ENDOCARDITIS

CLASSIFICATION OF ENDOCARDITIS

Organism Heart valve Metastatic foci Fatal Acute

S. aureus

Normal Yes < 6 weeks Subacute Viridans Streptococci Damaged No 6 wks - 1 yr

CATEGORIES OF ENDOCARDITIS

 Native valve  Prosthetic valve  IVDA

AETIOLOGY OF NATIVE VALVE ENDOCARDITIS

     Streptococci Staphylococci Enterococci Gram negative bacilli Fungi 55% 30% 6% rare rare

EPIDEMIOLOGY OF NATIVE VALVE ENDOCARDITIS

    Male Age > 50 yrs Mitral valve > aortic valve >>> tricuspid Predisposing Factors – – mitral valve prolapse congential heart disease

PROSTHETIC VALVE ENDOCARDITIS

  Early onset - symptoms within 60 days of surgery – – – usually valve contaminated during surgery S. epidermidis S. aureus – Gram-negative bacilli Late onset - symptoms occur > 60 days after surgery – usually due to Streptococci

INTRAVENOUS DRUG ABUSERS

Tricupsid (50%) > aortic (25%) > mitral (20%)      S. aureus Streptococci Enterococci Gram negative bacilli Fungi >50% 20% 20% 5% 5%

CLINICAL MANIFESTATIONS OF ENDOCARDITIS

Symptoms Fever Chills/Weakness/Dyspnoea Cough/Anorexia/Wt loss Skin lesions/Stroke/N/V/HA Myalgia/Arthralgia/Oedema/CP Delirium/Haemoptysis/Back pain Percentage 80 40 25 20 15 10

CLINICAL MANIFESTATIONS OF ENDOCARDITIS

Physical Findings Fever Heart murmur Embolic phemomenom Skin manifestations Splenomegaly Septic complications Clubbing Percentage 90 85 >50 18-50 20-57 20 12-52

CLINICAL INVESTIGATIONS

     FBC U+E Cr LFT Multiple Blood Cultures (At least 3 from 2 different sites) ESR CRP TTE  TOE CT/MRI (embolic phenomena)

CRITERIA FOR DIAGNOSIS OF ENDOCARDITIS

   Definite – – Pathologic criteria Clinical criteria  2 major or 1 major and 3 minor or 5 minor Possible if not definite or rejected Rejected – – Alternate diagnosis No evidence at surgery or resolution of endocarditis with < 4 days of abx therapy

MAJOR CRITERIA FOR IE

  Positive blood culture for IE – – Typical organism from 2 separate blood cultures or Persistently positive blood cultures Evidence of endocardial involvement – – Positive echocardiogram New valvular regurgitation

MINOR CRITERIA FOR IE

      Predisposition Fever Vascular phenomena Immunologic phenomena Echocardiogram Microbiologic evidence

INDICATIONS FOR SURGERY

NVE PVE Heart Fail ure – Severe Moderate - Mild 5 3 1 5 5 2 Fungal etiology Per sistent bacteremia Organism other than S strep.

Relapse 1 major embolus 2 or more emboli Vegetation on echo Right-sided disease Heart block Unstable prosthesis Early PVE (< 60 days) Prior prosthetic valve replace 4 1 -2 3 NA NA NA 5 5 1 2 2 4 1 NA 3 5 2 -2 5 5 2 3 2 5 or more points suggest the need for valve replacement

VIRIDANS STREPTOCOCCI

      S. sanguis S. mutans S. mitis S. milleri S. bovis Normal inhabitants of the oropharynx

RARE ORGANISMS

    Corynebacterium Listeria Bartonella Species Coxiella Burnetti (Q fever)

NATIVE VALVE ENDOCARDITIS DUE TO PENICILLIN SUSCEPTIBLE VIRIDANS STREPTOCOCCI (MIC 0.1 µg/ml) Duration, wk Antibiotic PCN G Dosage & Route 12-18 mu/d Ceftriaxone 2 g qd PCN G + Gentamicin 12-18 mu/d 1 mg/kg q8h Vancomycin 30 mg/kg/d 4 4 2 2 4 JAMA 1995;274:1706-1713.

NATIVE VALVE ENDOCARDITIS DUE TO VIRIDANS STREPTOCOCCI (MIC 0.1 AND < 0.5 µg/ml) Antibiotic Dosage & Route Duration, wk PCN G + Gentamicin 18 mu/day 1 mg/kg q8h 4 2 Cefazolin + Gentamicin 2 g q8h 1 mg/kg q8h Vancomycin 30 mg/kg/d 4 2 4 JAMA 1995;274:1706-1713.

