Endocarditis¶
Justin Smith
Background¶
- Multiple etiologies of endocarditis:
- Typical Bacterial
- S. aureus, Enterococcus spp (E. faecalis most commonly), viridans group streptococci, Strep gallolyticus (formerly S. bovis)
- HACEK : Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella
- Other infectious
- Culture negative: often recent antimicrobial exposure, slow growing organism
- Coxiella, Brucella, Bartonella, Chlamydia, Legionella, Mycoplasma, Tropheryma whipplei, Propionibacterium acnes
- Fungal: Candida and aspergillus most common
- Non-infectious: a.k.a., marantic endocarditis, Libbman-Sacks
Endocarditis
- Rare, most common in advanced malignancy, SLE, inflammatory conditions
- Higher risk for embolization compared to IE
- Risk factors: IV drug use, congenital heart disease, valve abnormalities, intracardiac devices, recent cardiac surgery
- Typical Bacterial
Presentation¶
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Fever (90%), Murmur (85%), Other: splenomegaly, splinter hemorrhages, Janeway lesions, Osler Nodes, Roth Spots
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Persistent bacteremia despite appropriate treatment, new onset cardiac dysfunction, new onset valve abnormalities, stroke, other thromboembolic events, metastatic infections/abscesses, splenic abscess, septic pulmonary emboli
Duke Criteria:¶
- Pathologic Criteria
- Microorganisms: culture or histology proven: vegetation, embolus, or intracardiac abscess
- Pathologic vegetations: vegetation of abscess with histology proven endocarditis
- Clinical Criteria
- Major:
- 2x positive blood cultures from a typical organism
- Evidence of endocardial involvement
- Major:
- Minor
- Predisposing heart condition/IVDU
- Fever
- Vascular phenomena (Glomerulonephritis)
- Immunologic phenomena (Osler Nodes, Roth Spots, +Rheumatoid factor, GN)
- Micro (Cultures that don’t fit the above, or serologic evidence
of acute infection)
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- Definite: 2 Major, 1 major and 3 minor, or 5 minor
- Possible: 1 major and 1 minor, or 3 minor
- Rejected: firm alternate diagnosis, resolution of evidence with \<4 days of antibiotics, or absence of pathologic evidence with \<4days of antibiotics
Evaluation¶
- Physical exam: murmur, decreased peripheral perfusion, evidence of heart failure, petechiae, splinter hemorrhages, Janeway lesions/Osler nodes, organomegaly
- Blood cultures: at least three sets from different sites over a span of several hours
- Echo (TTE vs TEE)
- It can be reasonable to start with TEE if pretest probability is high enough, if patient has known valvular abnormalities, or TTE will be technically difficult -
- EKG: new heart block or prolonged PR raises concern for endocardial/perivalvular abscess. Endocarditis patients should be on telemetry, monitored closely by team
- CXR: infiltrates suggestive of septic pulmonary emboli, pulmonary edema, cardiomegaly
- Imaging of distant affected site if concerned for septic emboli
- Other advanced imaging in select scenario: cardiac CTA, cardiac MRI, FDG-PET/CT
Management¶
- Empiric antibiotics:
- If bacteria isolated from blood, reference bacteremia section for abx choice
- If awaiting cultures
- Native valve: Vancomycin
- Prosthetic valve: Vancomycin and cefepime, consider gentamicin
- Duration: determined by ID, often 4-6 weeks
- Surgical consult, if valve dysfunction, perivalvular abscess, large (>20mm) vegetations
Additional Information:¶
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Complications:
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Cardiac:
- Heart failure: usually secondary to valve dysfunction. Most common when aortic valve involved, risk also depends on organism (worst is Staph aureus )
- Perivalvular abscess: suspect when there are conduction abnormalities on EKG; most likely when aortic valve involved, less likely with mitral valve.
- Pericarditis: can be suppurative or non-suppurative
- Intracardiac Fistula
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Septic emboli and metastatic abscesses
- Mycotic aneurysm: usually occurs at vessel branch points
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Follow Up
- Repeat TTE at completion of treatment to establish new baseline
- Followed for valvular dysfunction with frequency determined by nature of the dysfunction. (MR caused by IE should be followed on a timeline like other MR)
- Regular dental care, Prior IE is an indication for SBE prophylaxis with dental work.
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Episode of IE is an indication for PDA or VSD closure
Last update:
2022-06-21 22:27:11