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| | __NOTOC__ |
| | {| class="infobox" style="float:right;" |
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| | | [[File:Siren.gif|30px|link=Infective endocarditis resident survival guide]]|| <br> || <br> |
| | | [[Infective endocarditis resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
| | |} |
| {{Infobox_Disease | | | {{Infobox_Disease | |
| Name = {{PAGENAME}} | | | Name = {{PAGENAME}} | |
| Image = 1698.jpg | | | Image = 1698.jpg | |
| Caption = Mitral valve vegetations in a patient with bacterial endocarditis. | | | Caption = Mitral valve vegetations in a patient with bacterial endocarditis. | |
| DiseasesDB = 4224 |
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| ICD10 = {{ICD10|I|33||i|30}} |
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| ICD9 = {{ICD9|421}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = 001098 |
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| eMedicineSubj = emerg |
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| eMedicineTopic = 164 |
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| eMedicine_mult = {{eMedicine2|med|671}} {{eMedicine2|ped|2511}} |
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| MeshID = D004696 |
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| }} | | }} |
| | {{endocarditis}} |
| | {{CMG}}; '''Associate Editor(s)-In-Chief:''' {{Fs}}, {{Maliha}}, {{CZ}}; [[Michael W. Tempelhof]] M.D., {{DN}} |
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| {{SI}} | | {{SK}} Infective Endocarditis (IE); Subacute bacterial endocarditis (SBE); Acute bacterial endocarditis; Fungal endocarditis; Nosocomial infective endocarditis; Intravenous drug abuse endocarditis; Intravenous drug abuse infective endocarditis; Prosthetic valve endocarditis; Endocardial infection; Native valve endocarditis; HACEK endocarditis; Bloodstream infection |
| {{CMG}}
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| '''Associate Editor-In-Chief:''' {{CZ}}
| | ==[[Endocarditis overview|Overview]]== |
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| | ==[[Endocarditis historical background|Historical Perspective]]== |
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| {{MWT}}
| | ==[[Endocarditis classification|Classification]]== |
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| {{Editor Join}}
| | ==[[Endocarditis pathophysiology|Pathophysiology]]== |
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| '''''Related Key Words and Synonyms:''''' Infective endocarditis, IE, subacute bacterial endocarditis, acute bacterial endocarditis, fungal endocarditis, nosocomial infective endocarditis, NIE, intravenous drug abuse endocarditis, intravenous drug abuse infective endocarditis, IVDA endocarditis, IVDA IE, prosthetic valve endocarditis, PVE, pacemaker endocarditis, PM infective endocarditis, PM IE, endocardial infection, native valve endocarditis, NVE, HACEK infection, bloodstream infection, marantic endocarditis
| | ==[[Endocarditis causes|Causes]]== |
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| ==[[Endocarditis overview|Overview]]== | | ==[[Endocarditis differential diagnosis|Differentiating Endocarditis for other Disorders]]== |
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| ==[[Endocarditis historical background|Historical Background]]== | | ==[[Endocarditis risk factors|Risk Factors]]== |
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| ==[[Endocarditis epidemiology and demographics|Epidemiology and Demographics]]== | | ==[[Endocarditis epidemiology and demographics|Epidemiology and Demographics]]== |
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| ==[[Endocarditis pathophysiology|Pathophysiology and Etiology]]== | | ==[[Endocarditis complications|Natural History, Complications, and Prognosis]]== |
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| ==Diagnosis== | | ==Diagnosis== |
| [[Endocarditis diagnosis|Diagnostic Criteria]] | [[Endocarditis differential diagnosis|Differential Diagnosis of Underlying Causes]] | [[Endocarditis symptoms|Symptoms]] | [[Endocarditis signs|Physical Examination and Signs]] | [[Endocarditis laboratory studies|Laboratory studies]] | [[Endocarditis echocardiography|Echocardiography]] | | [[Endocarditis diagnostic criteria|Diagnostic Criteria]] | [[Endocarditis history and symptoms|History and Symptoms]] | [[Endocarditis physical examination|Physical Examination and Signs]] | [[Endocarditis laboratory findings|Laboratory Findings]] | [[Endocarditis chest x ray|Chest X Ray]] | [[Endocarditis electrocardiogram|Electrocardiogram]] | [[Endocarditis cardiac MRI|Cardiac MRI]] | [[Endocarditis ct|CT]] | [[Endocarditis echocardiography and ultrasound|Echocardiography]] |
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| ==[[Endocarditis complications|Natural History and Complications]]== | | ==Treatment== |
| | [[Endocarditis medical therapy|Medical Therapy]] | | [[Endocarditis surgery|Surgery]] | [[Endocarditis antithrombotic therapy|Antithrombotic Therapy]] | [[Endocarditis primary prevention|Primary Prevention]] | [[Endocarditis secondary prevention|Secondary Prevention]] |
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| == History and Symptoms == | | ==2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease== |
| | [[AHA Guidelines on Endocarditis Diagnosis and Follow-up|Diagnosis and Follow-up]] | [[AHA Guidelines on Endocarditis Medical Therapy|Endocarditis Medical Therapy Guidelines]] | [[AHA Guidelines on Endocarditis Intervention|Endocarditis Intervention Guidelines]] |
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| ====A. Subacute Bacterial Endocarditis (SBE)==== | | ==Case Studies== |
| *Insidious onset
| | [[Endocarditis case study one|Case #1]] |
| *[[Fever]]
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| *[[Sweat]]s
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| *[[Weakness]]
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| *[[Myalgia]]s
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| *[[Arthralgia]]s
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| *[[Malaise]]
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| *[[Anorexia]]
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| *[[Fatigue]]
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| *[[Splenomegaly]], [[clubbing]], and [[Oslers nodes]] in long-standing SBE
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| ====B. Acute Bacterial Endocarditis==== | | ==Related Chapters== |
| | | * [[Pacemaker endocarditis]] |
| *Abrupt onset
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| *[[Rigors]]
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| *[[Fever]]s as high as 102.9° to 105.1° F (39.4° to 40.6° C), often remittent
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| ====C. Endocarditis Associated with Parenteral Drug Use====
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| #[[fever|High fever]]s, [[chills]], [[rigors]], [[malaise]], [[cough]], and [[chest pain|pleuritic chest pain]]
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| #[[pulmonary emboli|Septic pulmonary emboli]] causing [[sputum]] production, [[hemoptysis]], and signs suggesting [[pneumonia]]
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| #[[murmur|Cardiac murmurs]]
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| #[[Tricuspid insufficiency]]
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| #Metastatic infections
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| #Neurologic manifestations
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| #Peripheral emboli
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| ====D. Prosthetic Valve Endocarditis====
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| #Occurs in 1%–2% of cases at 1 yr and in 4%–5% of cases at 4 yr after implantation
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| #Infection of perivalvular tissues
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| #Valvular dysfunction
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| #[[abscess|Myocardial abscesses]]
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| #[[Fever]]
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| #[[Petechiae]], [[Roth's spot]]s, [[Osler's nodes]], [[Janeway lesion]]s
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| #[[Emboli]]
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| === Physical Examination ===
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| ====Vital Signs====
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| A [[fever]] will likely be present. Rigors may be present.
