Download Endocarditis - Wellington ICU

Endocarditis
1/9/10
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AHA/ACC Guidelines: Prevention of Infective Endocarditis (2007) – Summary Statements
A-Z page 182-183
OH
Critical Care – Just the Facts – Jesse Hall, Gregory A Schmidt (2007)
= infections of the endocardium -> heart valves
- most commonly effecting the AV (use to be MV)
HISTORY
- 50% occur in patients with normal valves!
- nil -> malaise, night sweats, anaemia, weight loss -> crashing cardiogenic shock and
sepsis
- haematuria
- CVA
Risk factors
-
congenital heart disease
rheumatic heart disease
MVP
valve regurgitation
degenerative valve disease
prosthetic valve (1-5%) – early (within 60 days) or late (after 60 days)
IV drug use – tricuspid, aortic and mitral valve
haemodialysis
high risk surgery = dental, respiratory and infective
long lines
bone marrow transplant recipients
immunosuppressed (HIV)
EXAMINATION
-
Skin rash
Oslers nodes – tender nodules on pulps of fingers and tones
Janeway lesions – non-tender haemorrhagic pulps on fingers and toes
Roth spots – retinal hemorrhages with a pale centre
Splenomegally
New neurological signs
New murmur
Signs of Aortic Regurgitation - collapsing pulse, wide pulse pressure, new murmur
Left ventricular failure – crackles at bases of lungs + effusions
Jeremy Fernando (2011)
INVESTIGATIONS
- Blood cultures (90% of the time positive)
- Serology
- ECG: look for widening PR interval, p mitrale, TWI
- ECHO: vegetations and valve incompetence (TTE = 60% sensitive, TOE = 90-99%
sensitive, specificity of 90%)
Organisms
Staphylococcus aureus (MSSA or MRSA)
Streptococcus epidermidis
Streptococcus viridans
HACEK organisms
->
->
->
->
->
Haemophillus aphrophilus, parainfluenzae and paraphrophilus
Actinobacillus actinomycetemcomitans
Cardiobacterium hominis
Eikenella corrodens
Kingella kingae
Fungi
Culture negative endocarditis
-
Brucella
Coxiella burnetti (Q fever)
Bartonella
Chlamydia
Mycoplasma
Legionella
Whipples
MANAGEMENT
- IV antibiotics:
Native Valve - Flucloxacillin OR Cephazolin +/- Gentamicin
Prostetic Valve or Hospital Acquired - Vancomycin + Gentamicin + Rifamipicin
Surgery
- valve replacement
- indications:
(1)
(2)
(3)
(4)
(5)
haemodynamic instability
abscess enlargement
abscess (root, paravalvular, intracardiac)
recurrent emboli
organism: Staph aureus, Q fever, fungal endocarditis
Infective Endocarditis Prophylaxis
Jeremy Fernando (2011)
- more conservative approach as risks of adverse effects from antibiotics higher than risks of
developing IE from dental, GI or GU tract procedure
- must have high risk patient and high risk surgery
- high risk patients;
1. any prosthetic material in used in valve repair
2. previous IE
3. congenital heart disease (unrepaired cyanotic, partially repaired, completely repaired within
6 months)
4. cardiac transplant patients with valvulopathy
+
- high risk surgery;
- all dental procedures that involve manipulation of gingival tissue or periapical region of
teeth or perforation of oral mucosa (thus only check ups and simple fillings that don’t involve
gingiva don’t need antibiotic prophylaxis)
- respiratory tract surgery (incision and biopsy, tonsillectomy, adenoidectomy)
Management
- give a single dose of antibiotic prior to procedure (or within 2 hours of procedure)
1.
2.
3.
4.
amoxylcillin 50mg/kg PO
cephazolin 50mg/kg IV/IM
cephalexin 50mg/kg PO (pencillin allergic)
clindamycin 20mg/kg PO (pencillin allergic)
- if currently infected with a bug and operation is taking place on that area and the organism
is likely to cause IE -> give prophylactic treatment perioperative (consult ID)
COMPLICATIONS
-
embolic (brain, limbs, organs)
sepsis (abscess formation)
death
valve incompetence
arrhythmias
Jeremy Fernando (2011)