heart failure update - dr. stultzdrstultz.com/presentations/2008 02 22 endocarditis.pdfrisk of...

EndocarditisEndocarditis

February 22, 2008February 22, 2008

David Stultz, MDDavid Stultz, MD

Southwest Cardiology, Inc.Southwest Cardiology, Inc.

(c) 2000-2008 David Stultz, MD

Topics to be coveredTopics to be covered

Overview of TreatmentOverview of Treatment

ComplicationsComplications

Indications for SurgeryIndications for Surgery

PrognosisPrognosis

ProphylaxisProphylaxis

Pearls for the BoardsPearls for the Boards

EpidemiologyEpidemiology

MicrobiologyMicrobiology

Clinical presentationClinical presentation

Physical Exam FindingsPhysical Exam Findings

Diagnostic ImagingDiagnostic Imaging


EndocarditisEndocarditis isis……

An infection of the heart, typicallyAn infection of the heart, typicallyinvolving valve leafletsinvolving valve leaflets

May also involveMay also involve

ChordaeChordae tendinaetendinae

MuralMural endocardiumendocardium

Site of aSite of a septalseptal defectdefect

ArteriovenousArteriovenous shuntsshunts

PatentPatent ductusductus arteriosusarteriosus

IntracardiacIntracardiac hardwarehardware


A vegetation isA vegetation is……

A collection ofA collection of

PlateletsPlatelets

FibrinFibrin

BacteriaBacteria

Inflammatory cellsInflammatory cells

Braunwald, 8th ed.


EndocarditisEndocarditis looks likelooks like……

Braunwald, 8th ed.


EpidemiologyEpidemiology

Incidence of 2.4Incidence of 2.4--11.6 per 100,000 patient years11.6 per 100,000 patient years

Stable or increasing in incidenceStable or increasing in incidence

Higher incidence in urban populationsHigher incidence in urban populations

Elderly at 4Elderly at 4--6x risk6x risk

Median age 47Median age 47--6969

Male:Female ratio of about 2:1Male:Female ratio of about 2:1

Up to 75% of patients with native valveUp to 75% of patients with native valveinvolvement have identifiable risk factorsinvolvement have identifiable risk factors

Cabell, 148Braunwald, 1723


Time course ofTime course of endocarditisendocarditis

AcuteAcute TypicallyTypically StaphylococcusStaphylococcus aureusaureus ToxicToxic Progresses over days to weeksProgresses over days to weeks Valvular destructionValvular destruction MetastaticMetastatic infectioninfection

SubacuteSubacute Less toxicLess toxic Weeks to monthsWeeks to months PathogensPathogens

ViridansViridans streptococcistreptococci EnterococciEnterococci CoagulaseCoagulase--negative staphylococcinegative staphylococci GramGram--negativenegative coccobacillicoccobacilli

Braunwald, 8th ed.


Risk factors for native valveRisk factors for native valveendocarditisendocarditis

Rheumatic heart diseaseRheumatic heart disease

Congenital heart diseaseCongenital heart disease

Mitral valveMitral valve prolapseprolapse

Degenerative heart diseaseDegenerative heart disease

AsymmetricalAsymmetrical septalseptal hypertrophyhypertrophy

Intravenous drug abuseIntravenous drug abuse

Braunwald, 1724


Mitral ValveMitral Valve ProlapseProlapse

High prevalenceHigh prevalence

22--4% of general healthy population4% of general healthy population

20% of young women20% of young women

77--30% of Native valve endocarditis without IVD30% of Native valve endocarditis without IVD

IncidenceIncidence

4.6 per 100,000 patient years without murmur4.6 per 100,000 patient years without murmur [0.004%/year][0.004%/year]

52 per 100,000 patient years with murmur52 per 100,000 patient years with murmur [0.05%/year][0.05%/year]

Braunwald, 1724AHA 2007


Rheumatic Heart DiseaseRheumatic Heart Disease

Declining in incidenceDeclining in incidence

2020--25% of endocarditis cases in 197025% of endocarditis cases in 1970’’ss

77--18% of endocarditis cases in 198018% of endocarditis cases in 1980’’ss

Commonly involvesCommonly involves

Mitral valve in womenMitral valve in women

Aortic valve in menAortic valve in men

Absolute risk 380Absolute risk 380--440 per 100,000440 per 100,000patientpatient--years [0.4%/year]years [0.4%/year]

Braunwald, 1724AHA 2007


Congenital Heart DiseaseCongenital Heart Disease

Accounts forAccounts for

1010--20% of endocarditis cases in young adults20% of endocarditis cases in young adults

8% of cases in older adults8% of cases in older adults

Common lesionsCommon lesions

PatentPatent ductusductus arteriosusarteriosus

VentricularVentricular septalseptal defectdefect

Bicuspid aortic valveBicuspid aortic valve

Braunwald, 1724


Intravenous drug useIntravenous drug use

Risk of endocarditis 2Risk of endocarditis 2--5 per 100 patient years5 per 100 patient years

Higher risk than rheumatic disease or prosthetic valveHigher risk than rheumatic disease or prosthetic valve

6565--80% of IVD endocarditis population is male80% of IVD endocarditis population is male

Average age 27Average age 27--3737

Commonly involves tricuspid valve (46Commonly involves tricuspid valve (46--78% of78% ofcases)cases)