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| ====Skin====
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| *[[Petechiae]] 10 - 40%
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| *[[Splinter haemorrhage]] 5 - 15%
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| *[[Oslers nodes]] 7 - 10% (tender subcutaneous nodules in pulp of digits)
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| *[[Janeway lesion]] 6 - 10% (erythematous, nontender lesions on palm or sole)
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| ==== Eyes ====
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| [[Image:Roth-spot (white-centered hemorrhage - endocarditis).jpg|left|150px|[[Roth's spot]]s (white centered hemorrhage)|thumb]]
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| *[[Conjunctival hemorrhage]]
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| *[[Roth's spot]]s in the [[retina]]
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| <br clear="left"/>
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| ==== Ear Nose and Throat ====
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| In patients in whom there is new acute onset of [[aortic regurgitation]], bobbing of the [[uvula]] may be present.
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| ==== Heart ====
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| *[[Murmur|Heart Murmur]]s: 80 - 85%
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| ==== Lungs ====
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| Signs of [[heart failure]] may present
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| ==== Abdomen ====
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| *[[Abdominal pain]] may be present due to mesenteric embolization or [[ileus]]
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| *[[Splenomegaly]] may be found in 15-30% patients. Left upper quadrant (LUQ) pain may be present as a result of a splenic infarct from embolization
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| *[[Flank pain]] may be present as a result of an embolus to the kidney
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| ==== Extremities ====
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| [[Image:Osler's Lesions (Endocarditis).jpg|Osler's nodes|left|thumb]]
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| *[[Janeway lesion]]s (painless hemorrhagic cutaneous lesions on the palms and soles)
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| *[[Gangrene]] of fingers may occur
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| *The fingers may show [[splinter haemorrhage]]s
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| *[[Osler's node]]s ([[lesions|painful subcutaneous lesions in the distal fingers]])
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| <br clear="left"/>
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| ==== Neurologic ====
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| [[Septic emboli]] may result in [[stroke]] and focal neurologic findings
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| [[Intracranial hemorrhage]] may occur
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| ==== Symptoms Frequency ====
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| *[[Fever]] 80 - 85%, often spiking
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| *[[Chills]] 42 - 75%
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| *[[Anorexia]] 25 - 55%
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| *[[Malaise]] 25 - 40%
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| *[[Weight loss]] 25 - 35%
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| *[[Back pain]]
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| *[[Stroke]] may be present in 10 - 15% of patients as a result of cerebral embolization
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| *[[Chest pain]] may be present as a result of embolzation in the coronary artery. The infarcts are usually not transmural. Pulmonary emboli, often septic, occur in 75% of patients with tricuspid endocarditis
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| * [[Abdominal pain]] may be present due to mesenteric embolization or [[ileus]]
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| * [[Blindness]] may be present due to retinal embolization in 3% of patients
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| === Laboratory Findings ===
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| An elevated [[erythrocyte sedimentation rate]] is present
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| A marked [[leukocytosis]] is present
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| A positive serum [[rheumatoid factor]] may be present (in approximately 50% of patients with subacute disease). It becomes negative after successful treatment.
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| The serum [[BUN]] and [[Cr]] may be elevated if [[glomerulonephritis]] is present
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| ====Urinalysis====
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| [[Glomerulonephritis]] may be present
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| ==== Electrocardiogram ====
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| There is no spesific [[EKG]] changes for diagnosis of [[Infective Endocarditis]]. [[EKG]] may help to detect the 10% of patients who develop a conduction delay during [[Infective Endocarditis]] by documenting an increased [[PR interval]].
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| ==== Chest X Ray ====
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| There are no specific [[chest x-ray]] findings specific for the diagnosis of endocarditis. Non specific findings would include findings of [[congestive heart failure]].
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| ==== MRI and CT ====
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| *A CT scan of the head should be obtained in patients who exhibit CNS symptoms or findings consistent with a mass effect (eg, macroabscess of the brain).
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| ===[[Endocarditis echocardiography|Echocardiography]]===
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| ==[[Endocarditis pathology|Pathology]]==
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| ==Differential Diagnosis==
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| * [[Antiphospholipid syndrome]]
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| * [[Reactive arthritis]]
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| * [[Atrial myxoma]]
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| * [[Systemic lupus erythematosus]]
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| * [[Primary cardiac neoplasms]]
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| * [[Lyme disease]]
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| * [[Polymyalgia rheumatica]]
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| * [[Thrombotic nonbacterial endocarditis]]
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| * [[Vasculitis]]
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| * [[Temporal arteritis]]
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| == Treatment ==
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| High dose [[antibiotic]]s are administered by the intravenous route to maximize diffusion of antibiotic molecules into vegetation(s) from the blood filling the chambers of the heart. This is necessary because neither the heart valves nor the vegetations adherent to them are supplied by blood vessels. Antibiotics are continued for a long time, typically two to six weeks. Specific drug regimens differ depending on the classification of the endocarditis as acute or subacute (acute necessitating treating for [[Staphylococcus aureus]] with [[oxacillin]] or [[vancomycin]] in addition to [[gram-negative]] coverage). [[Fungal]] [[endocarditis]] requires specific anti-fungal treatment, such as [[amphotericin B]].<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>
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| Surgical removal of the valve is necessary in patients who fail to clear micro-organisms from their blood in response to antibiotic therapy, or in patients who develop cardiac failure resulting from destruction of a valve by infection. A removed valve is usually replaced with an artificial valve which may either be mechanical (metallic) or obtained from an animal such as a pig; the latter are termed bioprosthetic valves.<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>
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| [[Infective endocarditis]] is associated with a 10-25% mortality.
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| === Primary Prevention (adapted from guidelines from the American Heart Association) ===
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| [[Amoxicillin]] is the preferred choice for oral therapy because it is well absorbed in the gastrointestinal (GI) tract and provides high and sustained serum concentrations. For individuals who are allergic to [[penicillin]]s or [[amoxicillin]], the use of [[cephalexin]] or another first-generation oral [[cephalosporin]], [[clindamycin]], [[azithromycin]], or [[clarithromycin]] is recommended.
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| Because of possible cross-reactions, a [[cephalosporin]] should not be administered to patients with a history of [[anaphylaxis]], [[angioedema]], or [[urticaria]] after treatment with any form of [[penicillin]], including [[ampicillin]] or [[amoxicillin]].
