Download Endocarditis - Hatzalah of Miami-Dade

Update on
Infective Endocarditis
Larry Baddour, MD
University of Tennessee
7/98
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Pathogenesis
• Disruption of the endocardial layer
as a complication of abnormal blood
flow associated with underlying
cardiac defect
• Bacterium-endothelium interaction
with bacterial attachment and
invasion of endothelial cells
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Epidemiology
• Underlying valvular abnormality
predisposing to infective endocarditis
– rheumatic fever
a common cause in the past
– mitral valve prolapse
currently represents the most common
underlying cardiac abnormality
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mitral valve prolapse
• risk for infective ednocarditis is 5x-8x
• mitral regurgitation increases the risk
• leaflet redundancy with myxomatous
degeneration is a frequent finding
• age <20 , female predominate
age >20 , male accounts for 60%
age >50 , male accounts for 68%
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Mitral Valve Prolapse
and Infective Endocarditis
20
18
16
14
12
10
8
6
4
2
0
Male
Female
<19
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20-29
30-39
40-49
Rev Infect Dis 1986;8:117-137
50-59
>60
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Coagulase-negative Staphylococci
• can produce native-valve endocarditis in
mitral valve prolapse
• usually subacute, difficult to diagnose,
and disregarded as a contaminant
• delay in diagnosis and treatment may
account for the severe complications
– myocardial abscess formation
– valvular insufficiency requiring valve surgery
– death
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Prosthetic Heart Valve
• positive blood culture in hospitalized
patients with underlying prosthetic valves
can be a harbinger of endocarditis
• 43% patients with nosocomial bacteremia
or fungemia had prosthetic valve infection
• a serious complication
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IV Drug Use
• Recurrent
• Polymicrobial
• Staph aureus accounts for the
majority of cases of endocarditis
• tricuspid valve, either alone or in
combination, us most often infected
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Predisposing Factors
Polymicrobial Infective Endocarditis
Iv drug use
Central line
Prosthetic valve
Previous IE
Murmur
Dental procedure
Rheumatic disease
Miscellaneous
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Polymicrobial Infective Endocarditis
clinical features
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•
•
•
•
•
•
IV drug use is the predominant risk factor
younger age (mean 36.5 years)
2/3 were male
right-sided cardiac involvement in > 60%
streptococci more frequent than S. aureus
1/3 of patients died
mortality rate is 4x higher for pure leftsides vs pure right-sided endocarditis
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Diagnostic (Duke) Criteria
• Definitive infective endocarditis
– pathologic criteria
• microorganisms or pathologic lesions:
demonstrated by culture or histology in a
vegetation, or in a vegetation that has
embolized, or in an intracardiac abscess
– clinical criteria (see below)
• two major criteria, or one major and three
minor criteria, or five minor criteria
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Diagnostic (Duke) Criteria
• Possible infective endocarditis
– findings consistent of IE that fall short of
“definite”, but not “rejected”
• Rejected
– firm alternate Dx for manifestation of IE
– resolution ofmanifestations of IE, with
antibiotic therapy for  4 days
– no pathologic evidence of IE at surgery or
autopsy, after antibiotic therapy for  4 days
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Diagnostic (Duke) Criteria
• Major criteria
– positive blood culture for IE
– evidence of endocardial involvement
• Minor criteria
–
–
–
–
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predisposition (heart condition or IV drug use)
fever of 100.40F or higher
vascular or immunologic phenomena
microbiologic or echocardiographic evidence
not meeting major criteria
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Duke’s Major Criteria
• positive blood culture for IE
– typical microorganism (strep viridans, strep
bovis, HACEK group, staph aureus or
enterococci in the absence of a primary locus)
for endocarditis from two separate blood
cultures
– persistently positive blood culture from:
• blood cultures drawn more than 12 hr apart, or
• all of 3 or a majority of 4 or more separate blood
cultures, with first and last drqwn at least 1 hr apart
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Duke’s Major Criteria
• Evidence of endocardial involvement
– positive echocardiogram for endocarditis
• oscillating intracardiac mass on valve or supporting
structure, or in the path of regurgitant jets, or on
implanted material, in the absence of an alternate
anatomic explanation
• abscess
• new partial dehiscence of prosthetic valve
– new valvular regurgitation (increase or change
in pre-existing murmur not sufficient)
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Duke’s Minor Criteria
• predisposition (predisposing heart
condition or iv drug use)
• fever of 100.40F or higher
• vascular phenomena (major arterial
emboli, septic pulmonary infarcts, mycotic
aneurysm, intracranial hemorrhage,
conjunctive hemorrhages, Janeway
lesions)
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Duke’s Minor Criteria
• immunologic phenomena
(glomerulonephritis, Osler’s nodes, Roth
spots, rheumatoid factor)
• microbiologic evidence (positive blood
culture not meeting major criteria or
serologic evidence of active infection with
organism consistent with IE)
• echocardiogram (consistent with IE but
not meeting major criteria)
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Risk for Endocarditis
• High risk
– prosthetic cardiac valve
– prior episodes of endocarditis
– complex congenital cardiac defect
– surgically constructed systemicpulmonary shunts or conduits
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Risk for Endocarditis
• Moderate risk
– patent ductus arteriosus
– VSD, primum ASD
– coarctation of the aorta
– bicuspid aortic valve
– hypertrophic cardiomyopathy
– acquired valvular dysfunction
– MVP with mitral regurgitation
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Risk for Endocarditis
• Low risk
– isolated secundum atrial septal defect
– ASD, VSD, or PDA >6 months past
repair
– “innocent” heart murmur by
auscultation in the pediatric population
– “innocent” heart murmur by
echocardiography in adult patients
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Treatment
• Pre-antibiotic era - a death sentence
• Antibiotic era
– microbiologic cure in majority of
patients
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New Treatments
• Right-sided infective endocarditis due to
methicillin-susceptible S aureus (MSSA) in
IV drug users
– 2-wk therapy with a penicillinase-resistant
penicillin and an aminoglycoside
– 2-wk monotherapy with IV cloxacillin
– short-term therapy is inappropriate if
complicated by ostomyelitis, meningitis,
myocardial abscess, or concomitant left-sided
involvement
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New Treatments
• Highly penicillin-susceptible
Streptococcus viridans or bovis
– Once-daily ceftriaxone for 4 wks
• cure rate > 98%
• easily administered as outpatient, avoid
hospitalization, offers significant cost savings
– Once-daily ceftriaxone 2 g for 2wks followed
by oral amoxicillin qid for 2 wks
– Once-daily ceftriazone and netilmicin for 2 wks
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New Treatments
• Prosthetic valve endocarditis due to
fluconazole-susceptible Candida species
– many are due to bloodstream invasion
– chronic oral suppressive therapy with
fluconazole for inoperable disease
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SBE Prophylaxis
Standard general prophylaxis
Unable to take oral meds
Allergic to penicilin
Allergic to penicillin and unable
to take oral medications
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amoxicillin
ampicillin
clindamycin
cephalexin
azithromycin
clarithromycin
clindamycin
cefazolin
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References
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•
•
Prevention of bacterial endocarditis. Recommended by the American
Heart Association.
Dajani AS, Taubert KA, Wilson W, et al. Circulation 1997;96:358-366
New Criteria for diagnosis of infective endocarditis: Utilization of
specific echocardiographic findings.
Durack DT, Lukes AS, Bright DK, et al. Am J Med 1994;96:200-209
Antibiotic treatment of adults with infective endocarditis due to
strptococci, enterococci, staphlococci, and HACEK microorganisms.
Wilson WR, Karchmer AW, Dajani AS. JAMA 1995;274:1706-1713
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