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Infective Endocarditis
Department of Cardiology
Terminology
• Infective endocarditis
- bacterial or fungal infection of the interior of the heart
• Acute IE
- severe febrile illness, rapidly damages
hematogenously seeding to extracardiac site and
progress to death without treatment
• Subacute IE
- indolent course, gradual progression during several
weeks to months
• Prosthetic valve IE
- infection with foreign valve materials
- early PVE (within 2 mo. of op),
late PVE (more than after 12 mo. of op)
Epidemiology
• Incidence
- 1.7 to 6.2 per 100,000 person-years
- male-to female ratio 1.7 : 1
- the median age 47 to 69 years
- injection drug use 150 to 2000 per 100,000 person-years
- mitral valve prolapse 100 per 100,000 person-years
• In developing countries
- rheumatic heart disease
- young age
• Prosthetic valve
- 7-25%
• Nosocomial infective endocarditis
- 7-29% GU, GI tract procedures, surgical wound
Etiology
Modified Duke Criteria
Major Criteria
I. Positive blood culture
Typical microorganism for IE from 2 separated blood culture
Viridans streptococci, Streptococcus bovis, S. aureus or
Community-aquired enterococci in the absence of primary focus
Microorganism consistent with IE persistently positive blood cultures
Single positive blood culture for Coxiella burnetii
II. Evidence of endocardial involvement
Positive echocardiogram
Oscillating intracardiac mass on valvular surface or structure Abscess
New valvular regurgitation
Increase or change in preexisting murmur not sufficient
Minor Criteria
I. Predisposing heart condition or injection drug use
II. Fever > 38℃
III. Vascular phenomena : major arterial emboli, mycotic aneurysm,
conjunctival hemorrhage, intracranial hemorrhage
IV. Immunologic phenomena : GN, Osler’s node, Roth’s spot, RF
V. Microbiologic evidence
: positive blood culture but not meeting major criteria
¶ Definite infective endocarditis
2 major criteria or
1 major criteria + 3 minor criteria or
5 minor criteria
¶ Possible infective endocarditis
1 major criteria + 1 minor criteria
3 minor criteria
Predisposing condition
More common
Less common
Mitral valve prolapse
Rheumatic heart disease
Degenerative valvuar disease
Idiopathic Hypertropic AS
IV drug use
Pulmonary system shunts
Prosthetic valve
Coarctation of the aorta
Congenital anomaly
Previous endocarditis
Clinical Manifestation
• Fever : most common symptom
- highly suspicious in a febrile patients with valvular
abnormalities, IV drug abuser, or bacteremia with
organisms frequently causing IE
- Subacute IE : low-grade fever (< 39.4)
- Acute IE : often high fever (39.4~40)
• Absence or blunting of fever
-
elderly, severe debilitated
congestive heart failure
renal or liver failure
previous use of antibiotics
• Other common Sx of subacute IE
- anorexia, malaise, night sweat, weight loss
Cardiac manifestation
• Heart murmur
- predisposing pathologic factor or
newly regurgitant murmur
- detected in 85% of IE involving normal valve
• Congetive heart failure : 30~40% of patients
- due to consequence of valve dysfunction
- more rapid progression in aotic valve involvement
• Perivalvular abscess
- due to extension of infection beyond valve leaflet
into valvular annulus
- cardiac fistulae with new murmur
- conduction blockade
• MI due to emboli to a coronary artery
Noncardiac manifestation
• Classic nonsuppurative peripheral lesion
- Janeway lesion, Osler’s node, splinter hemorrhage
• Hematogenous metastastic focal infection
- skin, spleen, kidney, skeletal systems, meninges
• Arterial emboli : often with infarction
- more likely in large vegetation (>10mm)
or mitral vegetation
• Neurologic symptoms
- most often due to embolic stroke
intracranial hemorrhage, ruptured mycotic
aneurysm, seizure
Petechiae
Conjuctival Hemorrhage
Osler’s Node
Roth’s Spot
Splinter Hemorrhage
Janeway Lesion
Treatment
• Acute endocarditis, especially IV drug user
- coverage for MRSA & enterococci
 Vancomycin + Gentamicin, immediately after blood culture
• Native valve, community-acquisition of infection,
MRSA-unlikely
 Nafcillin + Penicillin + gentamicin
• Culture – negative episode in subacute IE
