeletal=== | ||
*[[Osteomyelitis|Vertebral osteomyelitis]] | |||
==External Links== | ==External Links== | ||
Revision as of 19:07, 8 August 2015
Background
- Consider in pts w/ known risk factors and unexplained fever
- Mitral valve most commonly affected overall; tricuspid valve most common in IVDA
- Noninfectious vegetations can arise in pts w/ malignancy and SLE
- S. aureus is single most common cause
- 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[1]
Prophylaxis
- No longer recommended at all in the United Kingdom[2]
- In United States, only recommended for invasive dental procedures (not routine cleanings) and invasive respiratory procedures in setting of: [3][4]
- Prosthetic valves
- Prior endocarditis
- Un-repaired congenital cyanotic heart disease
- Repaired congenital heart disease/valvulopathy with prosthetic material
Risk Factors
- IVDA
- Tricuspid valve most commonly affected
- Prosthetic heart valve
- Structural heart disease
- Rheumatic heart disease
- Mitral valve prolapse
- Bicuspid aortic valve
- Hemodialysis
- HIV infection
Clinical Features
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%)
Embolic manifestations
CNS
- 65% of emboli involve the CNS[5]
- Central retinal artery occlusion
Pulmonary
- PNA
- Empyema
Cardiac
- MI
- Myocarditis
Abdominal Organs
- Bowel, renal, splenic infarcts
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 - painless macules on palms and soles due to microabscesses
Prehospital
- Empiric antibiotics should not be given in prehopsital setting since it would affect the accuracy of blood cultures drawn in the hospital
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.[6]
Modified Duke Criteria[7]
- 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:
- Viridans-group streptococci, or
- Streptococcus bovis including nutritional variant strains, or
- HACEK group, or
- Staphylococcus aureus, or
- Community-acquired Enterococci, in the absence of a primary focus
- 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 byone positive blood culture or IgG
- Typical microorganism consistent with IE from 2 separate blood cultures, as noted below:
- 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 doesn't meet a major criterion) or serologic evidence of infection
Work-Up
- Blood culture (from 3 separate sites)[8]
- CBC
- Staphylococcal endocarditis: Leukocytosis +/- thrombocytopenia
- Subacute endocarditis: WBC may be normal or elevated
- UA
- Hematuria
- ESR
- Elevated in >90% of cases
- ECG
- Ischemia, heart block
- CXR
- Pulmonary emboli, CHF
- Ultrasound
- Obtain as soon as possible
- TEE may be required for:
- Prosthetic valves
- Difficulty obtaining clear TTE images (obesity, COPD)
- High clinical probability of endocarditis
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:[9]
- Ampicillin/Sulbactam 12g/day IV in 4 doses + Gentamicin 3mg/kg/day IV in 2 or 3 doses
- Amoxicillin/Clavulanate 12g/day in 4 dose + Gentamicin 3mg/kg/day IV in 2 or 3 doses
- Oxacillin or Nafcillin 2g IV six times daily + Gentamicin 1mg/kg IV three times daily AND Ampicillin 2g IV six times daily
- Daptomycin 6mg/kg IV once daily
Suspected MRSA:[9]
- Vancomycin 30mg/kg/day IV in 2 doses PLUS
- Gentamicin 3mg/kg/day IV in 2 or 3 doses PLUS
- Ciprofloxacin 1000mg/day PO in 2 doses or 800 mg/day IV in 2 doses
Prosthetic Valves (Early)
- Early prosthetic valve endocarditis defined as < 12 months post surgery[9]
- Vancomycin 30mg/kg/day IV in 2 doses PLUS
- Gentamicin 3mg/kg/day IV in 2 or 3 doses PLUS
- Rifampin 1200 mg/day PO in 2 doses
IV Drug User without Prosthetic Valve
- Vancomycin 15-20 mg/kg IV BID daily
- Daptomycin 6mg/kg IV once daily
Prosthetic Valve (Late)
- Late prosthetic valve endocarditis defined as ≥ 12 months post surgery[9]
- 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:[10]
- Amoxicillin 2g or 50mg/kg
- Ampicillin 2g (50mg/kg) IV or IM
- Cefazolin or Ceftriaxone 1g (50mg/kg) IM or IV
- Clindamycin 600mg (20mg/kg) PO or IV
- Azithromycin or Clarithromycin 500mg (15mg/kg) PO
Disposition
Admit all suspected cases and consult Cardiothoracic surgery for endocarditis complicated by:[1]
- New Heart failure suspected due to severe regurgitation
- Cardiogenic Shock
- Echocardiography demonstrating a new fistula
Complications
Cardiac
- Heart Failure
- Most common cause of death due to IE
- Perivalvular Abscess
Embolic
- CVA
- Blindness
- Painful, ischemic extremities
- Unusual pain sydromes (due to splenic or renal infarction)
- Hypoxia
- MI
Neurologic
- Embolic stroke
- Acute encephalopathy
- Meningoencephalitis
- Purulent or aseptic meningitis
- Cerebral hemorrhage
- Seizure
- Spinal Abscess
Renal
- Infarction
- Glomerulonephritis
Musculoskeletal
External Links
Source
- ↑ 1.0 1.1 Hoen, B. et al. Infective Endocarditis. NEJM. 2013. 368;15. 1425-1433 PDF
- ↑ 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.
- ↑ Richey R, Wray D, Stokes T. Prophylaxis against infective endocarditis: summary of NICE guidance. BMJ 2008;336: 770-1.
- ↑ Wilson W, et al. Prevention of Infective Endocarditis: Guidelines from the American Heart Association. Circulation. 2007;116:1736-1754
- ↑ Mylonakis. E, Calderwood S. Infective endocardidits in adults. NEJM. 2001;345(18):138-1330
- ↑ 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
- ↑ Li, JS et al. "Proposed Modifications to the Duke Criteria for the Diagnosis of Infective Endocarditis". Clinical Infectious Diseases. 2000. 30(4). 633.
- ↑ 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
- ↑ 9.0 9.1 9.2 9.3 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
- ↑ AHA Pocket Card Dental Prophylaxis Endocarditis