S.S. AureusAureus involved in over 50% of casesinvolved in over 50% of cases

Braunwald, 1724-25


Prosthetic ValvesProsthetic Valves

Account for 10Account for 10--30% of all endocarditis cases30% of all endocarditis cases

Risk is greatest in first 6 months after implantRisk is greatest in first 6 months after implant ““EarlyEarly”” endocarditis occurs in first 60 daysendocarditis occurs in first 60 days

Incidence about 5% at 5 yearsIncidence about 5% at 5 years

Risk declines over timeRisk declines over time

Mechanical valve has higher risk thanMechanical valve has higher risk thanbioprosthesisbioprosthesis initiallyinitially

After 1 yearAfter 1 year bioprosthesisbioprosthesis is more risky thanis more risky thanmechanical valvemechanical valve

Braunwald, 1725-26


Microbiology in a nutshellMicrobiology in a nutshell Any pathogen can cause endocarditisAny pathogen can cause endocarditis

Common organismsCommon organisms StrepStrep viridiansviridians –– 28%28%

StaphStaph aureusaureus –– 28%28%

OtherOther StrepStrep speciesspecies –– 23%23%

CoagCoag negativenegative StaphStaph –– 7%7%

GramGram--negativesnegatives –– 4%4%

OtherOther –– 5%5%

No growthNo growth –– 5%5%

Drug resistance seen commonly in IV drug useDrug resistance seen commonly in IV drug use

StaphStaph aureusaureus incidence appears to be risingincidence appears to be risingCabell, 150Braunwald, 8th ed


Clinical presentationClinical presentationNonspecific symptoms and signsNonspecific symptoms and signs

FeverFever

Mitral or aortic regurgitation murmursMitral or aortic regurgitation murmurs

SplenomegalySplenomegaly (50% of cases)(50% of cases)

MicroscopicMicroscopic hematuriahematuria

SepsisSepsis –– especially in acute infective endocarditisespecially in acute infective endocarditis

Joint arthritis andJoint arthritis and arthralgiasarthralgias

Chronic wastingChronic wasting ––inin subacutesubacute endocarditisendocarditis

CutaneousCutaneous signs are infrequentsigns are infrequent


OslerOsler’’ss NodesNodes

TenderTender violaceousviolaceousnodules in pulp ofnodules in pulp offingers or toesfingers or toes

Due to infectiveDue to infectiveemboli or immuneemboli or immunecomplex depositscomplex deposits

Fitzpatrick, 633


PetechialPetechial LesionsLesions

PetechiaePetechiae may appearmay appearon extremities, chest,on extremities, chest,or mucousor mucousmembranesmembranes

Fitzpatrick, 633


Splinter HemorrhageSplinter Hemorrhage

Due to rupture of fineDue to rupture of finesubungualsubungual capillariescapillaries

Usually 2Usually 2--3mm long in3mm long inlong axis of naillong axis of nail

Initially blueInitially blue--purple inpurple incolor, change to brown ofcolor, change to brown ofblack in 1black in 1--2 days2 days

Move distal with nailMove distal with nailgrowthgrowth

Trauma is the mostTrauma is the mostcommon cause; 20% ofcommon cause; 20% ofpopulation have thempopulation have them

Fitzpatrick, 968, 971


Splinter HemorrhageSplinter Hemorrhage

Braunwald, 8th ed


JanewayJaneway LesionsLesions

NontenderNontender

Small hemorrhagicSmall hemorrhagicmaculesmacules or nodulesor nodules

Commonly on palmsCommonly on palmsor solesor soles

Fitzpatrick, 630-31


Roth SpotsRoth Spots

Red retinalRed retinalhemorrhagehemorrhage

Pale centerPale center

http://www.nyee.edu/page_deliv.html?page_no=208&origin=210


Clinical PresentationClinical PresentationCardiac signs and symptomsCardiac signs and symptoms

Heart failureHeart failure –– especially unexplained inespecially unexplained inyoung ptyoung pt

PericarditisPericarditis –– uncommon, often the resultuncommon, often the resultof abscess or fistulous tract formationof abscess or fistulous tract formation

Abnormal echocardiogramAbnormal echocardiogram

Crawford, 162-4


Clinical PresentationClinical PresentationComplications of endocarditisComplications of endocarditis

Septic pulmonary emboliSeptic pulmonary emboli

Commonly in tricuspid valve endocarditis due to IVCommonly in tricuspid valve endocarditis due to IVdrug usedrug use

May cause chest pain andMay cause chest pain and dyspneadyspnea

Pulmonary fleeting patchy infiltrates on chestPulmonary fleeting patchy infiltrates on chest xrayxray

StrokeStroke –– due to embolism of vegetation ordue to embolism of vegetation orthrombusthrombus

Renal failureRenal failure –– rare complication due to sepsis,rare complication due to sepsis,embolism, or immune complex reactionembolism, or immune complex reaction

Peripheral vascular embolismPeripheral vascular embolismCrawford, 164-6


Endocarditis and EmbolismEndocarditis and Embolism

Up to 75% of embolic events occur priorUp to 75% of embolic events occur priorto diagnosis or treatmentto diagnosis or treatment

