Infective Endocarditis Overview

Contents

Overview
Criteria for High Clinical Suspicion of IE
General Therapeutic Principles of Empiric Pharmacological Therapy
General Therapeutic Principles of Pathogen-specific Pharmacological Therapy
Principles of Surgical Treatment
Follow-Up
Diagnosis
Empiric Pharmacological Therapy
Pathogen-specific Pharmacological Therapy
Surgery
Guideline References

Overview

Infective Endocarditis (IE): An infection of the endocardial surface of the heart including infections of the large thoracic vessels & intracardiac foreign bodies characterized by the presence of vegetation which is a nidus for microorganism invasion
Native Valve Endocarditis (NVE): An endovascular microbial infection of native heart valves that may be local (cardiac) including valvular & perivalvular destruction or distal (noncardiac) due to detachment of septic vegetations w/ embolism, metastatic infection & septicemia. May also be broken down as acute & subacute; the only difference is that subacute endocarditis has a more indolent course than the acute form
Prosthetic Valve Endocarditis (PVE): An endovascular microbial infection of prosthetic heart valves (intracardiac foreign body) & may be classified as an infection likely to have been acquired perioperatively & thus being nosocomial (early PVE) or likely to have been community-acquired (late PVE). Early PVE occurs w/in 60 days of valve implantation & late PVE occurs ≥60 days after valve implantation

Characteristics of IE
  • IE often presents in an occult fashion & early diagnosis depends on a high index of clinical suspicion esp in patients w/ congenital heart disease, prosthetic valves or previous IE
  • The established diagnosis of IE is demonstrated by a positive blood culture & involvement of the endocardium detected during sepsis or systemic infection
    • IE may also be established if there is involvement of the endocardium detected during sepsis or systemic infection but blood culture (BC) is negative

Top


Criteria For High Clinical Suspicion of IE

  • Embolic event(s) of unknown origin
  • Fever, plus:
    • Positive blood culture (organism identified is typical for NVE/PVE)
    • Previous history of IE, valvular or congenital heart disease
    • Evidence of CHF or pulmonary embolism
    • Focal or nonspecific neurological signs & symptoms
    • Cutaneous (Osler, Janeway) or ophthalmic (Roth) manifestations
    • Newly developed ventricular arrhythmias or conduction disturbances
    • Peripheral abscesses (renal, splenic, spine) of unknown origin
    • Predisposition & recent diagnostic/therapeutic interventions known to result in significant bacteremia
    • Prosthetic material inside the heart
    • Pulmonic infiltrations that are multifocal/rapid changing (right IE)
  • Hematuria, glomerulonephritis & suspected renal infarction
  • New valve lesion/regurgitant murmur
  • Sepsis of unknown origin
Cardiac Risk Factors for IE

High Risk Factors
  • Aortic regurgitation
  • Aortic stenosis
  • Coarctation of aorta
  • Cyanotic congenital heart disease
  • Mitral regurgitation
  • Mitral stenosis w/ regurgitation
  • Patent ductus arteriosus
  • Previous IE
  • Prosthetic heart valves
  • Surgically repaired intracardiac lesion w/ residual hemodynamic abnormality
  • Ventricular septal defect
Intermediate Risk Factors
  • Asymmetrical septal hypertrophy
  • Bicuspid aortic valve disease
  • Calcific aortic sclerosis w/ minimal hemodynamic abnormality
  • Degenerative valve diseases in elderly patients
  • Mitral valve prolapse
  • Pulmonary stenosis
  • Pure mitral stenosis
  • Surgically repaired intracardiac lesion w/ minimal hemodynamic abnormality <6 mth after surgery
  • Tricuspid valve disease
Non-Cardiac Risk Factors Predisposing Patient to IE
  • Older age
  • Nonbacterial thrombotic vegetation (NBTV): Microorganisms may adhere more easily in the presence of fresh platelet thrombi associated w/ leukemia, cirrhosis of the liver, carcinomas which may cause hypercoagulability (marantic endocarditis), inflammatory bowel disease, SLE & steroid medication
  • Compromised host defense typical in steroid medication & possibly in chronic alcoholism
  • IVDA risk of IE is 12-fold higher than non-IVDAs
  • Compromised local non-immune defense mechanism
    • Found in increased transmucosal permeability in mucous membrane lesions eg chronic inflammatory bowel disease
    • Reduced capillary clearance in arteriovenous fistulas of patients on chronic hemodialysis
  • Increased risk or an increased frequency for bacteremia
    • Patients w/ broken skin (eg DM, burns), on intensive care (eg lines, respirators), w/ polytrauma, w/ poor dental status or on hemodialysis
    • Previous exposure to endocarditis-causing microorganisms