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| Patients who are unable to tolerate an oral antibiotic may be treated with [[ampicillin]], [[ceftriaxone]], or [[cefazolin]] administered intramuscularly or intravenously. For [[ampicillin]]-allergic patients who are unable to tolerate an oral agent, therapy is recommended with parenteral [[cefazolin]], [[ceftriaxone]], or [[clindamycin]]. <ref name=Wilson>{{cite journal | author = Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT| title = American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group| journal = Circulation | volume = 116 | issue = 15 | pages = 1736-54 | year = 2007 | id = PMID 17446442}}</ref>
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| *List of antibiotics can be used for prophylaxis of Infective Endocarditis; | |
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| #[[Amoxicillin]]
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| #[[Ampicillin]]
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| #[[Cefazolin]]
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| #[[Ceftriaxone]]
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| #[[Cephalexin]]
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| #[[Clindamycin]]
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| #[[Azithromycin]]
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| #[[Clarithromycin]]
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| *'''POTENTIAL HARM:''' The administration of prophylactic antibiotics is not risk free. Additionally, the widespread use of antibiotic therapy promotes the emergence of resistant microorganisms most likely to cause [[endocarditis]], such as viridans group streptococci and enterococci. The frequency of multidrug-resistant viridans group streptococci and enterococci has increased dramatically during the past 2 decades. This increased resistance has reduced the efficacy and number of antibiotics available for the treatment of infective endocarditis.<ref name=Wilson>{{cite journal | author = Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT| title = American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group| journal = Circulation | volume = 116 | issue = 15 | pages = 1736-54 | year = 2007 | id = PMID 17446442}}</ref>
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| *'''CONTRAINDICATIONS:''' [[Cephalosporins]] should not be used in an individual with a history of [[anaphylaxis]], [[angioedema]], or [[urticaria]] with [[penicillin]]s or [[ampicillin]].<ref name=Wilson>{{cite journal | author = Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT| title = American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group| journal = Circulation | volume = 116 | issue = 15 | pages = 1736-54 | year = 2007 | id = PMID 17446442}}</ref>
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| ====Antibiotic prophylaxis with Respiratory Tract Procedures====
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| Currently there is no published data conclusively demonstrate a link between these procedures and Infective Endocarditis.
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| Antibiotic prophylaxis is reasonable for high risk patients who undergo an invasive procedure of the respiratory tract that involves incision or biopsy of the respiratory mucosa, such as [[tonsillectomy]] and [[adenoidectomy]].
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| Antibiotic prophylaxis for [[bronchoscopy]] is not usually recommended unless the procedure involves incision of the respiratory tract mucosa. For high risk patients who undergo an invasive respiratory tract procedure to treat an established infection, such as drainage of an [[abscess]] or [[empyema]], antibiotic regimen should contain an agent active against [[Streptococcus viridans]].
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| If the infection is known or suspected to be caused by [[Staphylococcus aureus]], the regimen should contain an agent active against [[Staphylococcus aureus|S aureus]], such as an antistaphylococcal [[penicillin]] or [[cephalosporin]], or [[vancomycin]] in patients unable to tolerate a [[beta-lactam]]. [[Vancomycin]] should be administered if the infection is known or suspected to be caused by a [[methicillin-resistant Staphylococcus aureus]].
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| As a summary; individuals at the highest risk group who need procedures listed below require proper antibiotic prophylaxis;<ref name=Wilson>{{cite journal | author = Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT| title = American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group| journal = Circulation | volume = 116 | issue = 15 | pages = 1736-54 | year = 2007 | id = PMID 17446442}}</ref>
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| *[[Tonsillectomy]]
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| *[[Adenoidectomy]]
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| *Rigid bronchoscopic manipulations
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| *Respiratory mucosa related surgery
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| ====Antibiotic prophylaxis with GI or Genitourinary (GU) Tract Procedures====
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| The administration of prophylactic antibiotics solely to prevent [[endocarditis]] is not recommended for patients who undergo GU or GI tract procedures, including diagnostic [[esophagogastroduodenoscopy]] or [[colonoscopy]].
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| The significance of the increased frequency of multiresistant strains of [[enterococci]] on prevention of IE in patients who undergo GI or GU tract procedures is unknown. The high prevalence of resistant strains of [[enterococci]] adds further doubt about the efficacy of prophylactic therapy for GI or GU tract procedures. Patients with infections of the GI or GU tract may have intermittent or sustained enterococcal bacteremia.
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| For patients with high risk conditions who have an established GI or GU tract infection or for those who receive antibiotic therapy to prevent wound infection or sepsis associated with a GI or GU tract procedure, it may be reasonable that the antibiotic regimen include an agent active against [[enterococci]], such as [[penicillin]],[[ampicillin]], [[piperacillin]], or [[vancomycin]]; however, currently no published studies demonstrate that such therapy would prevent enterococcal IE.
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| For patients with high risk conditions and scheduled for an elective cystoscopy or other urinary tract manipulation who have an enterococcal urinary tract infection or colonization, antibiotic therapy to eradicate [[enterococci]] from the urine before the procedure may be reasonable. If the urinary tract procedure is not elective, it may be reasonable that the empiric or specific antimicrobial regimen administered to the patient contain an agent active against [[enterococci]].
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| [[Amoxicillin]] or [[ampicillin]] is the preferred agent for enterococcal coverage for these patients. [[Vancomycin]] may be administered to patients unable to tolerate[[ampicillin]]. If infection is caused by a known or suspected strain of resistant enterococcus, consultation with an infectious diseases expert is recommended.
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| As a summary; individuals at the highest risk group who need procedures listed below require proper antibiotic prophylaxis;<ref name=Wilson>{{cite journal | author = Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT| title = American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group| journal = Circulation | volume = 116 | issue = 15 | pages = 1736-54 | year = 2007 | id = PMID 17446442}}</ref>
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| ===Primary Prevention in Specific Situations and Circumstances===
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| ====Patients Already Receiving Antibiotics====
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| If a patient is already receiving long-term antibiotic therapy with an antibiotic that is also recommended for Infective Endocarditis prophylaxis for a dental procedure, it is prudent to select an antibiotic from a different class rather than to increase the dosage of the current antibiotic. For example, antibiotic regimens used to prevent the recurrence of acute [[rheumatic fever]] are administered in dosages lower than those recommended for the prevention of [[Infective Endocarditis]].
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| Individuals who take an oral penicillin for secondary prevention of rheumatic fever or for other purposes are likely to have
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| viridans group streptococci in their oral cavity that are relatively resistant to [[penicillin]] or [[amoxicillin]]. In such cases, the provider should select either[[clindamycin]], [[azithromycin]], or [[clarithromycin]] for IE prophylaxis for a dental procedure, but only for patients shown in the table above. Because of possible cross-resistance of viridans group streptococci with [[cephalosporin]]s, this class of antibiotics should be avoided.