5050--65% of clinically evident emboli involve65% of clinically evident emboli involvethe CNS, especially in middle cerebralthe CNS, especially in middle cerebralartery distributionartery distribution

Embolism risk decreases after 1 week ofEmbolism risk decreases after 1 week ofantibioticsantibiotics

Surgery indicated for 2 or more embolicSurgery indicated for 2 or more emboliceventsevents

Olaison, 245-246


Prosthetic Valve EndocarditisProsthetic Valve Endocarditis

Early endocarditis occurs within 60 days of surgeryEarly endocarditis occurs within 60 days of surgery More common in patients needingMore common in patients needing reoperationreoperation or long ventilatoror long ventilator

supportsupport

Commonly involvesCommonly involves S.S. aureusaureus or fungal speciesor fungal species

Acute presentation, 65% mortalityAcute presentation, 65% mortality

Late endocarditis occurs more than 60 daysLate endocarditis occurs more than 60 days postoppostop SubacuteSubacute presentationpresentation

TypicalTypical subacutesubacute organismsorganisms

Prosthetic valve endocarditis can cause mechanicalProsthetic valve endocarditis can cause mechanicalfailure due to abscess, valve dehiscence,failure due to abscess, valve dehiscence, paravalvularparavalvularleaksleaks

Crawford, 163


Duke CriteriaDuke Criteria -- DiagnosisDiagnosis

Definite EndocarditisDefinite Endocarditis Positive histology or culture from vegetationPositive histology or culture from vegetation

Two major criteriaTwo major criteria

One major and three minor criteriaOne major and three minor criteria

Five minor criteriaFive minor criteria

RejectedRejected Firm alternative diagnosisFirm alternative diagnosis

Resolution afterResolution after 4 days of antibiotics4 days of antibiotics

Possible EndocarditisPossible Endocarditis

Crawford, 161


Duke criteriaDuke criteria -- MajorMajor

1)1) More than one positive blood cultureMore than one positive blood culturetypical for endocarditistypical for endocarditis

2)2) Evidence ofEvidence of endocardialendocardial involvementinvolvement

New regurgitation murmurNew regurgitation murmur

EchocardioramEchocardioram with oscillating mass,with oscillating mass,abscess or valve dehiscenceabscess or valve dehiscence

Crawford, 161


Major CriteriaMajor Criteria Positive blood culturePositive blood culture

Typical microorganism for infectiveTypical microorganism for infective endocarditisendocarditis from two separatefrom two separateblood culturesblood cultures ViridansViridans streptococci,streptococci, StreptococcusStreptococcus bovisbovis, HACEK group, HACEK group oror StaphylococcusStaphylococcus aureusaureus or communityor community--acquiredacquired enterococcienterococci in the absence ofin the absence of

a primary focus,a primary focus, oror

Persistently positive blood culture, defined as recovery of aPersistently positive blood culture, defined as recovery of amicroorganism consistent with infectivemicroorganism consistent with infective endocarditisendocarditis from:from: Blood cultures (Blood cultures (≥≥2) drawn more than 12 hr apart,2) drawn more than 12 hr apart, oror All of three or a majority of four or more separate blood culturAll of three or a majority of four or more separate blood cultures, with firstes, with first

and last drawn at least 1 hr apartand last drawn at least 1 hr apart

Single positive blood culture forSingle positive blood culture for CoxiellaCoxiella burnetiiburnetii oror antiphaseantiphase II IgGIgGantibody titer >1:800antibody titer >1:800

Evidence ofEvidence of endocardialendocardial involvementinvolvement Positive echocardiogram (TEE advised for PVE or complicated infePositive echocardiogram (TEE advised for PVE or complicated infectivective

endocarditisendocarditis)) OscillatingOscillating intracardiacintracardiac mass, on valve or supporting structures,mass, on valve or supporting structures, oror in thein the

path ofpath of regurgitantregurgitant jets,jets, oror on implanted material, in the absence of anon implanted material, in the absence of analternative anatomical explanation,alternative anatomical explanation, oror

Abscess,Abscess, oror New partial dehiscence of prosthetic valve,New partial dehiscence of prosthetic valve, oror

New valvular regurgitation (increase or change in preexisting muNew valvular regurgitation (increase or change in preexisting murmurrmurnot sufficient)not sufficient)

Braunwald, 8th ed


Duke criteriaDuke criteria -- MinorMinor

1)1) Cardiac risk factor including IV drug useCardiac risk factor including IV drug use

2)2) FeverFever 100.4100.4°° FF

3)3) Vascular manifestationVascular manifestation

4)4) Immunologic phenomenaImmunologic phenomena

5)5) Echocardiogram consistent withEchocardiogram consistent withendocarditis but not meeting majorendocarditis but not meeting majorcriterioncriterion

6)6) Positive blood culture not meeting majorPositive blood culture not meeting majorcriterion or serologic evidence ofcriterion or serologic evidence oforganismorganismCrawford, 161


Minor CriteriaMinor Criteria

Predisposition: predisposing heart conditionPredisposition: predisposing heart condition ororintravenous drug useintravenous drug use

FeverFever ≥≥38.038.0°°C (100.4C (100.4°°F)F)

Vascular phenomena: major arterial emboli, septicVascular phenomena: major arterial emboli, septicpulmonary infarcts,pulmonary infarcts, mycoticmycotic aneurysm, intracranialaneurysm, intracranialhemorrhage,hemorrhage, conjunctivalconjunctival hemorrhages,hemorrhages, JanewayJaneway lesionslesions

