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Amen Corner: Endocarditis Prophylaxis

Amen Corner: Endocarditis Prophylaxis. Jimmy Klemis, MD Cardiology Conference April 18 2002. Amen Corner -- where the 11th green, 12th hole and 13th tee meet at the southeast corner of Augusta National -- got its name when the

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Amen Corner: Endocarditis Prophylaxis

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  1. Amen Corner:Endocarditis Prophylaxis Jimmy Klemis, MD Cardiology Conference April 18 2002

  2. Amen Corner -- where the 11th green, 12th hole and 13th tee meet at the southeast corner of Augusta National -- got its name when the great golf writer Herbert Warren Wind observed more than 40 years ago that a golfer who successfully negotiates it should say "Amen." Amen Corner II – where the patient with structural heart disease, a bacteremic-inducing procedure, and a bad outcome meet – got its name when the lowly cardiology fellow Jimmy Klemis observed more than 4 weeks ago that a physician who misses the opportunity to prevent it doesn’t get to say “Amen”

  3. Case Presentation • 60 M admitted for 5 wk history of “not feeling well”; c/o, fatigue, DOE, and nocturnal angina. Patient states was doing well until 1-2d after recent colonoscopy/bx for hx heme + stools. Found to have colon polyp, discharged to f/u with PCP. • PMHx: CAD/LAD stent 12wk ago, HLP, hx mild AI/AS • Denies drug/etoh

  4. Case Presentation • PE: T 99.8 HR 95 BP 102/62 • HNT: poor dentition, no jvd, nl carotid pulsation • CV: nl S1/2, +S3, no S4, 2/6 diastolic decr m LSB, 2/6 sys m RUSB • RESP: basilar rales • ABD: nt/nd • EXT: no edema

  5. Case Presentation • Admitted for eval new CP, suspected endocarditis – empiric Abx started, Bld Cx 4/4 + for S. viridans • TEE: 4+AI, vegetation NCC AV, EF 60% • Abx continued, CT surg consulted. Pt initially hemodynamically stable and defervesced. ~10d into hosp course pt decompensated – tachy/hypotension/EMD • Unsuccessful resucitation, pt died

  6. Endocarditis • Bacteremia (daily activites, procedures, infections) • adherence/colonization on platelet fibrin aggregates which have formed on valve endothelium due to congenital or acquired dz • if host defenses overwhelmed  ENDOCARDITIS

  7. Endocarditis Prophylaxis • No randomized or controlled clinical trials proving that antimicrobial prophylaxis prevents IE in structurally abnl hearts after procedures • Overall incidence of procedure-related endocarditis is low • However, significant literature establishing certain hi-risk conditions more likely predisposed to endocarditis and certain procedures which may have higher incidence of bacteremia with aggressive pathogens known to cause endocarditis

  8. Determining Risk • Cardiac conditions • Type of Procedure

  9. Cardiac conditions which predispose pt for IE • Based on risk of progression to severe endocarditis with substantial morbidity and mortality (not simply risk of developing IE) • Classified into • HIGH risk - prophylaxis • MODERATE risk - prophylaxis • NEGLIGIBLE risk - no prophylaxis

  10. Cardiac Conditions – High Risk1 • Prosthetic Valves (400x risk2) • Previous endocarditis • Congenital • Complex cyanotic dz (Tetralogy, Transposition, Single Vent) • Patent Ductus Arteriosus • VSD • Coarctation • Valvular: • Aortic Stenosis/ Aortic Regurg • Mitral Regurgitation • Mitral Stenosis with Regurg • Surgically constructed systemic pulmonary shunts or conduits 1Durack, et al. NEJM 1995 Mod Risk per 1997 AHA guidelines 2Steckleberg, et al. Inf Dis Clin N Amer 1993

  11. Cardiac Conditions - Moderate Risk1 • Valvular • MVP + regurg and/or thickened leaflets • pure Mitral Stenosis • TR/TS • Pulmonic Stenosis • Bicuspid AV/ Aortic Sclerosis • degenerative valve dz in eldery • Asymmetric Septal Hypertrophy/HOCM • surgically repaired intracardiac lesions w/o hemodynamic abnormality, < 6 mos after surg 1Durack, et al. NEJM 1995

