Infective Endocarditis

Question 1

Prevention - Dental

Answer 1

Only recommend antibiotic prophylaxis for highest risk patients AND highest risk procedures

Highest Risk Patients
* Prosthetic valves, transcatheter valves, valve repair
* Previous infective endocarditis
* Congenital heart disease: Cyanotic, prosthetic material (6/12 of abx for procedures), shunt or regurge (abx for procedures for life)

Highest Risk Procedures
* Manipulation of gingival orvperiapical region of teeth or perforation of oral musosa

Rx:
Amoxicillin or Ampicillin 2g PO or IV (children 50mg/kg)
Clincamycin 600mg in penacillin allergic

Question 2

Prevention - Operations

Answer 2

• Screen patients and treat carriers of S. aureus
• Peri-procedural prophylaxis for PPM or ICD
• Eliminate septic sources for 2 weeks prior to valve replacement or other intracardiac or intravascular foreign material, unless urgent
• Consider in patients undergoing valve replacement, transcather valve implantation, intravascular prosthetic or other foreign material

Question 3

Diagnosis - pathway

Answer 3

Question 4

Diagnosis - Modifed Duke Criteria

Answer 4

Question 5

Diagnosis - Major Duke Criteria

Answer 5

Question 6

Diagnosis - Minor Duke Criteria

Answer 6

Question 7

Diagnosis - Duke Criteria Pathway

Answer 7

Question 8

Treatment - Empirical Antibiotics

Answer 8

Community acquired NVE or late PVE (>12m post op):
* Ampicillin, Flucloxacillin and Gentamicin

OR

• Vancomycin and Gentamicin

Early PVE or nosocomial
* Vancomycin, gentamicin and rifampacin

Question 9

Indications for Surgery

Answer 9

**1. Heart Failure **
* AV or MV NVE or PVE with severe acute regurgitation/obstruction/fistula cusing refractory pulmonary oedema or cardiogenic shock - EMERGENCY
* HF symptoms or echo features of poor haemodynamic tolerance URGENT

2. Uncontrolled Infection
* Locally uncontrolled infection: abcess/false anuerysm/ fistula/enlarging vegetation URGENT
* Fungi or multiresistent orgnanism URGENT/ELECTIVE
* Persistent blood culture postivie despite antibiotics and control of metastatic foci URGENT
* PVE caused by S aureus or non-HACEK gram negative URGENT/ELECTIVE

**3. Prevention of Embolism **
AV or MV NVE or PVE with:
* persistent vegetations >10mm after 1 or more embolism - URGENT
* severe valve stenosis with low operative risk URGENT
* isolated large vegetation >30mm URGENT (IIaB)
* large vegetation >15mm and no other indication for surgery (IIaC)

Question 10

Neurological Complications

Answer 10

Question 11

Right Sided Endocarditis - Surgery Indications

Answer 11

• Micro-organisms difficult to erradicate (Fungi) or bacteraemia after ≥7 days despite antibiotics

OR

• Tricuspid valve vegetations** >20mm after recurrent PE** with or without RV failure

OR

• Right heart failure secondary to severe TR with poor diuretic response

Question 12

Cardiac Device Related - CDRIE

Answer 12

Diagnosis
* 3 sets of blood cultures then prompt abx
* Lead tip culture on explant
* TOE if suspected CDRIE irrespective or TTE result
* ICE if suspected CSRIE and TTE and TOE negative
* **Leucocyte scan / FDG PET **if blood culture positive, TTE/TOE negative

Treatment
* Prolonged abx pre and post device removal in CDRIE and isolated pocket infection
* Consider removal with occult infection and without other source
* Consider removal in NVE/PVE without evidence of device infection

Device Removal
* Percutaneous in most, consider surgery in severe IE related TR and vegatation >20mm

Reimplant
* Reassess implant need, postpone where possible
* Pacing dependent - temporary active fixation
* No TPW routinely

Prophylaxis
* Routine at implant
* Eliminate septic sources for 2 weeks pre implant unless urgent