Immunological phenomena:Immunological phenomena: glomerulonephritisglomerulonephritis,, OslerOslernodes, Roth spots, rheumatoid factornodes, Roth spots, rheumatoid factor

Microbiological evidence: positive blood culture but notMicrobiological evidence: positive blood culture but notmeeting major criterion as noted previously[meeting major criterion as noted previously[**]] ororserologic evidence of active infection with organismserologic evidence of active infection with organismconsistent with infectiveconsistent with infective endocarditisendocarditis

Braunwald, 8th ed


Diagnostic ImagingDiagnostic Imaging

EchocardiographyEchocardiography

ChestChest XrayXray

CTCT

MRIMRI

NuclearNuclear


ChestChest XrayXray

Nonspecific findingsNonspecific findings

CardiomegalyCardiomegaly

Nodular infiltratesNodular infiltrates

Tricuspid valveTricuspid valveendocaritisendocaritis causingcausingseptic emboliseptic emboli

Sachdev, 192Braunwald, 1730


CT and MRICT and MRIStill Mostly ExperimentalStill Mostly Experimental

Primarily evaluate brain for complicationsPrimarily evaluate brain for complications

Isolated CT case reportsIsolated CT case reports

Large aortic root abscess and AV fistulaLarge aortic root abscess and AV fistula

MRI can potentially diagnoseMRI can potentially diagnosecomplications of aortic root aneurysms orcomplications of aortic root aneurysms orabscessesabscesses

Sachdev, 192-193


Nuclear ImagingNuclear Imaging

Tagged WBC scans have been usedTagged WBC scans have been used

Can identify vegetationsCan identify vegetations

NonspecificNonspecific

High false negativeHigh false negative

Case reports suggest that positive scanCase reports suggest that positive scancan be used to detect local complicationscan be used to detect local complicationsof endocarditisof endocarditis

Useful to detectUseful to detect metastaticmetastatic septicsepticembolismembolism

Sachdev, 193


EchocardiographyEchocardiography

Major Duke criteriaMajor Duke criteria

Diagnose and management of infectiveDiagnose and management of infectiveendocarditisendocarditis

VegetationsVegetations –– detected in 67% ofdetected in 67% of ““definitedefinite””cases by Duke criteriacases by Duke criteria

Irregular shapeIrregular shape

Occur on lowOccur on low--pressure side of turbulent jetpressure side of turbulent jet

Atrial side in mitral and tricuspid regurgitationAtrial side in mitral and tricuspid regurgitation

Ventricular side in aortic andVentricular side in aortic and pulmonicpulmonic regurgitationregurgitation

May occur on otherMay occur on other nonvalvularnonvalvular locationslocations

Sachdev, 187-188


Vegetation characteristicsVegetation characteristics

Large vegetation (>10mm) has 3 timesLarge vegetation (>10mm) has 3 timesrisk ofrisk of embolizationembolization compared to smallcompared to smallonesones11

ProlapsingProlapsing vegetations orvegetations or extravalvularextravalvularinvolvement carries higher risk of heartinvolvement carries higher risk of heartfailure, brainfailure, brain embolizationembolization, need for valve, need for valvereplacementreplacement22

However, poorHowever, poor interobserverinterobserverreproducibility of these characteristicsreproducibility of these characteristics

1Tischler M, Vaitkus P. The ability of vegetation size on echocardiography to predict complications: a meta-analysis. JAmer Soc Echo 1997; 10:562-8.2Sanfillipo A, Picard M, Newell J, et al. Echocardiographic assessment of patients with infectious endocarditis:prediction of risk for complication. J Am Coll Cardiol 1991; 18:1191-9.


Valvular locationValvular location

Small series show 26% mortality of aorticSmall series show 26% mortality of aorticlocation vs. 16% with mitral locationlocation vs. 16% with mitral location

Aortic valve endocarditis more resistant toAortic valve endocarditis more resistant toantibiotic therapy, more likely to needantibiotic therapy, more likely to needsurgerysurgery

Mitral valve endocarditis, especiallyMitral valve endocarditis, especiallyanterior leaflet, has highest incidence ofanterior leaflet, has highest incidence ofembolizationembolization

Sachdev, 189-190


Mitral valve vegetationMitral valve vegetation

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Mitral valve vegetation with perforationMitral valve vegetation with perforation

Feig

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Aortic valve vegetationAortic valve vegetation

Feig

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Tricuspid valve vegetationTricuspid valve vegetation

Feig

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TEE Tricuspid vegetationTEE Tricuspid vegetation

Feig

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EchocardiographicEchocardiographic mimicsmimics

Sterile vegetations (Sterile vegetations (maranticmarantic endocarditis)endocarditis)

LibmanLibman--Sacks endocarditisSacks endocarditis

Systemic malignancySystemic malignancy

MyxomatousMyxomatous valvesvalves

Cardiac tumorsCardiac tumors

Degenerative thickeningDegenerative thickening

LamblLambl’’ss excrescenceexcrescence –– small, multiplesmall, multiplefilamentous tags on heart valves found in 70filamentous tags on heart valves found in 70--90% of adults at autopsy90% of adults at autopsy

