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]; Mohamed Moubarak, M.D. [3]

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:

❑ Onset of the symptoms

❑ Acute
❑ Subacute

Fever
Chills
Rigors
Sweats
Weakness
Myalgias
Arthralgias
Anorexia
Fatigue
Shortness of breath
Hemoptysis
Sputum
Cough
Pleuritic chest pain
Seizures
❑ Symptoms suggestive of stroke
❑ Symptoms suggestive of transient ischemic attack

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Identify existing risk factors:

❑ History of rheumatic heart disease
Prosthetic valves patients
Intravenous drug users
❑ Previous infective endocarditis
Cardiac transplant recipients with valves abnormality
Congenital heart diseases

❑ Unrepaired cyanotic congenital heart diseases
❑ Completely repaired defect with prosthetic material or device
❑ Repaired with residual defects at the site or adjacent to the site of a prosthetic material
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:


Vital signs
Temperature

Fever

Blood pressure

❑ Wide pulse pressure (sign of aortic insufficiency)
❑ Narrow pulse pressure (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

Aortic insufficiency
Tricuspid regurgitation
Mitral regurgitation

Lungs

Rales as a sign of heart failure

Abdomen

Reduced bowel sounds (sign of mesenteric embolization or ileus)
Abdominal pain

Flank pain (sign of embolus to the kidney)
❑ Left upper quadrant pain (sign of splenic infarct)

Splenomegaly

Extremities

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

Neurologic

❑ Full neurological exam

❑ Focal deficits (suggestive of stroke or brain abscess)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any of the following:

❑ Unexplained fever for more than 48 hours and high risk for infective endocarditis

❑ Congenital or acquired valvular heart disease
❑ Previous infective endocarditis
❑ Prosthetic heart valve
❑ Congenital heart malformation
❑ Immunodeficiency
❑ History of drug injection

❑ Newly diagnosed valve regurgitation

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order laboratory tests:[2]

Blood culture (at least two sets)
WBC

❑ Marked leukocytosis is present

Erythrocyte sedimentation rate

❑ Markedly elevated

Rheumatoid factor

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

BUN
Cr
Urinalysis


EKG

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

❑ Order a TTE
❑ Order a TEE if one or more of the following is present

❑ Non diagnostic TTE in a suspected infective endocarditis (Class I, level of evidence B)
❑ Clinical complications (Class I, level of evidence B)
❑ Intracardiac device leads (Class I, level of evidence B)
❑ Staphylococcus aureus bacteremia without a known cause (Class IIa, level of evidence B)
❑ Prosthetic valve with persistent fever without bacteremia (Class IIa, level of evidence B)
❑ Prosthetic valve with a new murmur (Class IIa, level of evidence B)
❑ Nosocomial Staphylococcus aureus bacteremia with known extra-cardiac port of entry (Class IIb, level of evidence B)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Evaluate the Modified Duke Criteria for infective endocarditis:

❑ Two major criteria, OR
❑ One major and three minor criteria, OR

❑ Five minor criteria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Consult an infectious disease specialist
❑ Consult a cardiologist
❑ Consult a cardiac surgeon
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Reevaluate the patient with TTE and/or TEE

❑ Change in clinical signs and symptoms

❑ New murmur
Embolism
❑ Persistent fever
Heart failure
Abscess
❑ Atrioventricular heart block

❑ High risk of complications

❑ Large vegetations on echocardiogram
❑ Staphylococcus, enterecoccal, or fungal infections
 
 
 
 

Therapeutic Approach

Shown below an algorithm depicting the general therapeutic approaches of infective endocarditis based on the 2005 American Heart Association (AHA) technical review and medical position statement regarding guidelines on infective endocarditis.[3]

 
 
 
 
 
 
 
 
 
❑ Evaluate the patient
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute presentation or hemodynamically unstable
 
 
 
 
 
 
 
 
 
Subacute presentation and hemodynamically stable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Stabilize the patient
 
 
 
 
 
 
 
 
 
❑ Wait for blood culture results
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Don`t wait for blood culture results and start empirical antibiotic therapy
 
 
 
 
 
 
 
 
 
Start antibiotic therapy according to the detected pathogen
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Streptococci antibiotic regimen
 
 
 
Enterococci antibiotic regimen
 
 
 
Staphylococci antibiotic regimen
 
 
 
HACEK Organisms antibiotic regimen
 
 
 
Culture negative antibiotic regimen
 

Prophylactic Approach

Shown below an algorithm depicting the general prophylactic approaches of infective endocarditis based on 2014 AHA/ACC Guideline for the management of patients with valvular heart disease.[4] Classification of recommendations class IIa

 
 
 
 
 
 
Identify the high risk patients:

Prosthetic valves patients
❑ Previous infective endocarditis
Cardiac transplant recipients with valves abnormality
Congenital heart diseases

❑ Unrepaired cyanotic congenital heart diseases
❑ Completely repaired defect with prosthetic material or device
❑ Repaired with residual defects at the site or adjacent to the site of a prosthetic material
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Decide if the patient needs prophylaxis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Choose a prophylaxis regimen
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Infective endocarditis prophylaxis regimens
 
 
Prophylaxis regimens if the patient is penicillin or pmpicillin allergic
 
 
 
Prophylaxis regimens if the patient is penicillin or ampicillin allergic and cannot take oral medications
 
 
 
 
 
 
 

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)
  3. Baddour, LM.; Wilson, WR.; Bayer, AS.; Fowler, VG.; Bolger, AF.; Levison, ME.; Ferrieri, P.; Gerber, MA.; Tani, LY. (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: endorsed by the Infectious Diseases Society of America". Circulation. 111 (23): e394–434. doi:10.1161/CIRCULATIONAHA.105.165564. PMID 15956145. Unknown parameter |month= ignored (help)
  4. "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary". Retrieved 4 March 2014.


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