Infective Infective Endocarditis: Endocarditis: Epidemiology, Diagnosis and Epidemiology, Diagnosis and Management Management Holger P. Salazar, MD, FACC Holger P. Salazar, MD, FACC Stern Cardiovascular Stern Cardiovascular Foundation Foundation No financial relation to disclose No financial relation to disclose
Infective Endocarditis : Epidemiology, Diagnosis and Management Holger P. Salazar, MD, FACC Stern Cardiovascular Foundation No financial relation to disclose. Epidemiology of Infective Endocarditis. Epidemiology of Infective Endocarditis. - PowerPoint PPT Presentation
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Infective Endocarditis: Infective Endocarditis: Epidemiology, Diagnosis and Epidemiology, Diagnosis and
ManagementManagement
Holger P. Salazar, MD, FACCHolger P. Salazar, MD, FACCStern Cardiovascular FoundationStern Cardiovascular Foundation
No financial relation to discloseNo financial relation to disclose
Epidemiology of Infective EndocarditisEpidemiology of Infective Endocarditis
Epidemiology of Infective Epidemiology of Infective EndocarditisEndocarditis
Annual incidence in USA 10,000-20,000 new Annual incidence in USA 10,000-20,000 new cases, stable over past 30 yearscases, stable over past 30 years
Prosthetic valve endocarditis accounts for Prosthetic valve endocarditis accounts for 15% of cases15% of cases
Mortality is about 20%, due to CHF, valvular Mortality is about 20%, due to CHF, valvular dysfunction, or uncontrolled infectiondysfunction, or uncontrolled infection
50% over the age of 5050% over the age of 50
Valvular Involvement in Infective Valvular Involvement in Infective EndocarditisEndocarditis
ValveValve Percent of Cases Percent of Cases
MitralMitral 28-45% 28-45%
AorticAortic 5-36% 5-36%
Aortic + MitralAortic + Mitral 0-35% 0-35%
TricuspidTricuspid 5% 5%
Combined right and leftCombined right and left 0-4% 0-4%
Most Common Underlying Cardiac Most Common Underlying Cardiac Lesions In Infective Endocarditis Lesions In Infective Endocarditis
Echocardiography and Diagnosis of Echocardiography and Diagnosis of EndocarditisEndocarditis
Transthoracic Echocardiography Transthoracic Echocardiography and Endocarditisand Endocarditis
No technological advance has had as much impact on No technological advance has had as much impact on approach to patients with IEapproach to patients with IE
Rapid, non-invasive and specific for vegetations (98%)Rapid, non-invasive and specific for vegetations (98%)
May be inadequate in 20% of patients because of May be inadequate in 20% of patients because of obesity, COPD, or chest-wall deformitiesobesity, COPD, or chest-wall deformities
TTE should be used in the evaluation of those with TTE should be used in the evaluation of those with suspected native valve IE who are good candidates for suspected native valve IE who are good candidates for imagingimaging
Transesophageal Echocardiography Transesophageal Echocardiography and Endocarditisand Endocarditis
More costly and invasive but increases the More costly and invasive but increases the sensitivty (from 75% to 95%) while maintaining sensitivty (from 75% to 95%) while maintaining specificity (85-98%)specificity (85-98%)
More sensitive for defining perivalvular More sensitive for defining perivalvular extension, perforation of valves, and myocardial extension, perforation of valves, and myocardial abscessabscess
A negative TEE has a negative predictive value A negative TEE has a negative predictive value for IE of > 92%for IE of > 92%
TTE or TEE or Both?TTE or TEE or Both?