Sachdev, 188-189


MyxomatousMyxomatous mitral valvemitral valve

Nanda, 90

Flail myxomatous mitral valve prolapsing into left atrium


LamblLambl’’ss ExcrescenceExcrescence

Nanda, 27-28


EchocardiographyEchocardiographyTTE vs. TEETTE vs. TEE

TransthoracicTransthoracic

1818--63% sensitivity63% sensitivity

Can rule out endocarditis only with good qualityCan rule out endocarditis only with good qualityimages and a low preimages and a low pre--test probabilitytest probability

Low sensitivity for detecting complications ofLow sensitivity for detecting complications ofendocarditisendocarditis

TransesophagealTransesophageal

4848--100% sensitive100% sensitive

Indicated in all cases of suspected prosthetic valveIndicated in all cases of suspected prosthetic valveendocarditisendocarditis

Sachdev, 188-192


NonbacterialNonbacterial ThromboticThromboticEndocarditisEndocarditis

LibmanLibman--SacksSacks EndocarditisEndocarditis

EtiologyEtiology

HypercoagulableHypercoagulable statestate

Endothelial injuryEndothelial injury

Found in 1.3% of patients at autopsyFound in 1.3% of patients at autopsy

Advanced age, malignancy,Advanced age, malignancy, lupuslupus, valvular, valvular

heart disease, indwelling catheters are all riskheart disease, indwelling catheters are all riskfactorsfactors

Can convert to infectiveCan convert to infective endocarditisendocarditis

Braunwald, 8th ed


Overview of Medical TreatmentOverview of Medical Treatment

Target therapy to blood cultureTarget therapy to blood culture

Bactericidal antibioticsBactericidal antibiotics

--lactamlactam preferredpreferred

MonotherapyMonotherapy for MRSA with 1for MRSA with 1stst generationgenerationcephalosporin is feasiblecephalosporin is feasible

VancomycinVancomycin less bactericidal thanless bactericidal than penicillinspenicillins

Therapy for >4 weeksTherapy for >4 weeks

Studies involving 2 week courses generally not asStudies involving 2 week courses generally not asefficaciousefficacious

Sexton, 280-281


Anticoagulation and EndocarditisAnticoagulation and Endocarditissomewhat controversialsomewhat controversial

Anticoagulation not indicated in nativeAnticoagulation not indicated in nativevalve endocarditisvalve endocarditis

In prosthetic valve endocarditis due toIn prosthetic valve endocarditis due toStaphStaph AureusAureus,, it may be beneficial to stopit may be beneficial to stopanticoagulation during the acute phaseanticoagulation during the acute phase

Aspirin therapy does not reduce embolicAspirin therapy does not reduce emboliccomplications, and may increase bleedingcomplications, and may increase bleeding

Chan KL, Dumesnil JG, Cujec B et al. A randomized trial of aspirin on the risk of embolic events in patients withinfective endocarditis. J Am Coll Cardiol. 2003 Sep 3;42(5):775-80Sexton, 280



Heart failure refractory to medical treatmentHeart failure refractory to medical treatment NYHA class 3NYHA class 3--4 due to endocarditis4 due to endocarditis

Caused by aortic or mitral regurgitation (acute orCaused by aortic or mitral regurgitation (acute or subacutesubacute))

Prosthetic valve endocarditis (most cases)Prosthetic valve endocarditis (most cases) Medical management may suffice ifMedical management may suffice if

Late onset infection (>12 months after prosthesis)Late onset infection (>12 months after prosthesis)

Low virulence organism (viridians step, HACEK,Low virulence organism (viridians step, HACEK, enterococcienterococci))

No evidence of invasive infectionNo evidence of invasive infection

Local invasive complicationsLocal invasive complications PeriannularPeriannular extension, abscess,extension, abscess, mycoticmycotic aneurysm,aneurysm,

pseudoaneurysmpseudoaneurysm, fistula, fistula

Heart block may herald local extensionHeart block may herald local extension

Cabell, 151Olaison 242-247



2 or more Major embolic events2 or more Major embolic events A recent stroke presents higher operative risk (CVA extension)A recent stroke presents higher operative risk (CVA extension)

Prefer to perform surgery at least 10Prefer to perform surgery at least 10--14 days after CVA14 days after CVA

Major valve dysfunctionMajor valve dysfunction Valve obstructionValve obstruction

RegurgitationRegurgitation

Leaflet perforationLeaflet perforation

Resistance to antibiotic therapyResistance to antibiotic therapy PersistentPersistent bacteremiabacteremia after 7 days of antibioticsafter 7 days of antibiotics

ExcludeExclude extracardiacextracardiac foci of infectionfoci of infection

Recurrent fever is common, not necessarily an indication ofRecurrent fever is common, not necessarily an indication ofantibiotic failureantibiotic failure

Olaison 242-247Sexton 276-277


Surgical ConsiderationsSurgical Considerations

Surgery needed in 25Surgery needed in 25--30% in acute phase, 2030% in acute phase, 20--40% in40% in subacutesubacute phasephase

No prerequisite for antibiotics before surgeryNo prerequisite for antibiotics before surgery

Equivalent mortality (8.5%) for patients havingEquivalent mortality (8.5%) for patients havingsurgery before 10 days and after 10 days ofsurgery before 10 days and after 10 days ofantibioticsantibiotics

Consider early surgical intervention withConsider early surgical intervention withaggressive pathogen (aggressive pathogen (StaphStaph AureusAureus, fungal sp.), fungal sp.)

