Amonthep Waipara
Endocarditis
An inflammation of the endocardium, Which is the membranes lining the chamberof the heart and covering the cusps of the heart valves.
Endocarditis
Infection of the heart valves by various microorganisms. Average motality is 20% Classified by clinical presentation: Acute bacterial endocarditis (ABC) Subacute bacterial endocarditis (SBC)
Infection
Symptoms
ABE
Fulminating, high fever, WBC systemic toxicity
SBE
Untreated
Indolent, fatigue, weakness,low grade fever, wt loss native Preexisting valvular heart disease or prosthetic S.aureus (virulent) Viridans strep (less Streptococcus pyogens, invasive), s.pneumoiae Staphylococcus epidermidis Death to < 6 wk Death 6 wk-3 mo
Classification of IE
Native-valve IE Posthetic valve IE Eaely (w/n 60 Congenital day after Sx) heart disease Late (after 60 Rheumatic day of Sx) heart disease Degenerative valve lesion IE in IVDU Nosocomial IE
IE in IVDU
Occurs in young people (30-40 years old)
Valve affected:
Tricuspid (>50%) > Aortic (25%) > Mitral (20%)
Nosocomial IE
About 22% pts with IE Etiology:
S.aureus, enterococci
Pathogenesis
Damaged endothelial surface of the heart
Deposition of platelets and fibrin on the surface Nonbacterial Thrombotic Endocarditis (NBTE) Bacteria adheres to damaged valve completeted w/n minutes during transient bacteremia A vegetation of fibrin, platelets, and bacteria form
Site of Involvement
Determined by the underlying cardiac defect and the infecting organisms.
Mitral valve : VS (85%) Tricuspid value : Staphylococci and IVDU Mitral > Aortic > Tricuspid> pulmonic valves
Complications
Cardiac complications
Heart failure
Neurologic complications
Ischemic stroke Intracranial hemorrhage S.aureus
splenomegaly
Risk factors
Previous IE (rheumatic heart disease) Hypertrophic cardiomyophathy Mitral valve prolapsed with regurgitation Hemodialysis IVDU
Etiologic Organisms IE
Streptococci
Viridans streptococci Other streptococci
55-62
30-40 15-25
Enterococci Staphylococci
Coagulase positive Coagulase negative
5-18 20-35
10-27 1-3
Gram ve aerobic bacteria Fungi Miscellaneous bacteria Mixed infection Culture negative
Incidence(%) of bact.
Dental
18-85 32-88 17-51 0-26 27-50
15 28-38 16
Upper airway
bronchoscopy suction
Heart murmur 85 Changing murmur 5-10 New murmur 3-5 Embolic phenomenon >50 Skin manifestation 18-50
Osler node Splinter hemorrhages Petechiae Janeway lesion
Osler node
Splinter hemorrhages
Janeway lesion
Petechiae
Laboratory Finding
Lab WBC ESR Other ABE Elevated Elevated SBE Elevated Elevated Normocytic, normochromic anemia, low SFe
Blood Cultures
Hallmark Continuous bacteremia, caused by bacteria shedding from the vegetation into the blood stream. 3 set, each from separate site, should be collected over 24 hr.
Blood Cultures
+ve result: 95% of bacterial endocarditis 50% of fungal endocarditis False negative:
Prior antibiotics (culture-negative endocarditis)suppress pathogens growth Fastidious organisms
Echocardiography
To identify and localize valvular lesions Transthoracic Echocardiography (TTE)
Sensitivity 60-65%
Echocardiographic finding
+ ve result :
A large vegetation (>1cm), a ring abscess, or intracardiac fistula Alert for monitoring complications: septic emboli and HF
- ve result
Does not exclude endocarditis
Diagnosis
Signs and symptoms : nonspecific Lab: nonreliable Diagnostic criteria: Duke criteria Blood culture: identify infecting pathogens TEE: determine the presence of valvular vegetation
Treatment
Desired outcome
Relieve the S&S of the disease Eradicate the causative organism with minimal drug exposure Provide cost-effective abx therapy, determined by:
The likely or identified pathogen Drug susceptibilities Hepatic and renal function Drug allergies Anticipated drug toxicities
Antibiotic
PCN G Naf- / Oxa- / cloxacillin Ampicillin Gentamicin
Use
DOC for streptococci DOC for staphylococci DOC for enterococci Synergitic effect for enterococci hhasten the pace of cure (strep & staphy) Prevent emergence of resistant org(PVE caused by coagulase ve staphy) Reserved for resistant orgs and pts with immediate B-lactam allergies
