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Update on Endocarditis

Update on Endocarditis. Dr Catherine Berry May 2012. Endocarditis. Pathological characteristics of an episode of GBS AV endocarditis Group B streptococcus in endocarditis What we know about endocarditis in 21 st century? Review of endocarditis at JHH, 2011 Recent guidelines Case.

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Update on Endocarditis

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  1. Update on Endocarditis Dr Catherine Berry May 2012

  2. Endocarditis • Pathological characteristics of an episode of GBS AV endocarditis • Group B streptococcus in endocarditis • What we know about endocarditis in 21st century? • Review of endocarditis at JHH, 2011 • Recent guidelines • Case

  3. Valve… From : www.clevelandclinicmeded.com

  4. History • 1554 - First described pathologically by Jean François Fernel • 1646 – Riverius noted thrill with valvular “outgrowths” at autopsy • 1816 – 1st stethoscope • 1835 – Bouillaud named disease endocarditis • 1884 – Gram stain reported • 1885 – Osler’s Gulstonian lectures – attempted classification and clinical features • 1890’s – 1st routine blood cultures • 1930 – 1st clinical cures with penicillin • 1966 – “Infective Endocarditis in the antibiotic era” NEJM Miller B, EID 2004 Jun

  5. Osler’s simple vs malignant endocarditis • “.. the simple being those with few or slight symptoms, and which run a favourable course; the malignant, the cases with severe constitutional disturbance and extensive valve-lesions, whether ulcerative or vegetative, the term being more clinical than anatomical.” J R Soc Med. 1985 December; 78(12): 1039–1046.

  6. What do we know about endocarditis in the 2000’s? ICE –PCS 2000-5 (Arch Int Med 2009) • N=2781 - Nth/Sth America, Europe, Australasia • Median age 56.5; Incidence 3-10/100,000 • Acute disease • 77% in 1st month; Osler’s nodes 3% (prev 11-23%)

  7. 2 Archives of Internal Medicine. 169(5):463&hyhen;473, March 9, 2009. DOI: 10.1001/archinternmed.2008.603

  8. What do we know about endocarditis in the 2000’s? • Outcomes • 17.7% in hospital mortality • 48.2% required surgery • Risk factors for death • SA or CoNS • Pulmonary oedema • Prosthetic valve • Paravalvular dx. • NB. Surgery assoc with OR for death of 0.6

  9. Group B streptococcus • S. agalactiae • 1st recognised in cows • 20-35% colonisation • Previously- peripartum, neonatal dx. • Now – elderly, health-care assoc. , DM • Mostly Skin/Soft tissue infections, spontaneous bacteraemia

  10. GBS endocarditis • Epidemiology • complicates 2-9% of invasive GBS • 1.7  2.8% of all endocarditis in recent series • Rapid onset 6-9 days • Clinical features • Presentation with heart failure 70% • Embolisation 37% • Surgical management 40% • Death 41 - 47% • ?Gentamicin • Retrospective analysis of additive gent  increased rates HF (n=54) • No improvement in mortality.

  11. Endocarditis @ JHH, 201120 cases

  12. Mortality 2011 – 40%

  13. Morbidity or Mortality – 55%

  14. Endocarditis 2011 • male - 70% • Median age - 54.5 • >65 yrs (5 died) - 35% • inter-hospital transfers - 40% • surgical mmt. - 25% • IVDU - 40% • prosthetic valves - 25%

  15. Guidelines • ACC/AHA 2006 (Circulation)* • ECS 2009 (European Heart Journal) • BSAC 2012 (Journal of Antimicrobial chemo) • Whats new and ongoing controversies • Most recommendations remain on “C” level evidence • 16S PCR on valve tissue • Significance of Bartonella & Q-fever in culture neg IE • Optimal surgical timing • Combination therapy in staphylococcal IE • MRSA abx selection

  16. Indications for cardiac surgery in the management of infective endocarditis (IE) adapted from the European Society for Cardiology guidelines49 and the American Heart Association.50. Gould F K et al. J. Antimicrob. Chemother. 2012;67:269-289

  17. The dilemma • Recurrent embolisation is 4.8/1000 pt days (1st week)  1.7/1000 days • Surgical mortality 15% mortality 1st week (n=95) • 12% recurrence • 7% valvular dysfunction • Mortality 5-7% if delayed in non-perivalvular disease.

  18. AHA/European guidelines • No delay if TIA or clinically silent embolisation • Immediate indications should not be delayed in ischaemic CVA episodes unless • coma • ICH • Severe neurological dx. • Severe co-morbidities • Overall 70% survivors complete recovery • Peri-operative neurological risk (3-6%)

  19. Case - Mr DB • P/w back pain and “run out of medication” to Manning Base. • Bkd • Anxiety • “Prev.” IVDU • Chronic back pain – on jurnista • Hypotensive requiring inotropic support • Plt 16; INR 1.4; WCC 11.1; Cr 136; CRP 179

  20. Mr DB • Definite endocarditis (mod. Duke’s) • Blood cultures x 3 positive for Group B streptococcus • Echo – moderate to severe AR. • 14/11 - T/f’d JHH ?need for Sx.

  21. ECG

  22. Mr DB • Management plan • IV penicillin • HDU for inotropes • APS/D+A for pain management • Cardio BPT r/v  TOE

  23. Mr DB • 15/11 • Off inotropes; plt recovered  CCU • BP 90/60; HR 110 • 16/11 • S/B Cardiologist – Await TOE, for medical mmt. • TOE

  24. Mr DB • 17/11- 8pm • Rapid response for RR 40; HR 140 • “APO” • Responded to morphine; olanzapine; frusemide • Attempted contact with cardiologist – no response

  25. Mr DB

  26. Mr DB • 18/11- 22/11 • Transferred to ward • CRP/obs stable. • Escalating HF rx. • Digoxin • Frusemide • ACEi • Ongoing pain mmt

  27. Mr DB • 23/11 - pm • increased tachypnoea, desaturating off O2 • ID AMO non-contactable • Handed over to after hours medical staff • 24/11 1.20am • Found dead and unable to be revived • 14 days presentation to death

  28. Final diagnosis: • Aortic valve vegetative endocarditis. • Left heart failure. • Splenomegaly. • Splenic infarction, splenic septic emboli.

  29. Mr DB • Comments..

  30. RCA recommendations – Endocarditis protocol • An agreement on AMO1 • Consults should have outcome with intended follow-up time-frame and frequency documented ?consult form • How results of TOE’s should be conveyed • CTS should be aware of all IE patients in the hospital. • Documentation requirements by all members of treating teams • Process and person responsible to re-engage Cardiology and CTS if the pt is not improving.

  31. Conclusions • Endocarditis has the same morbidity and mortality it did 30 years ago! • Aetiology and presentation is evolving • GBS endocarditis has an acute and fulminant natural hx. • A co-ordinated, multi-disciplinary approach is required to optimise outcomes

  32. "Medicine is a science of uncertainty and an art of probability.” - William Osler (1849–1919)

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