Device removal almost always required forDevice removal almost always required fordevice relateddevice related endocarditisendocarditis

Olaison 242-247


PrognosisPrognosis

Overall mortality of 20Overall mortality of 20--25%25%

Patients with surgical intervention have 61%Patients with surgical intervention have 61%survival at 10 yearssurvival at 10 years

Risks of high mortalityRisks of high mortality ElderlyElderly

Aggressive pathogen (Aggressive pathogen (S.S. AureusAureus))

Presence of embolismPresence of embolism

More extensive valve damageMore extensive valve damage

Renal involvementRenal involvement

Longer duration of endocarditisLonger duration of endocarditis

Crawford, 166Olaison, 235


Diagnostic AlgorithmDiagnostic Algorithm

TEE indicated forTEE indicated forsuspected prostheticsuspected prostheticvalve endocarditisvalve endocarditis

TTE can rule inTTE can rule inendocarditisendocarditis

TTE can only rule outTTE can only rule outendocarditis withendocarditis withgood quality imagesgood quality images

and a low preand a low pre--testtestprobabilityprobability

Braunwald


Schematic approach to the diagnostic use of echocardiography. High-risk echocardiographic features include large vegetations, valveinsufficiency, suggestion of perivalvular extension, or ventricular dysfunction. Patients with high initial risk include those with prosthetic heartvalves, complex congenital heart disease, prior IE, new murmur, and heart failure. Rx indicates initiation of antibiotic therapy for IE. IE =infective endocarditis; TEE = transesophageal echocardiography; TTE = transthoracic echocardiography. (Reproduced from Bayer AS, BolgerAF, Taubert KA, et al: Diagnosis and management of infective endocarditis and its complications. Circulation 98:2936-48, 1998.)

Braunwald, 8th ed


EndocarditisEndocarditis ProphylaxisProphylaxis


EndocarditisEndocarditis prophylaxisprophylaxisRedefined 2007Redefined 2007

Why update the guidelines?Why update the guidelines?

IE is much more likely to result from frequent exposure to randoIE is much more likely to result from frequent exposure to randommbacteremiasbacteremias associated with daily activities than fromassociated with daily activities than from bacteremiabacteremiacaused by a dental, GI tract, or GU tract procedure.caused by a dental, GI tract, or GU tract procedure.

Prophylaxis may prevent an exceedingly small number of cases ofProphylaxis may prevent an exceedingly small number of cases ofIE, if any, in individuals who undergo a dental, GI tract, or GUIE, if any, in individuals who undergo a dental, GI tract, or GU tracttractprocedure.procedure.

The risk of antibioticThe risk of antibiotic--associated adverse events exceeds the benefit,associated adverse events exceeds the benefit,if any, from prophylactic antibiotic therapy.if any, from prophylactic antibiotic therapy.

Maintenance of optimal oral health and hygiene may reduce theMaintenance of optimal oral health and hygiene may reduce theincidence ofincidence of bacteremiabacteremia from daily activities and is more importantfrom daily activities and is more importantthan prophylactic antibiotics for a dental procedure to reduce tthan prophylactic antibiotics for a dental procedure to reduce theherisk of IE.risk of IE.

AHA 2007


Guidelines seek a balanceGuidelines seek a balanceWhy did they change them???Why did they change them???

Prophylaxis recommended for patients withProphylaxis recommended for patients withhighest risk of infection and/or highest risk ofhighest risk of infection and/or highest risk ofcomplicationscomplications

Risk of death from penicillin anaphylaxis isRisk of death from penicillin anaphylaxis isestimated at 15estimated at 15--25 per million (33% with known25 per million (33% with knownallergy)allergy)

Estimated 5370 minutes ofEstimated 5370 minutes of bacteremiabacteremia perpermonth inmonth in dentulousdentulous people (based on chewing,people (based on chewing,brushing teeth, flossing)brushing teeth, flossing)

Estimated 6 to 30 minutes ofEstimated 6 to 30 minutes of bacteremiabacteremia from afrom atooth extractiontooth extraction

AHA 2007


EndocarditisEndocarditis prophylaxis for dentalprophylaxis for dentalproceduresprocedures

Antibiotic prophylaxis with dental procedures is recommendedAntibiotic prophylaxis with dental procedures is recommendedonly for patients with cardiac conditions associated with theonly for patients with cardiac conditions associated with thehighest risk of adverse outcomes fromhighest risk of adverse outcomes from endocarditisendocarditis,,including:including:

Prosthetic cardiac valveProsthetic cardiac valve PreviousPrevious endocarditisendocarditis Congenital heart disease only in the following categories:Congenital heart disease only in the following categories:

UnrepairedUnrepaired cyanotic congenital heart disease, including those withcyanotic congenital heart disease, including those withpalliative shunts and conduitspalliative shunts and conduits

Completely repaired congenital heart disease with prosthetic matCompletely repaired congenital heart disease with prosthetic material orerial ordevice, whether placed by surgery or catheter intervention, duridevice, whether placed by surgery or catheter intervention, during theng thefirst six months after the procedure*first six months after the procedure*

Repaired congenital heart disease with residual defects at the sRepaired congenital heart disease with residual defects at the site orite oradjacent to the site of a prosthetic patch or prosthetic deviceadjacent to the site of a prosthetic patch or prosthetic device (which(whichinhibitinhibit endothelializationendothelialization))

Cardiac transplantation recipients with cardiac valvular diseaseCardiac transplantation recipients with cardiac valvular disease*Prophylaxis is recommended because*Prophylaxis is recommended because endothelializationendothelialization of prosthetic materialof prosthetic material

occurs within six months after the procedure.occurs within six months after the procedure.AHA 2007


Which Dental procedures needWhich Dental procedures needprophylaxis?prophylaxis?

