Download Native Valve Endocarditis - UCSF | Department of Medicine

NR 07-03
Native Valve Endocarditis
Mylonakis, E. and S. Calderwood. “Infective endocarditis in adults.” NEJM (2001); 345(18): 1318-30.
Spelman, D. and D. Sexton. “Complications of infective endocarditis.” UpToDate v11.2.
Key Points:
- Use the clinical scenario to decide pre-test probability -> then choose the test to change
the post-test probability
- Monitor endocarditis for complications that indicate need for more aggressive medical
or surgical treatment
Risk factors: valvular heart disease (MVP, RHD), IDU, dental hygiene, hemodialysis, diabetes, HIV?
Microbiology
- 16-60 years old: Streptococcus, S. aureus, enterococcus, coag-negative staph; culture-negative /
HACEK
- IDU: S. aureus, gram-negative bacilli, fungi
- Prevalence of endocarditis in S. aureus bactermia: 13-25%
- Mortality with S. aureus endocarditis up to 40%
Diagnosis:
- Duke Criteria: 76 - 100% sensitivity, 88 – 100% specificity; NPV is 92%
- Transthoracic echocardiogram: 60-70% sensitive, 98% specific
- Tranesophageal echocardiogram: 75-95% sensitive, 85-98% specific
o Abscess (87% sensitive, 95% specific)
o Fistulas, pseudoaneurysms
- If pre-test probability <4% -> TTE
- If pre-test probability 4-60% -> TEE
Rx:
-
Empiric: vancomycin + gentamicin (high rates of MRSA in community)
o Watch ototoxicity / nephrotoxicity (increased gent toxicity with vancomycin)
o Stop empiric therapy and narrow as soon as possible
Strep: penicillin or ceftriaxone 4 weeks +/- gentamicin (depends on MIC PCN)
MSSA: nafcillin 4-6 weeks
MRSA: vancomycin 6 weeks (no gentamicin)
o + rifampin for prosthetic valves
Rt sided staph: nafcillin 2 weeks + gentamicin 2 weeks (longer for high risk pts)
Enterococcus: penicillin or vancomycin + gentamicin
HACEK: ceftriaxone 4 weeks
Complications:
- Cardiac (up to 50%)
o Valvular insufficiency -> CHF
o Coronary emboli -> MI
o Abscess (30-40%, not correlated with size of vegetation) -> block
o Pericardial: pericarditis, hemopericardium, tamponade
o Fistulas
- Neurologic (65% of emboli are CNS, 20-40% of pts develop neuro complications)
o Embolic stroke
o Abscess
o Meningitis
o Mycotic aneurysms -> hemorrhage
- Emboli and systemic spread
o Splenic abscess -> rx splenectomy
o Pulmonary emboli
NR 07-03
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o Kidney, liver, iliac / mesenteric arteries
o Predictors: size / characteristics of vegetations, valvular abn, antiphosphlipid ab
o Osteomyelitis, septic arthritis
Renal: ARF in up to 1/3 (infarction, AIN, GN)
Persistent fever (>14d): extension, focal met, drug hypersentivity, nosocomial infection /
complication
Indications for surgery:
- CHF from valve dysfunction (aortic > mitral)
- Persistent or uncontrolled infection
- Fungal endocarditis
- Abscess / aneurysm
- Also: (grade II)
o Recurrent emboli after antibiotic therapy
o Relapse after therapy
o Highly resistant organisms
o Mobile vegetations >10mm
Duke Criteria
Major Criteria
1. Blood culture positive:
a. Typical organism (alpha-hemolytic streptococcus, S. bovis, HACEK organisms, or
community-acquired S. aureus or enterococcus without a primary focus) from 2
separate blood cultures
OR
b. Persistent bacteremia with any organism (2 positive cultures > 12 hours apart or 3
positive cultures or a majority of 4 or more cultures > 1 h apart)
2. Evidence of endocardial involvement
a. Echo findings: mobile mass attached to valve or valve apparatus, or abscess, or new
partial dehiscence of prosthetic valve
b. New valvular regurgitation
Minor Criteria
1. Predisposing condition: intravenous drug use or predisposing cardiac condition
2. Fever ≥ 38.0° C
3. Vascular phenomena: arterial embolism, septic pulmonary emboli, mycotic aneurysm,
intracranial hemorrhage, conjunctival hemorrhages, Janeway lesions
4. Immunologic phenomena: glomerulonephritis, Osler nodes, Roth spots, rheumatoid
factor
5. Echocardiogram findings consistent with endocarditis but not meeting major criteria
6. Microbiologic evidence: positive blood cultures not meeting major criteria, or
serologic evidence of active infection consistent with endocarditis
Adapted from Durack DT, Lukes AS, Bright DK et al. New criteria for diagnosis of infective endocarditis. Am J Med 1994; 96: 2009.
Table 6: Proposed Modifications to Duke Criteria
for Diagnosis of Infective Endocarditis
• The category “Possible IE” should be defined as at least 1 major and 1 minor criterion or 3 minor criteria
• The minor criterion of echocardiographic findings consistent with endocarditis but not meeting a major criterion
should be eliminated, due to the widespread use of the more accurate transesophageal echo
• Bacteremia with S. aureus should be considered a major criterion, regardless of whether the bacteremia was nosocomially
acquired or whether a removable focus of infection is found
• Positive Q fever serology should be made a major criterion
Adapted from Li JS, Sexton DJ, Mick N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis.
Clin Infect Dis 2000, 30(4): 633-8.