Vancomycin
Nonpharmacologic Treatment
Valve replacement surgery:
Large vegetation (> 10mm) >1 embolic event during 1st 2 wk of tx Severe valvular insufficiency Valvular perforation or dehiscence Decompensated heart faliure, perivalvular or myocardial abscess New heart block Persistent fever or bactermia
Viridans streptococci
The most etiologic agents in SBE (native valves) and non injection drug users. A large number of different species
Streptococcus sanguis Streptococcus oralis (mitis) Streptococcus salivarius Streptococcus mutans other
Tx of Native Valve Endocarditis due to Highly PCN-SViridans streptococci & S. bovis(MIC <0.12 mcg/mL)
Antibiotic Aq. PCN G Na or ceftriaxone Aq. PCN G Na +gentamicin Ceftriaxone +gentamicin Dosage ,Route 12-18 mU/d IV 2 g once daily IV/IM 12-18 mU/d IV Duration 4 wk 4 wk 2 wk 2 wk (Pk 3; Tr<1) 2 wk 2 wk(Pk 3; Tr<1) 4 wk(Pk 30-45)
3 mg/kg IM/IV od
2 g IV/IM od
3 mg/kg IM/IV od Vancomycin HCl (for pt 15 mg/kg (not 2 g/d) all to B-lactams) IV q 12(infused > 1 hr)
Tx of Native Valve Endocarditis due to Highly PCN-RelativelyR-Viridans Streptococci & S. bovis(MIC >0.12,< 0.5 mcg/mL)
Antibiotic Aq. PCN G Na +gentamicin Dosage ,Route 24 mU/d IV Duration 4 wk
3 mg/kg IM/IV od
Ceftriaxone +gentamicin 2 g IV/IM od 3 mg/kg IM/IV od Vancomycin HCl (for pt all to B-lactams) 15 mg/kg (not 2 g/d) IV q 12(infused > 1 hr)
2 wk (Pk 3; Tr<1)
4 wk 2 wk(Pk 3; Tr<1) 4 wk(Pk 30-45)
1 mg/kg IM/IV q8
This table is also for VS with MIC of> 0.5 mcg/mL, Abiotrophia defcetiva and Granulicatella spp, or prosthetic valve endocarditis caused by VS or S. bovis
6 wk
This table is also for VS with MIC of> 0.5 mcg/mL, Abiotrophia defcetiva and Granulicatella spp, or prosthetic valve endocarditis caused by VS or S. bovis
> 8wk
> 8wk > 8wk > 8wk > 8wk
Staphylococci
S. aureus
IVDU (60-90% of cases), prosthetic heart valve
Does not require a cardiac defect to be infective More acute onset Require immediate abx Tx
S. epidermidis
Prothetic heart valve Mostly MRSE
1 mg/kg IM/IV q 8
15 mg/kg IV q 12
3-5 d
6 wk
IVDU
Cloxacillin 2 g IV q 4 h + Amikacin 7.5 mg/kg IV q 12 h 2 week
300 mg IV/PO q 8
1 mg/kg IM/IV q 8
> 6 wk
2 wk
Late
Infection of the valve leaflet Caused by same organism that are responsible for native valve endocarditis
HACEK Group
Haemophilus parainfluenzae, Haemophilus aphrophilus Actinobacillus actinomycetamcomitans Cardiobacterium hominis Eikenella corrodens Kingella kingae
Culture-nagtive endocarditis
Cause:
Prior administration of Abx Presence of slow-growing and fastidious org: HACEK, Brucella, Coxiella, Chlamydiae, anaerobes, fungi
Culture-nagtive endocarditis
Treatment
if hemodynamic unstable, start empiric abx covering staphy and gr-ve bacilli, + antifungal agent If hemodynamic stable, withhold abx until culture become positive
Fungal Endocarditis
A life-threatening infection Caused by Canndida and aspergillus sp. Occurs primarily in:
IVDU Patients with prosthetic heart valve Immunocompromised pts Those with IV catheters Individual receiving broad-spectrum antibiotics
Monitoring during Tx
Efficacy
Blood Cx,temp
Safety
Depends on Abx
Prevention
Desired outcomes
Prevent IE in high-risk patients with appropriate prohylactic antimicrobials
Prophylactic Regimens for Dental Procedures Single dose regimen 30-60 min before procedure
Standard prophylaxis Unable to take PO Amoxicillin PO Ampicillin IM/IV Cefazolin/Ceftriaxone IM/IV PCN-allergy Cephalexin PO Clindamycin PO Azithromycin/Clarithromyci n PO A: 2 g, C: 50mg/kg A: 2 g, C: 50mg/kg A: 1 g, C: 50mg/kg A: 2 g, C: 50mg/kg A: 600 mg, C: 20mg/kg A: 500 mg, C: 15 mg/kg
IE prophylaxis
Is reasonable for procedures on respiratory tract or infected skin, skin structures, or musculoskeletal tissue only for patient with underlying cardiac conditions associated with the highest risk of adverse outcome from IE Is not recommend for GU or GI tract procedures