Recent guidelines suggest that among patients Recent guidelines suggest that among patients with suspected endocarditis appropriate use of with suspected endocarditis appropriate use of echocardiography depends on prior probability echocardiography depends on prior probability of IEof IE
If this probability is < 4% , a negative TTE is cost If this probability is < 4% , a negative TTE is cost effective and satisfactory in ruling out IEeffective and satisfactory in ruling out IE
If this probability is 4 to 60%, initial use of TEE If this probability is 4 to 60%, initial use of TEE is more cost effective and efficient than initial is more cost effective and efficient than initial TTE followed by TEE (if former negative)TTE followed by TEE (if former negative)
Mylonakis & Calderwood NEJM 2001;345:1318
Limitations of Echocardiography in Limitations of Echocardiography in the Diagnosis of Endocarditisthe Diagnosis of Endocarditis
Falsely negative early in diseaseFalsely negative early in disease
False positive diagnosis with thickened valve False positive diagnosis with thickened valve leaflets, valve nodules or tumorsleaflets, valve nodules or tumors
Inability to distinguish healed from active Inability to distinguish healed from active vegetationsvegetations
Lower sensitivity in those with mechanical Lower sensitivity in those with mechanical prostheses prostheses
Blood cultures remain the test of choice for Blood cultures remain the test of choice for patients with suspected endocarditispatients with suspected endocarditis
Duke Criteria for Diagnosis of Duke Criteria for Diagnosis of EndocarditisEndocarditis
Duke Criteria for Diagnosis of Infective Duke Criteria for Diagnosis of Infective Endocarditis: Major CriteriaEndocarditis: Major Criteria
Positive blood culture for typical organism (from 2 separate Positive blood culture for typical organism (from 2 separate culturescultures or Staphylococcus aureus or Staphylococcus aureus or enterococcal or enterococcal bacteremia without a primary focus) bacteremia without a primary focus) oror
Persistent bacteremia for any organism > 12 hrs apart Persistent bacteremia for any organism > 12 hrs apart oror
All of 3 or majority of 4 BC positive drawn > 1 hr apartAll of 3 or majority of 4 BC positive drawn > 1 hr apart
Microbiologic evidence: positive BC not meeting major Microbiologic evidence: positive BC not meeting major criteria criteria oror serology indicating active infection with consistent serology indicating active infection with consistent organismorganism
Duke Criteria for Diagnosis of Duke Criteria for Diagnosis of Infective EndocarditisInfective Endocarditis
Organisms by culture Organisms by culture oror histology in vegetation, histology in vegetation, embolus, or cardiac abscess embolus, or cardiac abscess oror
Pathologic lesion such as vegetation or cardiac Pathologic lesion such as vegetation or cardiac abscessabscess
Clinical criteriaClinical criteria
2 major, or 1 major plus 3 minor, 2 major, or 1 major plus 3 minor, oror 5 minor 5 minor criteria criteria
Right Sided Endocarditis in Injection Right Sided Endocarditis in Injection Drug UsersDrug Users
Right-sided Endocarditis in Injection Right-sided Endocarditis in Injection Drug UsersDrug Users
46 y/o man injection drug user (heroin)with fevers, sweats and right sided pleuriticchest pain. Blood cultures grew penicillin-susceptible S. aureus and echocardiogram showed 1 mm Tricuspid valve vegetation.HIV negative and in hospital for 7 days with oxacillin and gentamicin followed by21 days of outpatient ceftriaxone (2 gms/day).
