endocarditis Flashcards

1
Q

what is IE

A

◦ Definition
 Infective endocarditis (IE) is an infection of the
endocardial surface of the heart.
 Historically categorized as “acute” or “subacute” but now described according to etiology
◦ Epidemiology
 It is traditionally associated with heart valves
(damaged by rheumatic heart disease).
- May also involve non-valvular areas of the
endocardium or implanted mechanical devices In the current era, health care contact and
injection drug use are the primary risk factors.
 Most frequently mitral or aortic valvesaffected
◦ Related to degree of mechanical stress
(pressure resting on closed valve) on valve
(MV > AV > TCV > PV)

 A shift in usual causative organisms from
viridans group Streptococci to
Staphylococcus aureus as leading cause

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2
Q

common causes organisms

A

Staphylococcus aureus 31.6
Viridans group streptococci 18.0
Enterococci 10.6

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3
Q

risk factors

A

Valvular Disease
• E.g. Mitral valve prolapse with regurgitation, prosthetic heart valve, acquired valvular dysfunction (rheumatic heart disease)
Previous Endocarditis

Congenital abnormalities
• E.g. congenital bicuspid mitral valve or surgically constructed shunts or conduits
Hypertrophic myopathy
Injection Drug Use (IDU)
Turbulent blood flow
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4
Q

sequence of events

A

 Turbulent blood flow
 Development of non-bacterial thrombus on valve Transient bacteremia exposes thrombus to
bacterial colonization
 Development of IE
◦ Embolisation of septic fragments that can cause
hematogenous complications in other organs (spleen,
brain, lungs)

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5
Q

Incidence of Bacteremia after Various Procedures3

A

viridans strep ound in mouth
- poor dentition
- tooth brushing can cause bacteremia
dental extration, periodontal srugery, tonsillectomy

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6
Q

presentation

clinical signs

A
Fever 96
Heart murmur 85
Changing murmur 20
New murmur 48 
Hematuria 26 

clubbing (longterm), fingers - long term poor oxygenation(COPD, kung cancer)
splinter hemorrhages
conjunctival petechiae

Janeway Lesions
“numerous small hemorrhages
with slight nodular character in the
palms of the hand and soles of the feet”

Retinal Roth SpotsUsually caused by immune complex
mediated vasculitis often resulting
from bacterial endocarditis

Osler\s nodes: Found to be microabscesses in the papillary dermis together with
microemboli in the nearby dermal arterioles
not common

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7
Q

modified duke criteria

A

 Pathologic Criteria (definitive):
◦ Micro-organisms demonstrated by culture or
histologic examination of a vegetation, a vegetation that has emolised, or an intra-cardiac abscess
specimen, or
◦ Pathogenic lesions; vegetation or intra-cardiac
abscess confirmed by histologic examination
showing active endocarditis

 Clinical Criteria:
◦ Definitive diagnosis is made based on:  2 major criteria,  1 major criterion + 3 minor criteria, or
 5 minor criteria
◦ Possible diagnosis is based on:  1 major criterion + 1 minor criterion, or  3 minor criteria
 Clinical judgement is important
consideration despite criteria based
diagnosis standard

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8
Q

major criteria

A

Blood culture positive of IE

◦ Micro-organisms consistent with IE from 2 separate blood cultures (VGS, S. gallolyticus, HACEK, S. aureus), or
◦ Community acquired Enterococci, in absence of
primary focus, or
◦ Micro-organisms consistent with IE from persistently positive BC (at least 2 cultures, or all of 3 or most of > 4 separate BC), or
◦ Single positive BC for Coxiella burnetii or antiphase I IgG antibody titre > 1:800
 Evidence of Endocardial involvement:
◦ Positive TEE or TTE

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9
Q

minor criteria

A

 Predisposition, or predisposing heart condition, or IDU
 Fever > 38℃
 Vascular phenomena
◦ Major arterial emboli, septic pulmonary infarcts,
mycotic aneurysms, intra-cranial hemorrhage,
conjunctival hemorrhages, Janeway lesions
 Immunologic phenomena
◦ Glomerular nephritis, Osler’s nodes, Roth’s spots,
rheumatoid factor
 Microbiologic evidence – e.g. positive BC but
does not meet major criterion
 Echocardiographic minor criteria eliminated