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| If possible, it would be preferable to delay a dental procedure until '''at least 10 days after completion of the antibiotic therapy'''. This may allow time for the usual oral flora to be reestablished. <ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145}}</ref> <ref name=Wilson>{{cite journal | author = Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT| title = American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group| journal = Circulation | volume = 116 | issue = 15 |pages = 1736-54 | year = 2007 | id = PMID 17446442}}</ref>
| |
| | |
| ====Patients Who Receive Anticoagulants====
| |
| | |
| Intramuscular injections for [[Infective Endocarditis]] prophylaxis should be avoided in patients who are receiving [[anticoagulant]] therapy. In these circumstances, orally administered regimens should be given whenever possible. Intravenously administered antibiotics should be used for patients who are unable to tolerate or absorb oral medications. <ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref> <ref name=Wilson>{{cite journal | author = Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT| title = American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group| journal = Circulation | volume = 116 | issue = 15 | pages = 1736-54 | year = 2007 | id = PMID 17446442}}</ref>
| |
| | |
| ====Patients Who Undergo Cardiac Surgery====
| |
| | |
| Patients who undergo surgery for placement of prosthetic heart valves or prosthetic intravascular or intracardiac materials are at risk for the development of infection. Because the morbidity and mortality of infection in these patients are high, perioperative prophylactic antibiotics are recommended.
| |
| | |
| Early-onset prosthetic valve [[endocarditis]] is most often caused by [[S. aureus]], coagulase-negative staphylococci, or diphtheroids. No single antibiotic regimen is effective against all these microorganisms. Prophylaxis at the time of cardiac surgery should be directed primarily against staphylococci and should be of short duration. A first-generation [[cephalosporin]] is most often used, but the choice of an antibiotic should be influenced by the antibiotic susceptibility patterns at each hospital. For example, a high prevalence of infection by [[methicillin-resistant Staphylococcus aureus]] (MRSA) should prompt the consideration of the use of [[vancomycin]] for perioperative prophylaxis.
| |
| | |
| The majority of nosocomial coagulase-negative staphylococci are methicillin-resistant. Nonetheless, surgical prophylaxis with a first-generation cephalosporin may be recommended for these patients. In hospitals with a high prevalence of methicillin-resistant strains of [[S. epidermidis]], surgical prophylaxis with [[vancomycin]] may be reasonable but has not been shown to be superior to prophylaxis with a [[cephalosporin]].
| |
| | |
| Prophylaxis should be initiated immediately before the operative procedure, repeated during prolonged procedures to maintain serum concentrations intraoperatively, and continued for no more than 48 hours postoperatively to minimize emergence of resistant microorganisms. The effects of cardiopulmonary bypass and compromised renal function on antibiotic concentrations in serum should be considered and dosages adjusted as necessary before and during the procedure. <ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation |volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref> <ref name=Wilson>{{cite journal | author = Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT| title = American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group| journal = Circulation | volume = 116 | issue = 15 | pages = 1736-54 | year = 2007 | id = PMID 17446442}}</ref>
| |
| | |
| === Pharmacotherapy ===
| |
| | |
| Effective treatment requires identification of the etiologic agent and determination of its antimicrobial susceptibility.
| |
| | |
| Antibiotic therapy for subacute or indolent disease can be delayed until results of blood cultures are known; in fulminant infection or valvular dysfunction requiring urgent surgical intervention, begin empirical antibiotic therapy promptly after blood cultures have been obtained.
| |
| | |
| For prosthetic valve [[endocarditis]], treatment should be continued for 6–8 weeks.
| |
| | |
| ==== Acute Pharmacotherapies ====
| |
| | |
| =====Penicillin-Susceptible Viridans and Other Nonenterococcal Streptococci<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>=====
| |
| | |
| The minimum inhibitory concentration [MIC] <0.2 µg/ml
| |
| | |
| *[[Penicillin]] G: preferred regimen
| |
| | |
| '''Dose''': 12–18 million units I.V. daily in divided doses q. 4 hour for 4 weeks
| |
| | |
| *[[Penicillin]] G + [[gentamicin]] or [[ceftriaxone]]: preferred regimen
| |
| | |
| '''Dose''': [[penicillin]] G, 12–18 million units I.V. daily in divided doses q. 4 hour for 4 weeks; [[gentamicin]], 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hour for 2 weeks (peak serum concentration should be ~ 3 µg/ml and trough concentrations < 1 µg/ml); [[ceftriaxone]], 2 g I.V. daily as a single dose for 2 weeks
| |
| | |
| *[[Vancomycin]]: for patients with history of [[penicillin]] [[hypersensitivity]]
| |
| | |
| '''Dose''': 30 mg/kg I.V. daily in divided doses q. 12 hour for 4 weeks
| |
| | |
| =====Relatively Penicillin-Resistant Streptococci<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>=====
| |
| | |
| A- MIC 0.2–0.5 µg/ml
| |
| | |
| *[[Penicillin]] G + gentamicin: preferred regimen
| |
| | |
| '''Dose''': [[penicillin]] G, 20–30 million units I.V. daily in divided doses q. 4 hour for 4 weeks; [[gentamicin]], 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr for 2 wk (peak serum concentration should be ~ 3 µg/ml and trough concentrations < 1 µg/ml)
| |
| | |
| B- MIC > 0.5 µg/ml
| |
| | |
| *[[Penicillin]] G + [[gentamicin]]: preferred regimen
| |
| | |
| '''Dose''': [[penicillin]] G, 20–30 million units I.V. daily in divided doses q. 4 hour for 4 week; [[gentamicin]], 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hour for 4 week (peak serum concentration should be ~ 3 µg/ml and trough concentrations < 1 µg/ml)
| |
| | |
| *[[Vancomycin]]: regimen for patients with history of [[penicillin]] [[hypersensitivity]]
| |
| | |
| '''Dose''': 30 mg/kg I.V. daily in divided doses q. 12 hour for 4 weeks
| |
| | |
| =====Enterococci<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>=====
| |
| | |
| *[[Penicillin]] G + [[gentamicin]]: preferred regimen
| |
| | |
| '''Dose''': [[penicillin]] G, 20–30 million units I.V. daily in divided doses q. 4 hr for 4–6 weeks; [[gentamicin]], 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hour for 4–6 weeks (peak serum concentration should be ~ 3 µg/ml and trough concentrations < 1 µg/ml)
| |
| | |
| *[[Ampicillin]] + [[gentamicin]]
| |
| | |
| '''Dose''': ampicillin, 12 g I.V. daily in divided doses q. 4 hour for 4–6 weeks; [[gentamicin]], dose as above
| |
| | |
| *[[Vancomycin]] + [[gentamicin]]: regimen for patients with history of [[penicillin]] [[hypersensitivity]]
| |
| | |
| '''Dose''': [[vancomycin]], 30 mg/kg I.V. daily in divided doses q. 12 hour for 4–6 weeks; [[gentamicin]], dose as above
| |
| | |
| =====Staphylococci (Methicillin Susceptible) in the Absence of Prosthetic Material<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>=====
| |
| | |
| *[[Nafcillin]] or [[oxacillin]] + [[gentamicin]] (optional): preferred regimen
| |
| | |
| '''Dose''': [[nafcillin]] or [[oxacillin]], 12 g I.V. daily in divided doses q. 4 hour for 4–6 weeks; [[gentamicin]], 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr for 3–5 days (peak serum concentration should be ~ 3 µg/ml and trough concentrations <1 µg/ml)
| |
| | |