ENTEROCOCCI ENDOCARDITIS

Antibiotic PCN G + Gentamicin Ampicillin + Gentamicin Dosage & Route 18-30 mu/d 1 mg/kg q8h 12 g/day 1 mg/kg q8h Vancomycin + Gentamicin 30 mg/kg/d 1 mg/kg q8h Duration, wk 4-6 4-6 4-6 4-6 4-6 4-6 JAMA 1995;274:1706-1713.

STAPHYLOCOCCUS ENDOCARDITIS IN THE ABSENCE OF PROSTHETIC VALVE Antibiotic Nafcillin ± Gentamicin Cefazolin ± Gentamicin Dosage & Route 2 g q4h 1 mg/kg q8h 2 g q8h 1 mg/kg q8h Vancomycin 30 mg/kg/d Duration 4-6 wk 3-5 d 4-6 wk 3-5 d 4-6 wk JAMA 1995;274:1706-1713.

STAPHYLOCOCCAL ENDOCARDITIS IN THE PRESENCE OF A PROSTHETIC VALVE Antibiotic Dosage & Duration, wk Route Nafcillin + Rifampin + Gentamicin Vancomycin + Rifampin + Gentamicin 2 g IV q4h 300 mg q8h 1 mg/kg q8h 30 mg/kg/d 300 mg q8h 1 mg/kg q8h 6 6 2 6 6 2 JAMA 1995;274:1706-1713.

HACEK ORGANISMS

      Haemophilus parainfluenzae Haemophilis aphrophilus Actinobacillus actinomycetemcomitans Cardiobacterium hominis Eikenella corrodens Kingella kingae

ENDOCARDITIS DUE TO HACEK ORGANISMS

Antibiotic Dosage & Route Duration, wk Ceftriaxone 2 g qd 4 Ampicillin + Gentamicin 12 g/day 1 mg/kg q8h 4 4 JAMA 1995;274:1706-1713.

CARDIAC CONDITIONS ENDOCARDITIS PROPHYLAXIS RECOMMENDED  High Risk Conditions – Prosthetic valves – Previous bacterial endocarditis – Complex congenital heart disease – Surgically constructed pulmonic shunts  Moderate Risk Conditions – Most other Coronary Heart Diseases – Mitral prolapse with regurgitation – Hypertrophic cardiac myopathy

CARDIAC CONDITIONS ENDOCARDITIS PROPHYLAXIS NOT RECOMMENDED  Cardiac pacemakers and implanted defibrillators  Rheumatic fever without valve dysfunction  Physiologic, functional heart murmurs  Mitral valve prolapse without MI  Previous CABG  Atrial septal defect

DENTAL AND OTHER PROCEDURES FOR ENDOCARDITIS PROPHYLAXIS  Dental - extractions, periodontal procedures, implants, root canal  Respiratory - T&A, rigid bronchoscopy  GI - ERCP with biliary obstruction, Sclerotherapy of esophageal varices, dilation of esophageal  Biliary tract surgery, surgery on/through intestinal mucosa  GU - prostate surgery, cystoscopy, urethral dilatation

PROCEDURES ENDOCARDITIS PROPHYLAXIS IS NOT RECOMMENDED  Dental - filling cavities, orthodontic adjustments, dental x-rays  Respiratory - Intubation, flexible bronchoscopy  GI - transoesophageal echo  GU - vaginal hysterectomy, vaginal delivery, C section, insert/remove IUD, foley catheter  Other - cardiac catheter, balloon angioplasty, implanted pacemaker, defibrillators, circumcision, skin biopsy, coronary stents

PROPHYLACTIC REGIMENS FOR GU/GI PROCEDURES SITUATION AGENT REGIMEN High-risk pts High-risk pts allergic to PCN Moderate-risk pts Moderate-risk pts allergic to PCN Ampicillin + Gentamicin Amoxycillin or Ampicillin Vancomycin 2 g IV or IM + 1.5 mg/kg Vancomycin + Gentamicin 1 g IV over 1 hr + 1.5 mg/kg 2 g po or 2 g IV or IM 1 g IV over 1 hr

PROPHYLACTIC FOR DENTAL, ORAL, RESPIRATORY OR OESOPHAGEAL SITUATION Standard proph.

AGENT Amoxicillin Unable to take po Ampicillin Allergic to PCN Allergic to PCN & unable to take po Clindamycin Cephalexin Azi or clari Clindamycin Cefazolin REGIMEN 2 g po 2 g IM or IV 600 mg po 2 g po 500 mg po 600 mg IV 1 g IV

FAILURE TO RESPOND TO TREATMENT  Abscess formation - paravalvar - metastatic  Low cardiac output - flail mitral valve or perforation - free aortic regurgitation  Wrong diagnosis - lymphoma - sarcoidosis- AIDS - SLE - TB  Major Immune Activation - renal failure - vasulitis - emboli - coronary embolism