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10
Q

Rejected:

A
◦ Firm alternate diagnosis explaining
evidence of IE,
◦ Resolution of IE syndrome with AB therapy < 5 d,
◦ No pathologic evidence, or
◦ Does not meet any of the criteria
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11
Q

tx options

A

 Direct empiric therapy to the expected “usual” causes
◦ Staphylococcus aureus – needs vancomycin (not as good as b-lactam) and/or cloxacillin/cefazolin
- tend to use both vanco + cef/clox
◦ VGS – needs ceftriaxone (or other 3rd generation
cephalosporin)
◦ Role of aminoglycosides – consider in enterococcal
IE, prosthetic valve IE, allergic patients, and
potentially in IDU patients (where you may suspect Gram negative bacteria)
◦ Role of rifampin – generally in prosthetic valve
infections - breaks thru biofilm

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12
Q

Empiric
Antimicrobial Therapy

Adult Native Valve
Non IDU
S.aureus
Viridans
Streptococci
Enterococcus 
HACEK
A

Acute

Vancomycin 15 mg/kg IV q8 -12h
+
Ceftriaxone 2 g IV daily

IF Severe Penicillin Allergy
Gentamicin 1 mg/kg IV q8h
+ Vancomycin 15 mg/kg IV q8 -12h

Culture
positiveRefer to
B+D app for
pathogen
directed Rx
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13
Q
adult native valve
IDU
S.aureus/MRSA
Pseudomonas
Enterobacteraciae
Candida
Enterococcus
Viridans
Streptococci
Polymicrobial
A
Vancomycin 15 mg/kg IV q8
-12h +/-
Gentamicin 1.5-2
mg/kg IV q8h
or
Tobramycin 1.5-2 mg/kg
IV q8h
or
Ciprofloxacin 400 mg IV q12h/
750 mg PO bid
Culture
positive
Refer to B+D
app for
pathogen
directed Rx
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14
Q

culture directed tc

A

 Important to understand MIC’s of
Streptococci (Enterococcus as well)
◦ Penicillin MIC ≤ 0.1 mcg/mL – highly susceptible◦ Penicillin MIC 0.12 - < 5 mcg/mL – relatively
penicillin resistant
 Would need to add gentamicin to therapy
◦ Penicillin MIC ≥ 5 mcg/mL (or Enterococcus)  Add gentamicin and extend treatment length Add ceftriaxone to ampicillin for Enterococcus
 Potentially non-penicillin therapy (depending on
susceptibilities)

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15
Q

culture directed tx

role of rifampin

A

 Role of rifampin
◦ Synergistic activity for Gram positive organisms◦ Active against the bacterial biofilm◦ Has a positive role to play in prosthetic infections◦ Powerful enzyme inducer so must be assessed for
drug interactions
◦ Need to discuss with patient the expected adverse reactions to watch for while on treatment

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16
Q

oral tx for IE

A

 Adult, stable IE patients on IV therapy for left
sided IE
◦ Streptococcus, Enterococcus faecalis, S. aureus, CoNS◦ IV therapy of at least 10 days; including at least 7 days
post valvular surgery
 No abscess or valve abnormality on TEE
 Oral antibiotic regimens consisted of 2 agents,
from different classes
◦ had mod-high bioavailability and serum levels
monitored
 Primary outcome – composite all cause mortality, unplanned CV surgery, embolic events, relapse of bacteremia (from randomization to 6 months)

Results (Noninferiority trial design):
◦ 400 patients met inclusion criteria – 199 IV/201 PO◦ Groups well balanced
◦ Pathogens: Streptococcus > S. aureus > E.
faecalis/CoNS
◦ Aortic valve most common and 27% patients had
PVE
◦ Primary composite outcome [CI, 0.37 to 1.36]:  24 patients (12.1%) of IV  18 patients (9.0%) of oral
◦ 4 patients were switched from oral to IV therapy
(deemed treatment failure)