| *[[Cefazolin]] + [[gentamicin]] (optional): alternative regimen for patients with history of [[penicillin]] [[hypersensitivity]]
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| | |
| '''Dose''': [[cefazolin]], 12 g I.V. daily in divided doses q. 4 hour for 4–6 weeks; [[gentamicin]], dose as above
| |
| | |
| *[[Vancomycin]]: alternative regimen for patients with history of [[penicillin]] [[hypersensitivity]]
| |
| | |
| '''Dose''': 30 mg/kg I.V. daily in divided doses q. 12 hr for 4–6 weeks
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| | |
| =====Staphylococci (Methicillin Resistant) in the Absence of Prosthetic Material<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>=====
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| | |
| *[[Vancomycin]]
| |
| | |
| '''Dose''': 30 mg/kg I.V. daily in divided doses q. 12 hour for 4–6 weeks
| |
| | |
| =====Staphylococci (Methicillin Susceptible) in the Presence of Prosthetic Material<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>=====
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| | |
| *[[Nafcillin]] or [[oxacillin]] + [[rifampin]] + [[gentamicin]]
| |
|
| |
| '''Dose''': [[nafcillin]] or [[oxacillin]], 12 g I.V. daily in divided doses q. 4 hour for 6–8 weeks; rifampin, 300 mg p.o., q. 8 hour for 6–8 weeks; [[gentamicin]] (administer during the initial 2 weeks), 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hour for 2 weeks
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| | |
| =====Staphylococci (Methicillin Resistant) in the Presence of Prosthetic Material<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>=====
| |
| | |
| *[[Vancomycin]] + [[rifampin]] + [[gentamicin]]
| |
| | |
| '''Dose''': [[vancomycin]], 30 mg/kg I.V. daily in divided doses q. 12 hour for 6–8 weeks; [[rifampin]], 300 mg p.o., q. 8 hour for 6–8 weeks; [[gentamicin]] (administer during the initial 2 weeks), 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hour for 2 weeks
| |
| | |
| =====[[HACEK organism|HACEK Organisms]]<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>=====
| |
| | |
| *[[Ceftriaxone]] or another [[cephalosporin|third-generation cephalosporin]]
| |
| | |
| '''Dose''': 2 g I.V. daily as a single dose for 4 weeks
| |
| | |
| ==== Antithrombotic Therapy<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>====
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| | |
| * [[Anticoagulant]]s can cause or worsen hemorrhage in patients with [[endocarditis]] but may be carefully administered when needed
| |
| * [[Prothrombin time]] should be carefully maintained at INR of 2.0–3.0
| |
| * Anticoagulation should be reversed immediately in the event of CNS complications and interrupted for 1–2 wk after acute embolic stroke
| |
| * Avoid [[heparin]] administration during active [[endocarditis]] if possible
| |
| | |
| ==== Chronic Pharmacotherapies <ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>====
| |
| | |
| === Surgery and Device Based Therapy ===
| |
| | |
| ==== Indications for Surgery ====
| |
| | |
| Indications for surgical debridement of vegetations and infected perivalvular tissue, with valve replacement or repair as needed are listed below:<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>
| |
| | |
| #Moderate to severe [[congestive heart failure]] due to valve dysfunction
| |
| #Unstable valve prosthesis
| |
| #Uncontrolled infection for > 1–3 week despite maximal antimicrobial therapy
| |
| #Persistent bacteremia
| |
| #[[endocarditis|Fungal endocarditis]]
| |
| #Relapse after optimal therapy (prosthesis)
| |
| #Vegetation in Situ
| |
| #Prosthetic valve [[endocarditis]] with perivalvular invasion
| |
| #[[Endocarditis]] caused by [[Pseudomonas aeruginosa]] or other gram-negative bacilli that has not responded after 7–10 days of maximal antimicrobial therapy
| |
| #Perivalvular extension of infection and abscess formation
| |
| #Staphylococcal infection of prosthesis
| |
| #Persistent fever (culture negative)
| |
| #Large vegetation (>10 mm = increased embolism)
| |
| #Relapse after optimal therapy (native valve)
| |
| #Vegetations that obstruct the valve orifice
| |
| | |
| ====Principles of Surgical Management====
| |
| #Excise all infected valve tissue
| |
| #Drain and debride abscess cavities
| |
| #Repair or replace damaged valves
| |
| #Repair associated pathology such as septal defect, fistulas <ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>
| |
| | |
| =====Aortic Valve - Surgical Options=====
| |
| If the infection limited is limited to the leaflets, then replace the aortic valve.
| |
| | |
| If the infection extends to anulus or beyond, then debride the infected tissues, drain any abscesses to the pericardial sac and replace the aortic root.
| |
| | |
| =====Atrioventricular Valve - Surgical Options=====
| |
| If the infection is limited to the leaflets, then perform a vegectomy, repair perforations, and perform a reduction annuloplasty
| |
| | |
| If the infection extends to the anulus or beyond, then perform valve replacement, debride and abliterate abscesses. In some cases the tricuspid valve may be excised, but 20-30% of patients will develop [[congestive heart failure]].
| |
| | |
| ====Surgical Outcomes====
| |
| Operative mortality is 15 - 20%. The development of an infection of a prosthetic valve during operation for [[endocarditis|native valve endocarditis]] is 4%, it is higher (12 - 16%) if active [[endocarditis]] is present at the time of the surgery. Late survival at 5 years for [[endocarditis|native valve endocarditis]] is 70 - 80% and for [[endocarditis|prosthetic valve endocarditis]] is 50 - 80%.<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>
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| | |
| ===Antibiotic Prophylaxis with Dental Procedures===
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| {{MWT}}
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| ====Background====
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| *Endodontic procedures have been associated with a high incidence of bacteremia since the 1920s. Therefore, dental procedures were implicated as an independent risk factor for the development of bacterial endocarditis.
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| ** However, only 4%-7.5% of all bacterial endocarditis cases are related to endodontic associated bacteremia.<ref>Gendron R, Grenier D, Maheu-Robert L. The oral cavity as a reservoir of bacterial pathogens for focal infections. Microbes Infect. 2000;2:897-906. </ref>
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| ;'''AHA Guidelines'''
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| In 1955, the American Heart Association (AHA) published the first of ten subsequent IE prevention guidelines.
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| Most recent, 2007 guidelines underwent changes intended to clarify patient eligibility criteria for receiving IE prophylaxis.
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| *Major changes include, the consideration that frequent exposures to bacteremias associated with daily activities are considered more likely to induce IE then are endodontic-procedural induced bacteremias.
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| #Optimal oral hygiene is emphasized as an important practice for IE prevention.
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| #A patient’s lifetime acquisition risk of IE is no longer a consideration for initiating prophylactic antibiotic therapy.
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| #The AHA now recommends the administration of single-dose prophylactic antibiotics prior to endodontic procedure only to patients with cardiac conditions associated with the highest risk of adverse outcomes following the acquisition of bacterial endocarditis.