- in subacute endocarditis with native valve
: Ceftriaxone + Gentamicin
- in subacute endocarditis with prosthetic valve
: Ceftriaxone + Gentamicin + Vancomycin
• 2 or 3 additional culture in the case of culturenegative after 48~72hr
Treatment
Organism
Drug, Dose, Duration
Comments
Streptococci
Penicillin-susceptible
Penicillin G 2~3 million units IV
q 4h for 4wks
Penicillin G + Gentamicin
1mg/kg IM or IV q 8hr for 2wks
Penicillin G 6wks +
Gentamicin 2wks prosthetic
valve
Ceftriaxone 2g/d IV for 4wks
For nonimmediate penicillin
allergy
Vancomycin 15mg/kg IV q 12hr
for 4wks
For severe or immediate
penicillin allergy
Relatively Penicillinresistant
Streptococci
Penicillin G 3 million unit for 46 wks + Gentamicin for 2 wks
Penicillin G 6wks +
Gentamicin 4wks prosthetic
Moderately Penicillinresistant
Streptococci
Penicillin G 3-4 million unit IV
+ Gentamicin for 4-6 wks
Penicillin G 6wks +
Gentamicin 6wks prosthetic
** Relatively penicillin-resistant : MIC > 0.1 µg/ml and < 0.5 µg/ml
Moderately penicillin-resistant : MIC > 0.5 µg/ml and < 0.8 µg/ml
Enterococci /
Penicillin-resistant
Streptococci
(MIC>1µg/ml)
Penicillin G 3-4 million unit IV
q4h + Gentamicin for 4-6 wks
Vancomycin 15mg/kg IV q12h
+ Gentamicin for 4-6 wks
For penicillin-allergic patient
Nafcillin or Oxacillin 2g IV
q4h for 4-6 wks + Gentamicin
for 3-5 day
May use Penicillin G in the case
of penicillin-susceptible
Staphylococci
Methicillin-susceptible
infecting Native valves
Cefazolin 2g IV q8h for 4-6wks
+ Gentamicin for 3-5 day
Vancomycin 15mg/kg IV q 12h
for 4-6 wks
Methicillin-resistant
infecting native valves
Vancomycin 15mg/kg IV q 12h
for 4-6 wks
Methicillin-susceptible
infecting Prosthetic valves
Nafcillin/Oxacillin +
Gentamicin+ Rifampin
300mg PO q8h for 6-8wks
Methicillin-resistnat
infecting Prosthetic valves
Vancomycin + rifampin 6wks
+ Gentamicin 2 wks
HACEK organism
Ceftriaxone 2g/d IV for 4wks
For immediate or severe
penicillin allergy
Use gentamicin during initial 2
wks before initiating rifampin
for determine susceptibility
Haemophilus species
Treatment Monitoring
•
Daily EKG for evaluation of conduction abnormality
- herald of perivalvular extension of infection
•
Careful cardiac exam basis to assess for new
regurgitant murmur
- Widening of pulse pressure – suggestive of aortic
insufficiency
•
Renal function monitoring
- especially in the case of use of aminoglycoside
•
Follow up blood culture :
- at least 1h , If negative 48-72hrs
- should be repeated daily until sterile
- recheck in the case of fever
- perform again after 4~6 wks of therapy for document of cure
•
Duration of Fever
- resolution of fever within 5~7 days in almost patients
- defervescence within 3 days in half of patients
- defervescence in 75% of patients within 1 wk/ 90% in 2 wks
- more slow defervescence in S. aureus, G(-) organisms
•
Pronged fever over 1 week with appropriate therapy
 possible another new events other than treatment failure
- perivalvular extension of infection
- myocardial abscess
- focal metastatic infection
- drug fever
- nosocomial infection
- other complication of hospitalization ; eg) pulmonary embolism
 Blood culture F/U
TEE, abdomen CT, urine culture
Examination of intravascular devices
Surgical Intervention
I. Surgery required for optimal outcome
Moderate to severe congestive heart failure due to valve dysfunction
Partially dehisced unstable prosthetic valve
Persistent bacteremia despite optimal antimicrobial therapy
Lack of effective microbicidal therapy (e.g., fungal or Brucella endocarditis)
S. aureus prosthetic valve endocarditis with an intracardiac complication
Relapse of prosthetic valve endocarditis after optimal antimicrobial therapy
II. Surgery to be strongly considered for improved outcome
Perivalvular extension of infection
Poorly responsive S. aureus endocarditis involving the aortic or mitral valve
Large (>10-mm diameter) hypermobile vegetations and increased embolic risk
Persistent unexplained fever ( 10 days) in culture-negative native valve endocarditis
Poorly responsive or relapsed endocarditis due to highly antibiotic-resistant
enterococci or gram-negative bacilli