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Infective Endocarditis

Infective Endocarditis. What the Internist Needs to Know 2/09. Pathogenesis. Predosposing valve or endocardial lesion Platelet /fibrin sterile vegetation Bacteremia Seeding of vegetation/Platelet aggregation

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Infective Endocarditis

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  1. Infective Endocarditis What the Internist Needs to Know 2/09

  2. Pathogenesis • Predosposing valve or endocardial lesion • Platelet /fibrin sterile vegetation • Bacteremia • Seeding of vegetation/Platelet aggregation • Platelet –fibrin complex allows protected bacterial growth-high colony counts-low metabolic activity/protected from phagocytosis

  3. Mitral Valve Vegetation • Vegetations form on low pressure downstream side of obstructing lesion

  4. Predisposing Conditions • Prosthetic valve • Calcific aortic stenosis/mitral insufficiency • CHD: bicuspid aortic valve, MVP, VSD • Rheumatic heart disease • IVDA-adulterant injury to TV • Central catheters in HCA-IE • Prior IE

  5. Bacterial Factors • Produce “sticky” dextran substances • S. viridans:mutans, sanguis, mitior, salivarias • S. bovis-50% large bowel lesion • Enterococci- S. faecalis, S. faecium • HACEK group-gram neg GI flora • Group B strep: diabetics, cancer, alcoholics • Abiotrphia-old NVS, need B6 for growth

  6. Bacterial Factors-2 • Staph. aureus: both abnormal & normal valves, major cause of IVDA, and HCA-IE • Gram negative aerobic: uncommon cause of IE, except early PVE & focal outbreaks of IVDA

  7. Clinical Manifestations-1Native Valves • Systemic: fever, chills, fatigue, anorexia, weight loss, arthralgias, low back pain, manifestations of inflammatory mediators • Cardiac: new or increased reguritant murmurs, CHF-edema, DOE, PND, fatigue, heart block-syncope

  8. Clinical Manifestations-2 • Embolic: lungs-septic emboli, brain-stroke syndrome, kidney-pain & hematuria, heart-MI, peripheral small arteriioles-Janeway lesion, mycotic aneursym-bleeding,

  9. Clinical Manifestations-3 • Immunologic: Subacute presentations glomerulonephritis, Osler’s nodes, Roth spots, Rheumatoid factor

  10. Clinical Exam: IE • VS: temp, pulse rate, BP-pulse pressure • Skin/MM: petechiae- conjunctiva, nailbeds, • Fundus: Roth spots, flame hemorrhages • Cardiac: AI, MR, TR • ABD: LUQ tenderness • Ext: Osler nodes, Janeway, decreased perfusion

  11. Diagnosis: Duke Criteria • Clinical Endocarditis: Definite • 2 major • 1 major + 3 minor • 5 minor • Possible: 1 major 1 minor 3 minor

  12. Duke Criteria: Major • I Blood Cultures: • 2 cultures of typical organisms • 3 or a majority of > of 4, drawn > 1 hour apart II Echocardiogram: -oscillating mass on valve or supporting structures, path of regurgitant jet - endocardial abscess - new dehiscence of PV, new regurgitation

  13. Duke Criteria-Minor • Temp > 38.0 C (100.4) • Vascular: emboli, mycotic aneurysm, Janeway lesions, conjunctival hemorrhages • Immune: Roth, Osler, GMN, RF • Micro: + blood culture, does not meet maj. • Echo: suspicious, does not meet major • Predisposing condition or IVDA

  14. Therapy: General Principles • Isolation of the causative organism is key, and may dictate in certain situations withholding antibiotics until blood cultures positive. • Cidal therapy should be used. • Antibiotic choices guided by MIC values and when appropriate synergy testing. • Duration is usually 4-6 weeks • Surgical therapy increasingly utilized.