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| <blockquote>'''2007 AHA Guideline Recommendation for Which patients require Antiobiotic Prophylaxis Prior to Dental Procedure are those with documented'''</blockquote>
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| #Prosthetic cardiac valve.
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| #Previous IE
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| #Cardiac transplantation recipients who develop cardiac valvulopathy.
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| #Congential heart disease:
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| #*Unrepaired cyanotic CHD: shunts and conduits
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| #*Completely repaired congential heart defect during 1st 6months following procedure.
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| #*Repaired CHD with residual defects at site of prostetic patch or device.
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| | |
| ====Endodontic Procedures and Endocarditis risk====
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| *Following dental intervention, the absolute risk for developing IE is estimated at 1 case per 14 million dental procedures.<ref>Pallasch TJ. Antibiotic prophylaxis: problems in paradise. Dent Clin
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| North Am. 2003;47:665-679.
| |
| </ref>
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| *IE acquisition risk estimates following an endodontic induced bacteremia in patients with congenital heart disease are 1 per 475,000; rheumatic heart disease, 1 per 142,000; prosthetic heart valve, 1 per 114,000; and previous IE, 1 per 95,000 dental procedures.<ref>Pallasch TJ, Wahl MJ. Focal infection: new age or ancient history?
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| Endodontic Topics. 2003;4:32-45.
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| </ref>
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| *Inocula of 1 x 108 (100 million) colony forming units [cfu]/mL or greater are required to consistently induce experimental endocarditis.
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| **Recent human quantitative blood culture data support the implication that endodontic associated bacteremia inocula are of insufficient magnitude to induce endocarditis. Bacteremia intensities immediately following invasive human dental procedures are 1.5 cfu/ml-5.9 cfu/ml 10 fold less then necessary to induce IE in the animal model.<ref>Roberts GJ. Dentists are innocent! Everyday" bacteremia is the real culprit: A review and assessment of the evidence that dental surgical procedures are a principal cause of bacterial endocarditis in children. Pediatric Cardiology. 1999;20:317.</ref>
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| *The most recent case-control study of 104 patients with known, high-risk structural heart disease discovered that patients who developed IE were actually less likely to have experienced an endodontic procedure within the 180 days prior to diagnosis than did control patients who did not develop IE (OR 0.2 [95% CI 0.04-0.7]).<ref>Strom BL, Abrutyn E, Berlin JA, Kinman JL, Feldman RS, Stolley PD, et al. Dental and cardiac risk factors for infective endocarditis: A population-based, case-control study. Ann Int Med. 1998;129:761-769.</ref>
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| *Among high-risk patients with underlying structural heart disease, kidney disease (OR 16.9 [95% CI 1.5-193.0]), diabetes (OR 2.7 [95% CI 1.4-5.2]) and skin flora infection (OR 3.5 [95% CI 0.7-17.0]) were associated with a greater risk for the development of bacterial endocarditis.<ref>Strom BL, Abrutyn E, Berlin JA, Kinman JL, Feldman RS, Stolley PD, et al. Risk factors for infective endocarditis: oral hygiene and nondental exposures. Circulation. 2000;102:2842.</ref>
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| *Daily activities such as chewing and oral hygiene practices result in bacteremias more frequently, of longer duration and of greater magnitude in comparison to high-risk endodontic procedures.
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| '''These findings have led the AHA to conclude that the cumulative background bacteremia associated with chewing, daily dental hygiene practices, kidney disease, diabetes, and skin colonization present a greater risk of significant bacteremia than any single invasive dental procedure.'''
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| ====Prophylactic Antibiotic Efficacy====
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| *The efficacy of antibiotic regimens for IE prophylaxis has never been assessed under the scrutiny of a randomized controlled trial.
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| *Evidence supporting pre-endodontic chemoprophylaxis efficacy is extrapolated from data demonstrating reductions in bacteremia magnitudes immediately following the administration of antibiotics.
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| '''Antibiotic prophylaxis is reasonable for patients with the conditions who undergo any dental procedure that involves the gingival tissues or periapical region of a tooth and for those procedures that perforate the oral mucosa. Although Infective Endocarditis prophylaxis is reasonable for these patients, its effectiveness is unknown.'''
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| | |
| =====Efficacy Assesment=====
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| The '''Cochran Collaboration''' assessed whether prophylactic administration of penicillin to moderate- to high-risk patients prior to endodontic intervention conferred a mortality, serious illness or endocarditis incidence benefit.<ref>Oliver R, Roberts GJ, Hooper L. Penicillins for the prophylaxis of bacterial endocarditis in dentistry. Cochrane Database of Systematic Reviews 2004, Issue 2.</ref>
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| *The pooled, adjusted Odds Ratio across all studies for the development of IE among patients receiving prophylaxis was non-significant (0.56 [95% CI (0.15-2.15)]).
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| '''The Cochrane Collaboration concluded; it is unclear whether antibiotic prophylaxis is effective and there is a lack of evidence to support published guidelines using penicillin as chemoprophylaxis for IE.'''
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| '''' To date, only 4 case-control studies has assessed antibiotic efficacy for IE prevention.''''
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| #Strom et al discovered the administration pre-endodontic procedural antibiotics did not provide a protective benefit against the development of IE (OR 0.5 [CI .01-9.6]).
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| #Van Der Meer et al,<ref>Van der Meer JT, Thompson J, Valkenburg HA, Michel MF. Epidemiology of bacterial endocarditis in The Netherlands II. Antecedent procedures and use of prophylaxis. Arch Intern Med. 1992;152:1869-1873.</ref>8/48 case pts (16%) received antibiotics.26/200 control pts (13%) received antibiotics.Stratified Odds Ratio: 0.51 (0.11-2.29).Protective Efficacy 49%.
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| #Lacassin et al<ref>Lacassin F, Hoen B, Leport C, Selton-Suty C, Delahaye F, Goulet V, et al. Procedures associated with infective endocarditis in adults - A case control study. Eur Heart J. 1995;16:1968-1974.</ref>6/37 case pts (23%) received antibiotics.6/33 control pts (27%) received antibiotics.Matched and Adjusted Odds Ratio: 0.2 (0-0.8) Protective Efficacy 20%.
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| #Imperiale et al<ref>Imperiale TF, Horwitz RI. Does prophylaxis prevent post-dental infective endocarditis? A controlled evaluation of protective efficacy. Am J Med. 1990;88:131-136.</ref>
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| 1/8 case pts (13%) received antibiotics.15/24 control pts (63%) received antibiotics.
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| Matched Odds Ratio: .09 (CI upper limit of 0.93) (p=.025)Protective Efficacy 91%.
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| | |
| ====Safety Concerns with Antibiotic Prophylaxis====
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| ''Adverse reactions associated with the administration of beta-lactam antibiotics are common.''