Multiple peripheral septic emboli with cavitation
Right-Sided Endocarditis in Right-Sided Endocarditis in Injection Drug UsersInjection Drug Users
Common complication with overall favorable Common complication with overall favorable prognosisprognosis
Vegetations > 2 cm associated with higher Vegetations > 2 cm associated with higher mortality (33% vs 1.3%)mortality (33% vs 1.3%)
S. aureus most common pathogen (>80%) than S. aureus most common pathogen (>80%) than Viridans streptococciViridans streptococci
>50% with septic emboli on chest radiographs>50% with septic emboli on chest radiographs
Hecht SR and Berger M Ann Int Med 1992;117:560
Right Sided Endocarditis in Right Sided Endocarditis in Injection Drug Users: TreatmentInjection Drug Users: Treatment
Two week regimen (nafcillin or oxacillin + Two week regimen (nafcillin or oxacillin + gentamicin) for susceptible isolatesgentamicin) for susceptible isolates
Oral therapies still controversialOral therapies still controversial
Exclusion to “short-course” protocol:Exclusion to “short-course” protocol:
Extracardiac complications of IEExtracardiac complications of IE
Fever for > 7 daysFever for > 7 days
HIV infectionHIV infection
Vegetation > 1-2 cmVegetation > 1-2 cm
Chambers HF Ann Intern Med 1988;109:619
AHA Guidelines for Treatment of AHA Guidelines for Treatment of EndocarditisEndocarditis
Aortic Versus Mitral Valve Aortic Versus Mitral Valve EndocarditisEndocarditis
AorticAortic ~55% ~55% ~75% ~75%
MitralMitral ~85%~85% ~40%~40%
PulmonaryPulmonary ~1%~1%
TricuspidTricuspid ~20%~20%
Acute aortic regurgitation is poorly tolerated because the LV is Acute aortic regurgitation is poorly tolerated because the LV is less compliant than the LA resulting higher LV wall stress! less compliant than the LA resulting higher LV wall stress! Watch out for abrupt deterioration!Watch out for abrupt deterioration!
Overall Overall incidenceincidence
Surgical Surgical PatientsPatients
AHA Guidelines for Antibiotic Therapy in AHA Guidelines for Antibiotic Therapy in Native Valve EndocarditisNative Valve Endocarditis
OrganismOrganism RegimenRegimen WeeksWeeks
PCN-sensitive PCN-sensitive PCN G 12-18 MI qd PCN G 12-18 MI qd oror 44 Ceftriaxone 2 Ceftriaxone 2 g qd g qd or or 44 Ceftriaxone 2 g qd + Ceftriaxone 2 g qd +
22 Gentamicin 3 Gentamicin 3 mg/kg qd mg/kg qd or or Vancomycin 1 g bidVancomycin 1 g bid 44
PCN-insensitivePCN-insensitive PCN G 18 MI qd + PCN G 18 MI qd + 44 Gentamicin 1 Gentamicin 1 mg/kg tid mg/kg tid 22 or or Vancomycin 1 g Vancomycin 1 g bidbid 44
Doses assume normal renal functionDoses assume normal renal function
AHA Guidelines for Antibiotic Therapy in AHA Guidelines for Antibiotic Therapy in Native Valve EndocarditisNative Valve Endocarditis
OrganismOrganism RegimenRegimen WeeksWeeks
MSSAMSSA Oxacillin or Nafcillin 2 g q4hOxacillin or Nafcillin 2 g q4h 4-6 4-6 or or Cefazolin 2 g tidCefazolin 2 g tid4-6 4-6
both +/- Gentamicin 1 mg/kg tid 3-5dboth +/- Gentamicin 1 mg/kg tid 3-5d
or or Vancomycin 1 g bid +/- GentVancomycin 1 g bid +/- Gent
MRSAMRSA Vancomycin 1 g bidVancomycin 1 g bid 4-6 4-6 +/- +/- Gentamicin 1 mg/kg tidGentamicin 1 mg/kg tid 4-64-6 Doses assume normal Doses assume normal
renal functionrenal function
AHA Guidelines for Antibiotic Therapy in AHA Guidelines for Antibiotic Therapy in Native Valve EndocarditisNative Valve Endocarditis
Steel: Often the Best Antimicrobial Steel: Often the Best Antimicrobial Agent In Treating Infective EndocarditisAgent In Treating Infective Endocarditis
Medical versus Surgical therapyMedical versus Surgical therapy
Surgery is always in addition to medical Surgery is always in addition to medical therapytherapy
The vast majority of the operated patients The vast majority of the operated patients would die if not operatedwould die if not operated
Some medically treated patients are Some medically treated patients are “inoperable“inoperable” ”
Surgical Indications in EndocarditisSurgical Indications in Endocarditis
Valve perforation or Valve perforation or rupturerupture
Periannular Periannular extension of infectionextension of infection
AHA Committee on EndocarditisAHA Committee on Endocarditis
Homograft or Prosthetic Valve Homograft or Prosthetic Valve Replacement for Aortic Valve IEReplacement for Aortic Valve IE
There are no and probably will be no randomized studies!There are no and probably will be no randomized studies!