  15. Therapy: Antibiotics • Strep. viridans, bovis, MIC < 0.1 mcg/ml Pen G 18M/day or Ceftriaxone 2 gram 4 wks or 2 wks + gentamicin 3mg/kg q24h Strep. MIC > 0.1 to < 0.5 mcg/ml PenG/Ceftri 4 wks + Gentamicin 2 wks Strep/Enetrococci MIC > 0.5 mcg/ml PenG/Ampi + Gentamicin 4-6 wks

  16. Therapy-Antibiotics • Enterococci: Synergy testing, Genta/Strep • Enterococci: PCN/Ampi R, Vanco R • MSSA: Nafcillin/Oxacillin 2 g q4h 4-6 wks,some add 3 days gentamicin if “toxic” • MRSA:Vanco if MIC < 1.0, trough 15-20 • MRSA: Vanco > 1.0, Daptomycin + Genta • HACEK: Ceftriaxone 2 grm q24h for 4 wks

  17. Prosthetic Valve Endocarditis • Staph. epidermidis: Vancomycin, Rifampin 300mg TID X 6 weeks + gentamicin 3mg/kg for 2 wks • MRSA: same as above • MSSA: substitute nafcillin 2 g q4h for vanco Surgical therapy often necessary

  18. Surgical IndicationsEvidence/Consensus • Acute AI or MR with heart failure • Acute AR with MV preclosure • Fungal/Resistant organism • Aortic root abscess, aortic aneurysm • Persistent bacteremia after 7-10 days of appropriate antibiotic therapy, no non-cardiac etiology, usually vegetation > 10 mm. Or myocardial abscess

  19. Surgical Therapy/Conflicting Evidence • Recurrent emboli after antibiotic RX • Mobile vegetations > 10 mm

  20. Prophylaxis of IE • What is the risk? CID: 2006; 42: 10207 France: Predisposing condition/invasive dental procedure-observational pop. Prosthetic valve: 1/11,000 Native valves (NV): 1/54,000 NV + prophylaxis: 1/150,000 NNT 75,000

  21. Prophylaxis: Changes in AHA Guidelines: 2007 • Only for those at highest risk: • PV • Prior IE • Heart transplant with valvulopathy • Cyanotic CHD: palliative shunts, repaired with prosthetic material for first six months, repaired with residual defects

  22. Updated Prophylaxis • Only for high risk procedures: • Dental with gingival tissue and/or periapical • Respiratory tract with mucosal incision • GI/GU with ongoing infection • Procedures on infected SST

  23. Prophylaxis: Antibiotics • Dental/Resp: • Amoxicillin 2 grams 30-60 min before • Cephalexin 2 grams • Clindamycin 600 mg • Vancomycin 1 gram over 1 hour 1 ½-2 hrs before procedure

  24. Questions: • You are referred three patients in your clinic to suggest IE prophylaxis before procedures. • Pt.1. 24 YO woman with MR prolapse +moderate regurgitation. Elective C-section. • Pt. 2. 56 YO man with moderate AS due to bicuspid valve, extensive gum surgery.

  25. Pt. 3. History of bioprosthetic AV, undergoing TURP with chronic prostatic infection with Enterococci faecalis.

  26. Questions • A 46 YO Korean nurse is admitted with a 24 hour history of abrupt aphasia and mild right sided weakness.An MRI shows left temporal restricted diffusion, and multilpe similar smaller areas suggestive of emboli. She denies significant PMH except being told she had a heart murmur when she gave birth 20 years prior. In addition, over the past 6 weeks she has had intermittent fever and arthralgia for which she self-medicated with levofloxacin. • Exam: T 99, P 94, BP118/70 • Slight expressive aphasia-improving • Conjunctival hemorrhage L eye • III/VI diastolic rumble apical area/lungs clear

  27. Mild right pronator drift • Blood cultures negative X 3 from admission • Echo: very thickened calcified stenotic mitral valve consistent with RHD, cannot rule out vegetation • Rheumatoid factor negative

  28. Does this patient meet Duke Criteria for IE? • What would be your diagnostic and therapeutic approach? • Should you follow the neurologist’s recommendation to start anticoagulation?

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