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| *Ranging in severity from purititus to fatal anaphylactic shock, the frequency of all adverse reactions from the administration of penicillin to the general population is 0.7% to 10%.<ref>Idsoe O, Guthe T, Willcox RR, De Weck A. Nature and extent of penicillin side-reactions, with particular reference to fatalities from anaphylactic shock. Bull World Health Organ. 1968;38:159-188.</ref>
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| *Fatal anaphylaxis among patients receiving single-dose penicillin, ampillicin or amoxicillin therapy is approximately 20 cases per 1 million patients treated.<ref>The International Collaborative Study of Severe Anaphylaxis. Risk of anaphylaxis in a hospital population in relation to the use of various drugs: an international study. Pharmacoepidemiology and drug safety. 2003;12:195-202.</ref>
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| *Single-dose, cephalosporin-associated fatal anaphylaxis risk is estimated at 0.5-5.7 cases per 10 million patients treated.<ref>Kelkar P,James T. Current concepts: cephalosporin allergy. N Engl J Med. 2001;345:804-9.</ref>
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| *Macrolide and clindamycin single-dose fatal anaphylaxis risk is estimated at 0-5 cases per 1 million patients treated.<ref>Mazur N, Greenberger P, Regalado J. Clindamycin hypersensitivity
| |
| appears to be rare. Ann Allergy Asthma Immunol. 1999;82:443–5.
| |
| </ref>
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| '''With the highest associated mortality rate of all the recommended antibiotic regimens, the risk of anaphylaxis with the initiation of beta-lactam IE prophylactic therapy must be considered.'''
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| #The risk of mortality associated with the single-dose administration of beta-lactam antibiotics for IE prophylaxis is estimated at 1-3 anaphylactic deaths per 1 million patients treated.
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| #According to the AHA, single dose administration of a beta-lactam antibiotic for IE prophylactic therapy is a safe practice as it has never resulted in a reportable case of fatal anaphylaxis.
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| | |
| ====Cost Effectiveness of Oral Antibiotic Prophylaxis====
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| ''To date, one report has addressed the cost-effectiveness of providing chemoprophylaxis to patients of moderate- and high-risk of IE acquisition prior to endodontic procedure.''<ref>Agha Z, Lofgren RP, VanRuiswyk JV. Is antibiotic prophylaxis for bacterial endocarditis cost-effective? Med Decis Making. 2005;25:308-320.</ref>
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| #The risk of drug-induced anaphylaxis and associated loss of QALYs with prophylactic oral amoxicillin or ampicillin to moderate-risk patients rendered this practice ineffective and therefore the authors did not complete a cost-effectiveness analysis.
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| #The estimated cost-effectiveness ratio for the prophylaxis of 10 million moderate-risk patients with clarithromycin, clindamycin or cephalexin, was $88,007, $101,142 and $99,373 per QALY saved, respectively.
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| #Cost-effectiveness ratio for the use of clarithromycin in patients with the prior diagnosis of endocarditis was $40,334, and in patients with prosthetic valves, $16,818 per QALY saved.
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| #Cost-effectiveness ratio of treating 10 million high-risk patients administered single dose clindamycin was $46,678 (prior endocarditis) and $19,936 (prosthetic valve) per QALY saved. #Cephalexin was associated with a cost-effectiveness of $37,916 per QALY saved in patients with a history of IE and $14,060 per QALY saved, in patients with a prosthetic valves.
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| '''''The cost-effective analyses suggest that the 2007 AHA IE prevention guidelines advocating chemoprophylaxis to patients with a high-risk of adverse outcomes upon acquisition of IE is a reasonable, cost-effective practice.'''''
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| The term of prophylaxis required procedure '''include''' biopsies, suture removal, and placement of orthodontic bands, but it '''does not include''' routine anesthetic injections through non-infected tissue, the taking of dental radiographs, placement of removable prosthodontic or orthodontic appliances, placement of orthodontic brackets, or adjustment of orthodontic appliances.
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| | |
| ===SUMMARY for antibiotic prophlaxis prior to endodontic procedure===
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| *The presumed correlation of endodontic induced bacteremia, and new onset IE made pre-procedural antibiotic prophylaxis a reasonable practice for the preceding 60 years. However, there is a paucity of evidence in support of providing chemoprophylaxis for effective IE prevention.
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| *Chewing, dental hygiene practices, kidney disease, diabetes, and skin colonization present a greater risk of significant bacteremia and greater cumulative IE acquisition risk than any single invasive dental procedure.
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| *The AHA recommends reducing the incidence of bacteremia with the optimization of oral hygiene in at-risk patients and does not recommend indiscriminant pre-procedural chemoprophylaxis as a safe, IE prevention practice.
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| *Case-control studies have reported conflicting results on the protective efficacy conferred from providing pre-procedural antibiotic prophylaxis to at-risk patients.
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| The AHA acknowledges that even if chemoprophylaxis conferred 100% efficacy, few cases of IE would be prevented as the incidence of endodontic induced IE is so low.
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| <blockquote>The AHA now recommends the administration of pre-endodontic procedural prophylactic antibiotics to patients with the highest risk of adverse outcomes subsequent to the development of IE.</blockquote>
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| *Acknowledging an estimated 10-20 fold greater risk of single-dose fatal anaphylaxis with amoxicillin compared to single dose cephalosporin, macrolide and clindamycin regimens, the AHA believes prophylaxis with amoxicillin is a safe practice as there have been no reports of fatal anaphylaxis from a single-dose of pre-dental IE prophylaxis oral amoxicillin.
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| *'''The 2007, AHA guidelines appropriately advocate against providing chemoprophylaxis to moderate-risk patients and appropriately advocate for chemoprophylaxis to high-risk patients prior to endodontic procedure as this is a cost-effective practice for IE prevention.'''
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| Finally, there are other events that are not dental procedures and for which prophylaxis is not recommended, such as shedding of deciduous teeth and trauma to the lips and oral mucosa.
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| In this limited patient population, prophylactic antimicrobial therapy should be directed against [[Streptococcus viridans]].
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| | |
| As a summary; individuals at the highest risk group who need procedures listed below require proper antibiotic prophylaxis;<ref name=Wilson>{{cite journal | author = Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT| title = American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group| journal = Circulation | volume = 116 | issue = 15 | pages = 1736-54 | year = 2007 | id = PMID 17446442}}</ref>
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| | |
| *Any type of dental extractions
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| *Any type of periodontal procedures and gingival surgery
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| **Placement of dental implants and avulsed teeth replantation
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| **Dental canal or root surgery
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| **Antibiotic fibres or strips placement at subgingival area
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| **Initial placement of orthodontic brackets
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| **Intraligamentous injection of local anesthetic drugs
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| **Bleeding during prophylactic cleaning of teeth or implants
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| | |
| ====Antibiotic prophylaxis with Procedures on Infected Skin, Skin Structure, or Musculoskeletal Tissue====
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| These infections are often polymicrobial, but only staphylococci and beta hemolytic [[streptococci|beta-hemolytic streptococci]] are likely to cause Infective Endocarditis.
