Infectious Disease [INFECTIVE ENDOCARDITIS]

Pathogenesis
Infective Endocarditis (IE) is an infection on the heart valves. To
get infected there must be introduction of bacteria into the blood Major Criteria
stream AND a bad valve. Thus, some risk factors are intravenous Sustained Bacteremia by organism known to cause IE
drug use (most common in the US) or a patient with repeated (Strep, Staph, HACEK)
access (like dialysis). Others are valvular damage (rheumatic Endocardial Evidence by Echo
heart worldwide, congenital defects in the US) and a history of New valvular regurgitation
(increase or change of pre-existing not adequate)
endocarditis (100 fold increase in risk). Once the infection sets
Minor Criteria
up shop on the valve, embolic, vascular and rheumatologic
Predisposing Risk Factor (valve disease or IVDA)
manifestations are possible. Fever > 38 C
Vascular Phenomena
Presentation (septic emboli arterial, pulmonary, and Janeway lesions)
The Duke’s criteria (presented to the right) is a useful means of Immunologic Phenomena
building a table you can memorize. However, it was created for (glomerulonephritis, Osler nodes, Roth spots, RF)
study inclusion and isn’t a diagnostic tool. Instead, note there are
two types of endocarditis: Acute and Subacute. Definite
Two major criteria (Blood Culture and Echo)
Acute Endocarditis is going to be from virulent organisms One major and 3 minor
(Staph, Strep Pneumo) that will infect normal, native valves. 5 minor
Possible
These patients will be sick: persistent bacteremia, valve
1 major and 1 minor (almost every bacteremic patient, btw)
destruction, new murmur; we order a bunch of cultures to watch
3 minor
it clear (or not) and start antibiotics right away. Since the Rejected
presentation is obvious it doesn’t take long for the patient to seek Firm alternative diagnosis explaining evidence for IE
medical attention. Thus, there’s no time for the rheumatologic Resolution of everything in 4 days
manifestations to start. No pathologic evidence (a BIOPSY!?) at surgery or death
Failure to meet criteria as above
Subacute Endocarditis is caused by less virulent organisms (S.
bovis, S. viridans, HACEK) infecting abnormal native valves. It’s
the endocarditis people learn about in second year – Roth Spots
(eyes), Janeway lesions (painless hands), Splinter
Hemorrhages (nail beds), Osler nodes (painful distal digit pulp)
etc - subtle clues pointing to endocarditis because the patient isn’t
sick enough to warrant attention. This one requires multiple
cultures to make a diagnosis; antibiotics shouldn’t be started right
away.

Diagnosis
The echocardiogram and blood cultures are the cornerstone of
diagnosis. The TTE is often used first (usually to identify a
valvular abnormality rather than a vegetation) followed by a
Transesophageal Echocardiogram to make the final diagnosis
by identifying the vegetation. The TEE is the best test.

Acute endocarditis: hey, the bacteremia won’t clear. Keep

getting cultures until they do. OH NOES! A MURMUR!!! Get a
TEE.

Subacute endocarditis: my my, look at these interesting rashes. Diagnostic Steps

This one is painless on their hands, their nail beds have these Blood cultures x 3, one Subacute Endocarditis
small splinter like splotches, and their RF is up. I wonder if this hour apart, NO abx
is rheumatoid arthritis? Doesn’t sound like RA - get a culture… Blood cultures x 2 now, Acute Endocarditis
no… get THREE cultures… and wait. AHA! BACTEREMIA! start empiric abx, follow-
GET A TEE!!!!!! up cultures
Trans Thoracic Echo If you aren’t sure
Trans Esophageal Echo If you are sure

© OnlineMedEd. http://www.onlinemeded.org
 Infectious Disease [INFECTIVE ENDOCARDITIS]

Treatment Antibiotics
There are two elements to the treatment of Endocarditis: Native Valve
antibiotics and surgery. All Vancomycin Gentamycin
Native
Antibiotics will be required for a minimum of 6 weeks. Which Prosthetic Valve
antibiotic is chosen will be dependent on the culture and <60 Days Vancomycin Gentamycin Cefepime
sensitivity of the organism. But when treatment is begun we must 60-365 Vancomycin Gentamycin
use empiric coverage. That changes not on the endocarditis, but days
on the patient. See to the right. >365 Vancomycin Gentamycin Ceftriaxone
days
Surgery is designed to prevent CHF and embolization. Acute
endocarditis can cause valvular insufficiency. The worse the SBE Vancomycin Gentamycin Ceftriaxone
valve or the worse the CHF the sooner the surgery (someone in
cardiogenic shock goes right away while someone who is See the “vanc+gent” backbone. Just remember which ones
compensated but has severe insufficiency can wait a few days). gets Cefepime, Which one gets Ceftriaxone, and then Native
This is a clinical judgment: how sick the patient is. valves need only Vanc

But embolization isn’t clinical. There are fairly well described Vancomycin à Daptomycin à Linezolid
criteria for who goes to surgery for a vegetation that could (not for bacteremia)
embolize. Note that a stroke or MI would be a contraindication to
any surgery EXCEPT for IE, since failing to go to surgery will
result in further embolization. See to the right. Surgery
Go to surgery if
Prophylaxis >15mm even without embolization
There’s a long list of people that need to be prophylaxed against >10 mm + embolization
IE. But if you instead remember, “bad valve” and “mouth and Abscess
throat” you’ll get it right most of the time. Valve destruction or CHF
Fungus
Bad Valve means they have a congenital heart defect, previous
endocarditis, or a prosthetic valve.

Mouth and throat means they’re having a dental procedure or a

procedure that would involve bronchoscopy and biopsy of the
respiratory flora. Bad Valve Mouth and Throat
Congenital Heart Disease Dental Procedures
If both are seen, give amoxicillin. If they can’t tolerate a Prosthetic Valve Biopsy of the Airway
penicillin, use ceftaz. If that doesn’t work go to clinda, but you History of Endocarditis
won’t be drilling down to this level of detail as a medical student.

Unique Associations for Bonus Points

Strep bovis comes from the colon. If Strep bovi endocarditis, do
↓
colonoscopy for occult cancer.
Antibiotics
Staph aureus comes from the skin. IVDA and tricuspid valve Amoxicillin (1st line)
most often. Ceftaz (back up)
Clinda (last line)
Strep Anything Else comes from the mouth. Look for dental
disease.

© OnlineMedEd. http://www.onlinemeded.org