Good results are possible to obtain with eitherGood results are possible to obtain with either
However, an increasing number of publications favor However, an increasing number of publications favor homograftshomografts
Technically easier and saferTechnically easier and safer
Lower risk of heart blockLower risk of heart block Lower infection and re-infection rateLower infection and re-infection rate Homograft does not require anticoagulationHomograft does not require anticoagulation
Limited supply of homograftsLimited supply of homografts
Limited durability of homograftLimited durability of homograft
Timing of Timing of SurgerySurgery
30% require surgery in the acute phase30% require surgery in the acute phase
another 20-40% will require surgery lateranother 20-40% will require surgery later Main principle: Don’t postpone an indicated operation, however:Main principle: Don’t postpone an indicated operation, however:
Pts with strokes: Postpone surgery, if possible 1-3 weeks, Pts with strokes: Postpone surgery, if possible 1-3 weeks, particularly if evidence of hemorrhageparticularly if evidence of hemorrhage
If valve repair is planned: 1 week of preop antibiotic If valve repair is planned: 1 week of preop antibiotic treatmenttreatment
Re-infection rate is lower after surgery for healed Re-infection rate is lower after surgery for healed endocarditisendocarditis
Early Surgery Versus Conventional Treatment for IEEarly Surgery Versus Conventional Treatment for IEKaplan–Meier Curves for Cumulative Probabilities of Death Kaplan–Meier Curves for Cumulative Probabilities of Death
and Composite End Point at 6 Monthsand Composite End Point at 6 Months
Kang DH, et al: NEJM 2012; 366:2466
Early Surgery Versus Conventional Treatment for IEEarly Surgery Versus Conventional Treatment for IEClinical End PointsClinical End Points
Kang D et al. N Engl J Med 2012;366:2466-2473.
Kang DH, et al: NEJM 2012; 366:2466
Early Surgery Versus Conventional Treatment for Infective Endocarditis
Special Surgical Considerations Special Surgical Considerations Related to LocationRelated to Location
Aortic valve IE: Be aggressive!Aortic valve IE: Be aggressive!
Acute aortic regurgitation is poorly toleratedAcute aortic regurgitation is poorly tolerated
Mitral valve IE: Repair whenever possible, Mitral valve IE: Repair whenever possible, consider risk of embolismconsider risk of embolism
Right-sided IE: Be conservative!Right-sided IE: Be conservative!