17
Q

complicatitons in ie

A

 HF – should be immediately evaluated for
valve replacement surgery - impacts blood flow
◦ More common with aortic valve involvement
 Septic emboli – 22-50% of cases
◦ 65% to CNS (stroke) – and > 90% of these lodge in
MCA
◦ Usually occurs within first 2-4 weeks of therapy Periannular extension of infection
◦ Predictor of higher mortality, increased HF and
greater need for surgical intervention

 Uncommon/Rare complications
◦ Splenic abscess – requires urgent splenectomy
with appropriate antibiotics
◦ Mycotic aneurysms – occur most commonly in
intracranial arteries, followed by visceral arteries
and arteries of upper/lower extremities
 Mortality rate in intracranial mycotic aneuryms (ICMA) is 30% in unruptured ICMA and 80% in ruptured ICMA May require surgical intervention

18
Q

surgical intervention

A
• Heart failure unresponsive to therapy• Perivalvular invasive disease
• Uncontrolled infection despite
maximal antibiotic therapy
• Significant risk of embolic
complications
• Prosthetic valve infection
19
Q

anticoagulation

A
Does not prevent embolization & may
increase risk of intracerebral
hemorrhage
Native valve
• Must have a clear indication for
anticoagulation separate from infective
endocarditis
Non-native valve
• Anticoagulate with caution
20
Q

prophylax who?

A

 IE is an uncommon infection, but the
implications of infection are severe
◦ CV surgery
◦ Valve replacement – implanted devices
◦ Heart failure
◦ Death
 Bacteremia and “turbulent blood flow” are the factors that set patients up for infection◦ Pretty common?
 Refocusing the conversation on the potential benefit AND risk
 May only prevent a very small number ofcases
◦ Antibiotics are not without risks
◦ Optimal oral health & hygiene may be moreimportant in reducing the bacteremia risk thanantibiotics
Chewing candy or paraffin 17-51
Tooth brushing 0-26
Oral irrigation device 27-50

21
Q

endocard prophyl rec 2007

A
 Prosthetic cardiac valves
 Previous infective endocarditis
 Congenital heart disease (CHD)
◦ Unrepaired cyanotic CHD
◦ Congenital heart defect
 Repaired with prosthetic material, or
 Device during 1st 6 months after theprocedure (life long if residual defect at oradjacent to the site)
 Cardiac transplant recipients whodevelop valvulopathy
22
Q

abx prophylax

A
• Only for high risk heart defects
• Only for dental procedures with
manipulation of gingival tissues or
periapical tissue of teeth or
perforation of the oral mucosa
23
Q

abx prophylax Not required for:

A
• Routine anaesthetic injections through noninfected tissue
• Dental radiograph
• Placement or removal of prosthadontic or
orthodontic appliances or brackets
• Shedding of deciduous teeth
• Bleeding from trauma to lips or nose
• May be considered for surgeries of
Respiratory Tract or Infected skin, skin
structures or musculoskeletal tissues
e.g. tonisillectomy, adenoidectomy,
bronchoscopy with incision

• Gastrointestinal or genitourinary
procedures
• For selected surgeries e.g. hepatobiliary,
complicated urinary tract surgery may
need to ensure routine prophylaxis
includes enterococcal coverage
• Vaginal delivery and hysterectomy• Body piercing or tattooing

24
Q

drugs for oral propphyl

A

Standard Amoxicillin

Amoxicillin/Ampicillin/Penicillin allergic:
Cefuroxime axetil
Azithromycin
Clarithromycin
Doxycycline

Doses given 30 min - 1 hour before dental procedure

25
Q

drugs for parenteral propphyl

A

Standard Ampicillin

Amoxicillin/Ampicillin/Penicillin allergic:
Cefazolin
or ceftriaxone

Doses given 30 min - 1 hour before dental procedure