Infective endocarditis resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farman Khan, MD, MRCP [2]

Definition

Infection of the endothelium of the heart including but not limited to the valves. It can be either acute or subacute. Acute bacterial endocarditis is defined as Infection of normal heart valves with a virulent organism like S. aureus, Group A or other beta-hemolytic streptococci, Streptococcus pneumoniae. Subacute bacterial endocarditis is an indolent infection of abnormal valves with less virulent organism like Streptococcus viridans.

Criteria Definite Infective Endocarditis According to Modified Duke Criteria
Pathological Criteria
Microorganisms demonstrated by culture or histological examination of a vegetation
Pathological lesions; vegetation or intracardiac abscess confirmed by histological examination showing active endocarditis
Clinical Criteria
2 major criteria; or
1 major criterion and 3 minor criteria; or
5 minor criteria
Possible IE
1 major criterion and 1 minor criterion; or
3 minor criteria
Rejected
Firm alternative diagnosis explaining evidence of IE; or
Resolution of IE syndrome with antibiotic therapy for 4 days; or
No pathological evidence of IE at surgery or autopsy, with antibiotic therapy for 4 days; or
Does not meet criteria for possible IE as above

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Endocarditis can be a life-threatening condition if it is left untreated, and it must be treated as such irrespective of the causes.

Common Causes

Management

Diagnostic Criteria

Shown below is an algorithm depicting the diagnostic criteria of infective endocarditis based on the 2005 American Heart Association (AHA) technical review and medical position statement regarding guidelines on infective endocarditis.[1]

 
 
 
 
Duke Criteria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The Duke Clinical Criteria for Infective Endocarditis requires either:

❑ Two major criteria, or

❑ One major and three minor criteria, or

❑ Five minor criteria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Major Criteria
 
 
 
Minor criteria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Positive Blood Culture for Infective Endocarditis
  • Typical microorganism consistent with infective endocarditis from 2 separate blood cultures, as noted below:
Viridans streptococci, streptococcus bovis
HACEK group
❑ Community-acquired staphylococcus aureus
Enterococci, in the absence of a primary focus, or
  • Microorganisms consistent with infective endocarditis from persistently positive blood cultures defined as:
❑ 2 positive cultures of blood samples drawn >12 hours apart, or
❑ All of 3 or a majority of 4 separate cultures of blood (with first and last sample drawn 1 hour apart)

Echocardiographic evidence of endocardial involvement

❑ Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or
❑ On implanted material in the absence of an alternative anatomic explanation, or
❑ Abscess, or
❑ New partial dehiscence of prosthetic valve, or
❑ New valvular regurgitation (worsening or changing of preexisting murmur not sufficient)
 
 
 
  • Predisposition:
❑ Predisposing heart condition or intravenous drug use
  • Fever:
❑ Temperature > 38.0° C (100.4° F)
  • Vascular phenomena:
Major arterial emboli
❑ Septic pulmonary infarcts
Mycotic aneurysm
Intracranial hemorrhage
Conjunctival hemorrhage
Janeway lesions
  • Immunologic phenomena:
Glomerulonephritis
Osler's nodes
Roth spots
Rheumatoid factor
  • Microbiological evidence:
❑ Positive blood culture but does not meet a major criterion as noted above
❑ Serological evidence of active infection with organism consistent with infectious endocarditis
  • Echocardiographic findings:
❑ Consistent with infectious endocarditis but do not meet a major criterion as noted above
 
 
 
 
 
 

Diagnostic approach

Shown below is an algorithm summarizing the approach to infective endocarditis.

 
 
 
 
 
 
 
Characterize the symptoms


Symptoms suggestive of bacterial endocarditis

General sypmtoms:

❑ Predisposition, predisposing heart condition, or parenteral drug use
❑ Insidious onset (subacute cases)
❑ Abrupt onset (acute cases)
Fever(in acute cases, as high as 102.9° to 105.1° F (39.4° to 40.6° C), often remittent)
Sweats
Weakness
Myalgias
Arthralgias
Malaise
Anorexia
Fatigue
Splenomegaly, clubbing, and Osler’s nodes in long-standing SBE

Vascular symptoms:

Embolism
❑ Symptoms of septic pulmonary infarct
❑ Symptoms of intracranial hemorrhage
Conjunctival hemorrhage
Janeway lesions

Immunological symptoms:

❑ Symptoms of glomerulonephritis
Osler's nodes
Roth's spots

Symptoms suggestive of endocarditis associated with parenteral drug use

High fevers, chills, rigors, malaise, cough, and pleuritic chest pain
Septic pulmonary emboli causing sputum production, hemoptysis, and signs of pneumonia
Cardiac murmurs
Tricuspid insufficiency
❑ Metastatic infections such as renal or brain abscess
❑ Neurologic manifestations such as stroke, TIA, seizures
❑ Peripheral emboli

Symptoms suggestive of prosthetic valve endocarditis

❑ New symptoms consistent with valvular regurgitation such as shortness of breath
Fever
Petechiae, Roth's spots, Osler's nodes, Janeway lesions

Emboli
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient


Vital signs
Fever
Rigors
❑ Wide pulse pressure due to aortic insufficiency
❑ Narrow pulse pressure may be a sign of left ventricular failure

Skin

Petechiae
Splinter hemorrhages
Osler's nodes
Janeway lesions

Eyes

Conjunctival hemorrhage
Roth's spots in the retina

Heart

Heart Murmur(s) of:

Ο Aortic insufficiency
Ο Tricuspid regurgitation
Ο Mitral regurgitation

Lungs

Rales as a sign of heart failure

Abdomen

Reduced bowel sounds as a result to mesenteric embolization or ileus
Abdominal pain

Ο Flank pain may be present as a result of an embolus to the kidney
Ο Left upper quadrant pain (LUQ pain) may be present as a result of a splenic infarct

Splenomegaly

Extremities

Janeway lesions (painless hemorrhagic cutaneous lesions on the palms and soles)
Gangrene of fingers may occur
splinter haemorrhages
Osler's nodes (painful subcutaneous lesions in the distal fingers)

Neurologic

Stroke as a result of septic emboli
Seizures
Intracranial hemorrhage may occur

❑ Signs of a brain abscess may be present
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order laboratory tests:[2]

Blood culture

WBC

Ο Marked leukocytosis is present

Erythrocyte sedimentation rate

Ο Markedly elevated

Rheumatoid factor

Ο A positive serum rheumatoid factor in 50% of patients with subacute disease

BUN

Cr

Urinalysis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order imaging studies:

EKG

Echocardiography

CT scan of the head

MRI brain
 
 
 
 


 
 
 
 
 
 
 
A1 Box 1 in Row 1
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
B1 Box 1 in Row 2
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
C1 Box 1 in Row 3
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Box 4 in row 4
 
 
 
Box 5 in row 4
 
 
 
 
 
 
 
 
 
Box 6 in row 4
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Box 7 in row 5
 
 
 
 
 
 
 
 
 
Box 8 in row 5
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
box 9 in row 6
 
 
 
box 10 in row 6
 
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Box 13 in row 6
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Therapeutic Approach

Do's

Dont's

References

  1. 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. (2005). "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". Circulation. 111 (23): 3167–84. PMID 15956145.
  2. Bonow RO, Carabello BA, Chatterjee K; et al. (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Unknown parameter |month= ignored (help)


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