All dental procedures that involve manipulation ofAll dental procedures that involve manipulation ofgingival tissue or thegingival tissue or the periapicalperiapical region of teeth, orregion of teeth, orperforation of the oral mucosaperforation of the oral mucosa

Antibiotic prophylaxis is NOT recommended forAntibiotic prophylaxis is NOT recommended forthe following dental procedures or events:the following dental procedures or events: routine anesthetic injections throughroutine anesthetic injections through noninfectednoninfected tissuetissue

taking dental radiographstaking dental radiographs

placement of removableplacement of removable prosthodonticprosthodontic or orthodontic appliancesor orthodontic appliances

adjustment of orthodontic appliancesadjustment of orthodontic appliances

placement of orthodontic bracketsplacement of orthodontic brackets

shedding of deciduous teeth and bleeding from trauma to theshedding of deciduous teeth and bleeding from trauma to thelips or oral mucosa.lips or oral mucosa.

AHA 2007


Other proceduresOther procedures

EndocarditisEndocarditis prophylaxis no longerprophylaxis no longerrecommended for gastrointestinal andrecommended for gastrointestinal andgenitourinary proceduresgenitourinary procedures

Prophylaxis is recommended forProphylaxis is recommended forrespiratory procedures (except routinerespiratory procedures (except routinebronchoscopybronchoscopy without biopsy)without biopsy)

Recommended for procedures involvingRecommended for procedures involvingmanipulation ofmanipulation of infectedinfected skin, skinskin, skinstructure or musculoskeletal structurestructure or musculoskeletal structure

AHA 2007


Notable lesions no longerNotable lesions no longerrecommended for prophylaxisrecommended for prophylaxis

Rheumatic heart diseaseRheumatic heart disease

ValvularValvular stenosisstenosis

Valvular regurgitationValvular regurgitation


20 mg/kg IM20 mg/kg IMor IVor IV

600 mg IM or IV600 mg IM or IVClindamycinClindamycin


1 g IM or IV1 g IM or IVCefazolinCefazolin oror ceftriaxoneceftriaxone††

ORORAllergic toAllergic to penicillinspenicillins

oror ampicillinampicillin andandunable to takeunable to takeoral medicationoral medication

15 mg/kg15 mg/kg500 mg500 mgAzithromycinAzithromycin ororclarithromycinclarithromycin

OROR

20 mg/kg20 mg/kg600 mg600 mgClindamycinClindamycin

OROR

50 mg/kg50 mg/kg2 g2 gCephalexinCephalexin****††

Allergic toAllergic to penicillinspenicillinsoror ampicillinampicillin ––

Oral regimenOral regimen


1 g IM or IV1 g IM or IVCefazolinCefazolin oror ceftriaxoneceftriaxone


2 g IM or IV*2 g IM or IV*AmpicillinAmpicillinORORUnable to take oralUnable to take oral

medicationmedication

50 mg/kg50 mg/kg2 gm2 gmAmoxicillinAmoxicillinOralOral

ChildrenChildrenAdultsAdults

RegimenRegimen –– Single dose 30Single dose 30––6060minutes before procedureminutes before procedureAgentAgentSituationSituation

Prophylaxis RegimenProphylaxis Regimen(c) 2000-2008 David Stultz, MD

Pearls for the BoardsPearls for the Boards

Association ofAssociation of Strep.Strep. BovisBovis with GI malignancy,with GI malignancy,especially colon cancerespecially colon cancer

Identify patients who should and should not receiveIdentify patients who should and should not receiveendocarditis prophylaxisendocarditis prophylaxis Prosthetic valvesProsthetic valves

PriorPrior endocarditisendocarditis

Cardiac transplantCardiac transplant withwith valvular diseasevalvular disease

UnrepairedUnrepaired cyanotic congenital heart diseasecyanotic congenital heart disease

Completely repaired cyanotic CHD for 1Completely repaired cyanotic CHD for 1stst 6 months after repair6 months after repair

Recognize that a prosthetic valve withRecognize that a prosthetic valve with endocarditisendocarditis willwillmost likely need surgical treatmentmost likely need surgical treatment


ReferencesReferences

BraunwaldBraunwald E,E, ZipesZipes DP, Libby P: Heart Disease 8DP, Libby P: Heart Disease 8thth ed. Philadelphia, WB Saunders, 2007.ed. Philadelphia, WB Saunders, 2007. Cabell CH,Cabell CH, AbrutynAbrutyn E. Progress toward a global understanding of infective endocardE. Progress toward a global understanding of infective endocarditis;itis;