  12. Negligible Risk (no prophylaxis) • MVP no regurg • Physiologic/innocent murmur • Pacemaker/ICD • Isolated Secundum ASD • prev CABG • surgical repair ASD/VSD/PDA , no residua > 6mos after surgery

  13. Procedures • 1930’s – studies linking significant bacteremia induced after extraction of teeth1 • Serratia marcesens introduced as sentinal organism shown to be present in venous blood immediately after tooth extraction2 • incidental bacteremia also seen in control groups, less often, less virulent 1Okell, et al. Lancet. 1935 2Burket, et al. J Dent Res 1937

  14. Procedure related bacteremia1 • Procedure related bacteremias are short lived • highest freq + Bld Cx 30 secs after tooth extraction • episodes bacteremia from dental procedures generally last < 10 min • most pt have sxs within 1-2 wks of procedure and can occur as early as 1-2 days; if sxs occur later less likely procedurally related 1Durack, et al. NEJM 1995

  15. Procedures • Highest risk oral/dental • Int risk GU/Pulm • Low risk GI 1Durack, et al. NEJM 1995

  16. PROPHYLAXIS Procedures with gingival/mucosal bleeding extractions, periodontal, endodontal procedures professional cleaning or scaling orthodontic bands NO PROPHYLAXIS Minimal/no bleeding simple fillings above gumline Restorative dentistry* adjustment of orthodontic appliances xray, injections, fluoride treatments Dental/Oral Procedures *clinical judgement if potentially significant bleeding

  17. PROPHYLAXIS Esoph dilatation Sclerotherapy for esoph varices ERCP with biliary obstruction Biliary surgery Surgery involving intestinal mucosa Prostatic Surgery Cystoscopy Ureteral dilatation NO PROPHYLAXIS TEE* Endoscopy w/wo bx*1 Ureteral catheterization D&C “Therapeutic” Ab Vaginal hysterectomy* Vaginal delivery* (<5% risk) IUD insertion/removal GI/GU Procedures 1<10 cases of IE after dx GI/endoscopy Durack, et al. NEJM 1995 *Optional for High Risk pt

  18. PROPHYLAXIS Tonsillectomy Rigid Bronchoscopy Surgery involving resp mucosa NO PROPHYLAXIS Endotracheal intubation Flex Bronchoscopy w/wo biopsy* Cardiac cath/stent Pacer/ICD implantation Incision/Bx of surgically scrubbed skin Other Procedures *Optional for High risk pt

  19. ?Evidence linking IE to procedures • Largely circumstantial, unproven but based on organisms involved and temporal relation to procedures • Animal studies 1970’s showed endocarditis preventable with prophylaxis in rabbits • Estimates show only ~ 6% of endocarditis cases preventable with prophylaxis (240-480 cases annually in US) but extensive morbidity/mortality associated should sway toward appropriate identification and prophylaxis of at risk pt undergoing procedures known to cause significant bacteremia

  20. Prophylaxis • No randomized trials (would req 6000 pt with cardiac dz, ?ethical) • Retrospective analysis of 533 pt with prosthetic valves undergoing dental/ surgical procedures • No prophylaxis – 6/229 pt endocarditis • Prophylaxis – 0/304 Horstkotte, et al. Eur Heart J 1987

  21. Prophylactic RegimensDental/Oral, Respiratory, Esophageal Dajani, et al. Circ 1997

  22. Prophylactic RegimensGU/GI (excluding esophageal) Dajani, et al. Circ 1997

  23. Theoretical/Other Concerns with “over prophylaxis” • Microbial Resistance • Incidence of anaphylaxis (IV preps) may override benefit when looking at overall population if given in nonselective fashion

  24. Our Patient - ? Missed opportunity • “low risk” procedure (colonoscopy/bx) and organism common to oral mucosa • BUT, significant association of sxs with 24-48hrs after colonoscopy/bx • current guidelines would prophylax “hi risk pt” but AI/AS not included in this group

  25. Conclusions • Recognize at risk patients in your care • Educate them on importance of prophylaxis (you may not get consulted prior to procedures and not everyone knows the risks – pt may have to act as his own advocate ) • Err on the side of caution

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