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Endocarditis

Endocarditis

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Endocarditis

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  1. Endocarditis Heather Patterson PGY-2 Emerg June 6 2007

  2. Objectives • History and Epidemiology • Pathophysiology • Risk Factors • Duke Criteria • Management

  3. History • 1825: First described • 1846: Realized vegetations where bacterial • 1932-40: Supportive treatment until this time when ABx first used

  4. Epidemiology • 10,000-50,000 new cases per year in US • Mean age 55y • M:F = 2:1 – 9:1 • Rheumatic heart disease less common than nosocomial, prosthetic valve, IVDU

  5. Epidemiology • Native Valve: • >50yo • M>F • 60-80% with predisposing cardiac disease • Staph aureus in 50-60%

  6. Epidemiology • IVDU: • 20% have abnormal underlying valve pathology • R vs L

  7. Pathophysiology • Thrombus formation: • Subacute - often thrombus is preexisting or damage to valve is preexisting • Acute – bacteria can cause thrombus, +/- prior valve damage, rapid progression • Organism Adherence • Circulating bacteria/fungus adhere and colonize • Accelerated plt aggregation • Platelets coat and protect bacteria from immune response

  8. Pathophysiology • Valve Invasion: • Immune response damages valve leaflets, chordae tendinae • Systemic effects: • Infectious microemboli • CNS • Myocardium • Renal • Pulmonary • Vasculitis

  9. Microorganisms • Congenital valve disease & MVP: • Strep viridans • Strep milleri • IVDU & prosthetic valves • Coag neg staph • Other • Gram neg bacilli • HACEK—haemophilus, actinobacillus, cardiobacterium, eikenella, kingella • Candida • Aspergillus

  10. Risk Factors • IVDU • R vs L sided? • Recurrence up to 40% • Prosthetic heart valves • First yr- 1-4% develop IE • 0.5-4% risk each subsequent year • Type of valve not a determinant of risk • Pacemakers/ICDs • Indwelling caths • History of IE • 2.5-9% of pts recur

  11. Risk Factors • Structural heart disease • Up to ¾ of all IE have structural disease present at the time of diagnosis • Rheumatic: • Older studies show this is the most common • Mitral value prolapse with regurgitation • 5-8x the risk of general population • Reported in 22-29% of cases • Aortic valve disease • Reported in 12-30% of cases

  12. Risk Factors • Congenital Heart Disease • Seen in 10-20% of IE cases • Most common lesions: • Bicuspid aortic valve • PDA • VSD • Coarctation • TOF

  13. Risk Factors • 2401 pts followed for 40,000 days • Rates of IE in patients with AS, PS, VSD • Results: • Overall incidence was 35x the general population rate • AS • Risk increased with gradient across the valve • PS: • Lowest risk of the conditions studied. (1/592 patients) • VSD • Size of defect not related to risk of IE Circulation 1993 Feb;87(2 Suppl):I121-6.

  14. Duke Criteria • Any one of the following: • Direct evidence of IE on histologic exam • Gram stain/cultures of specimens • Two major criteria • One major and 3 minor criteria • Five minor criteria

  15. Duke Criteria • Major criteria • Positive blood cultures x2 (12 hours apart) • Strep viridans • Strep bovis • HACEK group • Community acquired Staph or entercoccus • Persistent bacteremia by cultures >12h apart

  16. Duke Criteria • Major criteria • Evidence of endocardial involvement with new murmur • Single positive culture for Coxiella burnetti OR Antiphase 1 IgG Ab titre >1:800

  17. Duke Criteria • Major criteria • Positive ECHO • Oscillating intracardiac mass on valve or supporting structures, regurgitant jets or prosthetic material • New partial detachment of prosthetic valve • New valvular regurgitation or increase or change • Abscess • NOTE: TEE recommended for prosthetic valves

  18. Duke Criteria • Minor criteria • Predisposing cardiac disease • IVDU • Fever>38 • Vascular phenomena • Arterial emboli • Septic pulmonary infaracts • Mycotic aneurysms • Intracranial hemorrhage • Conjunctival hemorrhage • Janeway lesions

  19. Duke Criteria • Minor criteria • Immune phenomena • Osler’s nodes • Roth spots • Positive rheumatoid factor • Glomerulonephritis • Microbiological evidence • Positive culture not meeting major criteria • Serologic evidence of active infection with organism that causes IE • ECHO • Non diagnostic but abnormal

  20. Duke Criteria • Sensitivity: 99% • Specificity: 95%

  21. Clinical Presentation • Most often nonspecific and varied presentation • High index of suspicion • Classic triad: • Fever • Anemia • Murmur • Most common symptoms: • Intermittent fever (85%) • Malaise (95%) • Others: • Weakness, anorexia, myalgias • SOB, CP, cough, • HA, neuro symptoms

  22. Investigations • CBC • Leukocytosis • Mild anemia • Elevated ESR, CRP • Blood culture x 3-4 • U/A: • microscopic hematuria (secondary to emboli) • EKG • conduction abnormality possible if abscess develops • ECHO • TTE: Native valve • TEE: Recommended for prosthetic valves • superior to TTE; NPV 95%

  23. Management Vanco 15mg/kg then 500mg q6h AND Gent 1-3mg/kg then 1mg/kg q8h OR • Ceftriaxone 1-2g q12h • AND • Gent 1-3mg/kg then 1mg/kg q8h

  24. Management • Surgical Indications: • Severe CHF due to valve incompetence • Paravalvular leak around prosthetic valve • Fungal endocarditis • Persistent bacteremia despite abx