Lessons from the InternationalLessons from the International CollborationCollboration onon EndocarditisEndocarditis.. CardiolCardiol ClinClin 21 (2003) 14721 (2003) 147--158.158. Crawford MH,Crawford MH, DurackDurack DT. Clinical presentation of infective endocarditis.DT. Clinical presentation of infective endocarditis. CardiolCardiol ClinClin 2121

(2003) 159(2003) 159--166.166. FeigenbaumFeigenbaum H, Armstrong WF, Ryan T.H, Armstrong WF, Ryan T. FeigenbaumFeigenbaum’’ss Echocardiography, 6Echocardiography, 6thth ed.ed. LippincottLippincott

Williams & Wilkins, 2004.Williams & Wilkins, 2004. Fitzpatrick TB et. Al: Color Atlas & Synopsis of Clinical DermatFitzpatrick TB et. Al: Color Atlas & Synopsis of Clinical Dermatology, 4ology, 4thth ed. New York,ed. New York,

McGrawMcGraw--Hill, 2001.Hill, 2001. NandaNanda, NC,, NC, DomanskiDomanski MJ. Atlas ofMJ. Atlas of TransesophagealTransesophageal Echocardiography. Philadelphia:Echocardiography. Philadelphia:

LippincottLippincott Williams & Wilkins, 1998.Williams & Wilkins, 1998. OlaisonOlaison L,L, PetterssonPettersson G. Current best practices and guidelines; Indications for surgiG. Current best practices and guidelines; Indications for surgicalcal

interventionininterventionin infective endocarditis.infective endocarditis. CardiolCardiol ClinClin 21 (2003) 23521 (2003) 235--251.251. SachdevSachdev M, Peterson GE,M, Peterson GE, JollisJollis JG. Imaging techniques for diagnosis of infectiveJG. Imaging techniques for diagnosis of infective

endocarditis.endocarditis. CardiolCardiol ClinClin 21 (2003) 18521 (2003) 185--195.195. Sexton DJ,Sexton DJ, SpelmanSpelman D. Current best practices and guidelines; Assessment and manageD. Current best practices and guidelines; Assessment and management ofment of

complicatiosncomplicatiosn in infective endocarditis.in infective endocarditis. CardiolCardiol ClinClin 21 (2003) 27321 (2003) 273--282.282.


ReferencesReferences

TleyjehTleyjeh IM,IM, SteckelbergSteckelberg JM,JM, MuradMurad HS,HS, AnavekarAnavekar NS,NS, GhomrawiGhomrawi HM,HM, MirzoyevMirzoyevZ,Z, MoustafaMoustafa SE,SE, HoskinHoskin TL,TL, MandrekarMandrekar JN, Wilson WR,JN, Wilson WR, BaddourBaddour LM. TemporalLM. Temporaltrends in infectivetrends in infective endocarditisendocarditis: a population: a population--based study in Olmsted County,based study in Olmsted County,Minnesota. JAMA. 2005 Jun 22;293(24):3022Minnesota. JAMA. 2005 Jun 22;293(24):3022--8.8.

Walter Wilson, Kathryn A.Walter Wilson, Kathryn A. TaubertTaubert, Michael, Michael GewitzGewitz, Peter B. Lockhart, Larry M., Peter B. Lockhart, Larry M.BaddourBaddour, Matthew, Matthew LevisonLevison, Ann Bolger, Christopher H. Cabell, Masato Takahashi,, Ann Bolger, Christopher H. Cabell, Masato Takahashi,Robert S. Baltimore, Jane W.Robert S. Baltimore, Jane W. NewburgerNewburger, Brian L. Strom, Lloyd Y., Brian L. Strom, Lloyd Y. TaniTani, Michael, MichaelGerber, Robert O.Gerber, Robert O. BonowBonow, Thomas, Thomas PallaschPallasch, Stanford T., Stanford T. ShulmanShulman, Anne H., Anne H.Rowley, Jane C. Burns, PatriciaRowley, Jane C. Burns, Patricia FerrieriFerrieri, Timothy Gardner, David Goff, David T., Timothy Gardner, David Goff, David T.DurackDurack, and The Council on Scientific Affairs of the American Dental A, and The Council on Scientific Affairs of the American Dental Associationssociationhas approved the guideline as it relates to dentistry. Preventiohas approved the guideline as it relates to dentistry. Prevention of Infectiven of InfectiveEndocarditisEndocarditis: Guidelines From the American Heart Association: A Guideline Fr: Guidelines From the American Heart Association: A Guideline Fromomthe American Heart Association Rheumatic Fever,the American Heart Association Rheumatic Fever, EndocarditisEndocarditis, and Kawasaki, and KawasakiDisease Committee, Council on Cardiovascular Disease in the YounDisease Committee, Council on Cardiovascular Disease in the Young, and theg, and theCouncil on Clinical Cardiology, Council on Cardiovascular SurgerCouncil on Clinical Cardiology, Council on Cardiovascular Surgery andy andAnesthesia, and the Quality of Care and Outcomes Research InterdAnesthesia, and the Quality of Care and Outcomes Research InterdisciplinaryisciplinaryWorking Group. Circulation, Oct 2007; 116: 1736Working Group. Circulation, Oct 2007; 116: 1736 -- 1754.1754.


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