Pulmonary valve IE is very uncommonPulmonary valve IE is very uncommon
Aortic Root Endocarditis With Aortic Root Endocarditis With Vegetation and Fistula to Right AtriumVegetation and Fistula to Right Atrium
The infection penetrates through to the floor of the The infection penetrates through to the floor of the Right atrium just about to destroy the A-V nodeRight atrium just about to destroy the A-V node
Endocarditis and Ventricular Endocarditis and Ventricular Assist DevicesAssist Devices
Patients with VADs are at high risk for nosocomial Patients with VADs are at high risk for nosocomial bloodstream infectionsbloodstream infections
Incidence of VAD associated IE may be as high as 13% Incidence of VAD associated IE may be as high as 13% (relapsing bacteremia/fungemia common)(relapsing bacteremia/fungemia common)
At least 24 cases in literature (33% Candida 20% At least 24 cases in literature (33% Candida 20% Enterococcus) with 50% associated mortalityEnterococcus) with 50% associated mortality
Difficult to visualize inflow and outflow conduits by Difficult to visualize inflow and outflow conduits by echocardiographyechocardiography
Treatment: tranplantation! Device exchange high rate of Treatment: tranplantation! Device exchange high rate of failure/deathfailure/death
Gordon and McCarthy in Advanced Therapy Cardiac Surgery 2002
>2 million people (including 1 million Americans) use >2 million people (including 1 million Americans) use pacemakers pacemakers
Infections uncommon but difficult to eradicate without Infections uncommon but difficult to eradicate without device removal (generator + leads via laser extraction device removal (generator + leads via laser extraction if possible)if possible)
Pacemaker endocarditis can be difficult diagnosis to Pacemaker endocarditis can be difficult diagnosis to make on clinical groundsmake on clinical grounds
TEE sensitive in finding suspicious lesions on TEE sensitive in finding suspicious lesions on pacemakerpacemaker
Prophylaxis to Prevent EndocarditisProphylaxis to Prevent Endocarditis
Endocarditis ProphylaxisEndocarditis Prophylaxis
Class I: No class I indications.Class I: No class I indications.
Class IIa: Reasonable for pts at highest risk for adverse outcomes from Class IIa: Reasonable for pts at highest risk for adverse outcomes from IE having dental procedures that involve manipulation of either gingival IE having dental procedures that involve manipulation of either gingival tissue or the periapical region of the teeth or perforation of the oral tissue or the periapical region of the teeth or perforation of the oral mucosamucosa
- Pts with prosthetic cardiac valves or prosthetic - Pts with prosthetic cardiac valves or prosthetic
material used for valve repairmaterial used for valve repair
- Pts with previous IE- Pts with previous IE
- Pts with CHD: unrepaired cianotic CHD including - Pts with CHD: unrepaired cianotic CHD including
paliative shunts and conduits paliative shunts and conduits
- Complete repaired CHD fixed with prosthetic material- Complete repaired CHD fixed with prosthetic material
or device, whether placed surgically or by catheteror device, whether placed surgically or by catheter
intervention, during first 6 months after procedureintervention, during first 6 months after procedure
- Repaired CHD with residual defects at the site or - Repaired CHD with residual defects at the site or
adjacent to the site of a prosthetic patch or deviceadjacent to the site of a prosthetic patch or device
- Cardiac transplant pts with valve regurgitation due- Cardiac transplant pts with valve regurgitation due
to structurally abnormal valveto structurally abnormal valve
Class III: Prophylaxis not recommended against nondental Class III: Prophylaxis not recommended against nondental procedures: TEE, EGD or colonoscopyprocedures: TEE, EGD or colonoscopy
ACC/AHA Guidelines for Prevention of ACC/AHA Guidelines for Prevention of Bacterial EndocarditisBacterial Endocarditis
Oral: Amoxicillin 2g 30-60 min before oral procedureOral: Amoxicillin 2g 30-60 min before oral procedure
Unable to take PO: Ampicillin 2g IM or IV, or cefazolin or Unable to take PO: Ampicillin 2g IM or IV, or cefazolin or
ceftriaxome IV 1g IM or IV 30-60 min before procedureceftriaxome IV 1g IM or IV 30-60 min before procedure
Allergic to PCN – oral: clindamycin 600mg,Allergic to PCN – oral: clindamycin 600mg,
azithromycin or clarithromycin 500mg 30-60 min beforeazithromycin or clarithromycin 500mg 30-60 min before
procedureprocedure
Allergic to PCN and unable to take PO: clindamycin 600mg Allergic to PCN and unable to take PO: clindamycin 600mg IM or IV or cefazolin or ceftriaxone 1g IM or IV (do not use if IM or IV or cefazolin or ceftriaxone 1g IM or IV (do not use if anaphylaxis, angioedema, urticaria with PCNanaphylaxis, angioedema, urticaria with PCN