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| | |
| For patients with high risk conditions who undergo a surgical procedure that involves infected skin, skin structure, or musculoskeletal tissue, it may be reasonable that the therapeutic regimen administered for treatment of the infection contain an agent active against [[staphylococci]] and [[streptococci|beta-hemolytic streptococci]], such as an antistaphylococcal [[penicillin]] or a [[cephalosporin]].
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| [[Vancomycin]] or [[clindamycin]] may be administered to patients unable to tolerate a [[beta-lactam]] or who are known or suspected to have an infection caused by a [[methicillin-resistant staphylococcus aureus]].<ref name=Wilson>{{cite journal | author = Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT| title = American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group| journal = Circulation | volume = 116 | issue = 15 | pages = 1736-54 | year = 2007 | id = PMID 17446442}}</ref>
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| | |
| === Secondary Prevention and Follow-Up===
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| | |
| ====Short-Term Follow-Up====
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| | |
| The majority of patients with IE are cured with appropriate medical and, if necessary, surgical treatment. Before completing antimicrobial therapy, the patient should receive TTE (Class IIb, Level of Evidence: C) to establish a new baseline for subsequent comparison.
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| | |
| A referral to a program to assist in cessation of drug use should be made for IDU patients. Patients should be educated about the signs of [[endocarditis]] and urged to seek immediate medical attention should they occur. A thorough dental evaluation should be obtained and all active sources of oral infection should be eradicated.
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| | |
| All catheters used to infuse antimicrobial treatment should be promptly removed at the end of therapy. In the short-term follow-up, patients should be monitored for development of several complications. A relapse of endocardial infection is a primary concern. Patients should be aware that relapses can occur and that new onset of fever, chills, or other evidence of systemic toxicity mandates immediate evaluation, including obtaining ≥3 sets of blood cultures from different phlebotomy sites after a thorough
| |
| history and physical examination.<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref> <ref name=Wilson>{{cite journal | author = Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT| title = American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group| journal = Circulation | volume = 116 | issue = 15 | pages = 1736-54 | year = 2007 | id = PMID 17446442}}</ref>
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| | |
| ====Long-Term Follow-Up====
| |
| | |
| Months to years after completion of medical therapy for IE, patients need ongoing observation and education regarding recurrent infection and delayed onset of worsening valvular dysfunction. Ongoing daily dental hygiene should be stressed, with serial evaluations by a dentist who is familiar with this patient population.
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| | |
| Patients should be questioned about the symptoms of decreased cardiac output and CHF. A thorough cardiac examination will be needed. Additional evaluations with TTE will be necessary in selected patients with positive findings from history and physical examination. Patients must be reminded to seek immediate medical evaluation for fever. This is necessary because IE can mimic a panoply of febrile illnesses.
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| | |
| Antibiotic therapy should not be initiated for treatment of undefined febrile illnesses without obtaining previous blood cultures. Antibiotics prescribed for nonspecific or unproved febrile syndromes are the major cause of (blood) culture negative endocarditis and should be strongly discouraged. <ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref> <ref name=Wilson>{{cite journal | author = Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT| title = American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group| journal = Circulation | volume = 116 | issue = 15 | pages = 1736-54 | year = 2007 | id = PMID 17446442}}</ref>
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| | |
| == Cost-Effectiveness of Therapy ==
| |
| Although cost-effectiveness calculations suggest that [[TEE]] should be the first examination in adults with suspected [[IE]], particularly in the setting of staphylococcal bacteriemia, many patients are not candidates for immediate [[TEE]] because of oral intake during the preceding 6 hours or because the patients are in institutions that cannot provide 24-hour [[TEE]] services. When [[TEE]] is not clinically possible or must be delayed, early [[TTE]] should be performed without delay.<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref> <ref name=Wilson>{{cite journal | author = Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT| title = American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group| journal = Circulation | volume = 116 | issue = 15 | pages = 1736-54 | year = 2007 | id = PMID 17446442}}</ref>
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| | |
| == Future or Investigational Therapies ==
| |
| | |
| Considering [[infective endocarditis]] to be an "emerging" problem in the 21st century may seem unusual, given that the illness has been well documented over the last 450 years. However, such emergence can be attributed to several factors:
| |
| | |
| #The emergence of antimicrobial resistance in classic [[infective endocarditis]] microflora, namely, the gram-positive cocci;
| |
| #The existence of antimicrobial resistance in complex ecologic biofilms;
| |
| #The changing pattern of causal agents now regarded as important pathogens of [[infective endocarditis]], e.g., Bartonella spp., T. whipplei, and fungi;
| |
| #Changing epidemiologic trends of persons who acquire [[infective endocarditis]], including '''injection drug users''', '''persons with HIV/AIDS''', '''children with congenital heart defects''', and persons undergoing '''body piercing'''.
| |
| | |
| Furthermore, the way we provide inpatient medical care has also been associated with the emergence of nosocomial [[infective endocarditis]], which can result from invasive '''procedures such as catheterization''', although no cardiac surgery has been performed.
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| | |
| The forthcoming years will likely witness the emergence of even more changing trends of [[infective endocarditis]], which as yet have not been well recognized. <ref>Millar BC, Moore JE. Emerging issues in infective endocarditis. Emerg Infect Dis 2004 Jun [Access date: 03-03-2008]. Available from: http://www.cdc.gov/ncidod/EID/vol10no6/03-0848.htm</ref> <ref name=Wilson>{{cite journal | author = Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT| title = American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group| journal = Circulation | volume = 116 | issue = 15 | pages = 1736-54 | year = 2007 | id = PMID 17446442}}</ref>
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| =="The Way I Like To Do It ..." Tips and Tricks From Clinicians Around The World==
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| ===Suggested Revisions to the Current Guidelines===
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| ==References==
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| <div class="reflist4" style="height: 220px; overflow: auto; padding: 3px" >
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| <references/>
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| </div>
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| ==External Links and Patient Resources==
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| *[http://www.annals.org/cgi/reprint/146/8/574.pdf Brief Communication: Treatment of Enterococcus faecalis Endocarditis with Ampicillin plus Ceftriaxone]
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| *[http://www.utmem.edu/cardiology/articles/InfectiveEndocarditisreview01.pdf Infective Endocarditis in Adults]
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| *[http://jama.ama-assn.org/cgi/reprint/293/24/3022 Temporal Trends in Infective Endocarditis]
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| ===For Patients:===
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| *[http://www.americanheart.org/presenter.jhtml?identifier=4436 A.H.A. Patient Information for Infective Endocarditis]
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| == Acknowledgements ==
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| The content on this page was first contributed by: [[C. Michael Gibson, M.S., M.D.]]
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| ==Contributors==
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| {{Electrocardiography}}
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| {{Circulatory system pathology}}
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| {{SIB}}
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| [[tr:İnfektif endokardit]] | | [[tr:İnfektif endokardit]] |
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| [[Category:Emergency medicine]] | | [[Category:Emergency medicine]] |
| [[Category:Cardiology]] | | [[Category:Cardiology]] |
| [[Category:Infectious disease]]
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| [[Category:Intensive care medicine]] | | [[Category:Intensive care medicine]] |
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