Below is the overview of disease management of Infective Endocarditis:

overview of disease management of Infective Endocarditis 1

Top


General Therapeutic Principles of Empiric Pharmacological Therapy

  • Counting days of duration of therapy should start on the 1st day on which BCs were negative in cases in which initial BCs were positive
  • At least 2 sets of BCs should be obtained every 24-48 hr until bloodstream infection is cleared
  • For patients w/ NVE who undergo valve resection w/ prosthetic valve replacement, the post-op treatment should be the one recommended for NVE, not for PVE
    • If the resected tissue is culture positive, then the entire course of therapy is recommended after valve resection
    • If the resected tissue is culture negative, then treatment should be given less the number of days of treatment administered for NVE before valve replacement
  • If combination antimicrobial therapy is used, then the agents should be administered close together to improve synergistic killing effect
  • Antibiotic prophylaxis has been limited to patients undergoing an invasive dental procedure in whom exists a history of IE, prosthetic valve, a heart transplant w/ abnormal heart valve function, or congenital heart disease w/ the following: Unrepaired cyanotic congenital heart disease, congenital heart defect completely repaired w/ prosthetic material or device for the 1st 6 mth post procedure, or repaired congenital heart disease w/ residual defects
    • Patients w/ prosthetic valves are at the highest risk of developing IE
    • Recommended regimens include the standard Amoxicillin, Ampicillin if unable to take PO meds, & Clindamycin (PO or IV), Clarithromycin, Cefazolin or Cefalexin if w/ penicillin allergy

Top


General Therapeutic Principles of Pathogen-Specific Pharmacological Therapy

  • Counting days of duration of therapy should start on the 1st day on which BCs become negative in cases in which initial BCs were positive
  • At least 2 sets of BCs should be obtained every 24-48 hr until blood stream infection is cleared
  • For patients w/ NVE who undergo valve resection w/ prosthetic valve replacement, the post-op treatment should be the one recommended for NVE, not for PVE
    • If the resected tissue is culture positive, then the entire course of therapy is recommended after valve resection
    • If the resected tissue is culture negative, then treatment should be given less the number of days of treatment administered for NVE before valve replacement
  • If combination antimicrobial therapy is used, then the agents should be administered close together to improve synergistic killing effect
The therapeutic goal is to produce bactericidal levels of drugs at the infected site for a max period of time

Top


    Principles of Surgical Treatment

    • Combined medical & surgical therapy for IE can decrease mortality among patients who have CHF, perivalvular invasive disease, or uncontrolled infection despite maximal antimicrobial therapy
    • The decision to perform surgery & its timing is dependent upon the cardiac & systemic complications caused by the infection, the microorganism’s virulence & the response to antimicrobial therapy
      • The optimal time to perform surgery is before severe hemodynamic disability or spread of the infection to perivalvular tissue occurs
    • CHF is the strongest indication for surgery in IE

    Below is the overview of treatment of Infective Endocarditis:

    overview of treatment of Infective Endocarditis 2

     Top


    overview of treatment of Infective Endocarditis 3

      Top


    overview of treatment of Infective Endocarditis 4

     Top


    Follow-Up

    • Daily exam including temp & periodic blood tests to monitor for signs of infection
      • Temp should normalize w/in 5-10 days w/ uncomplicated IE
    • Continue to monitor for cardiac murmurs, BP, signs of HF & embolism in the CNS, lungs, spleen & skin
    • Secondary infections in joint & spine may occur
    • C-reactive protein (CRP) decreases rapidly during 1st or 2nd wk of therapy but may stay slightly elevated for 4-6 wk or longer
      • Persistently high CRP typically means an inadequately controlled infection
    • Normalization of WBC should also occur w/in 1-2 wk
      • Persistently elevated WBC indicates active infection
    • Monitor renal function
    • Good oral & overall hygiene are recommended for risk reduction

    Top

    Infective Endocarditis Symptoms▶

    Version: 07 Apr 2015

    Guideline References:

    1. Baddour LM, Wilson WR, Bayer AS, et al. 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. 2005 Jun;111(23):e394-e434. http://www.ncbi.nlm.nih.gov/pubmed/?term=15956145. PMID: 15956145
    2. Bayer AS, Bolger AF, Taubert KA, et al. Diagnosis and management of infective endocarditis and its complications. Circulation. 1998 Dec;98(25):2936-2948. http://www.ncbi.nlm.nih.gov/pubmed/?term=9860802. PMID: 9860802
    3. Bernstein D. Infective endocarditis. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson textbook of Pediatrics. 18th. Philadelphia: Saunders, Elsevier; 2007
    4. Brouqui P, Raoult D. Endocarditis due to rare and fastidious bacteria. Clin Microbiol Rev. 2001 Jan;14(1):177-207. PMID: 11148009
    5. Brown PD, Levine DP. Infective endocarditis in the injection drug user. Infect Dis Clin North Am. 2002 Sep;14(3):645-665, viii-ix. PMID: 12371120
    6. Brusch JL. Infective endocarditis. eMedicine. http://www.emedicine.com/MED/topic 671.htm. Accessed 01 Dec 2007.
    7. Cardiovascular infections. In: Park MK. Pediatric cardiology for practitioners. 5th. Philadelphia: Mosby, Elsevier; 2008
    8. Crawford MH, Durack DT. Clinical presentation of infective endocarditis. Cardiol Clin. 2003 May;21(2):159-166. PMID: 12874890
    9. Cunha BA, Gill MV, Lazar JM. Acute infective endocarditis. Diagnostic and therapeutic approach. Infect Dis Clin North Am. 1996 Dec;10(4):811-834. http://www.ncbi.nlm.nih.gov/pubmed/?term=8958170. PMID: 8958170
    10. Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service. Am J Med. 1994 Mar;96(3):200-209. http://www.ncbi.nlm.nih.gov/pubmed/?term=8154507. PMID: 8154507
    11. Endocarditis. Lexi-Comp, Inc. http://www.lexi.com/web/news.jsp?id=100025.Ferrieri
    12. Ferrieri P, Gewitz MH, Gerber MA, et al. Unique features of infective endocarditis in childhood. Circulation. 2002 Apr;105(17):2115-2126. PMID: 11980694
    13. Giessel BE, Koenig CJ, Blake RL Jr. Management of bacterial endocarditis. Am Fam Physician. 2000 Mar;61(6):1725-1732,1739. PMID: 10750879
    14. Gilbert DN, Moellering RC, Eliopoulos GM, et al, eds. The Sanford guide to antimicrobial therapy. 35th ed. Hyde Park (VT): Antimicrobial Therapy Inc; 2005
    15. Gilbert DN, Moellering RC, Eliopoulos GM, et al. The Sanford guide to antimicrobial therapy. 40th ed. Sperryville, VA: Antimicrobial Therapy Inc; 2010
    16. Habib G, Hoen B, Tornos P, et al; ESC Committee for Practice Guidelines. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the International Society of Chemotherapy (ISC) for Infection and Cancer. Aug 27, 2009. Eur Heart J. 2009 Oct;30(19):2369-2413. http://www.ncbi.nlm.nih.gov/pubmed/?term=19713420. PMID: 19713420
    17. Harris GD, Steimle J. Compiling the identifying features of bacterial endocarditis. Vague clues may point to this dangerous infection. Postgrad Med. 2000 Jan;107(1):75-83. http://www.ncbi.nlm.nih.gov/pubmed/?term=10649666. PMID: 10649666
    18. Hoen B, Duval X. Clinical practice. Infective Endocarditis. N Engl J Med. 2013 Apr 11;368(15):1425-1433. doi: 10.1056/NEJMcp1206782. Accessed 08 Nov 2013. PMID: 23574121
    19. Horstkotte D, Follath F, Gutschik E, et al;Task Force Members on Infective Endocarditis of the European Society of Cardiology; ESC Committee for Practice Guidelines (CPG). Guidelines on prevention, diagnosis and treatment of infective endocarditis executive summary; the task force on infective endocarditis of the European Society of Cardiology. Eur Heart J. 2004 Feb;25(3):267-276. http://www.ncbi.nlm.nih.gov/pubmed/?term=14972429. PMID: 14972429
    20. Infective endocarditis. Merck Manual. http://www.merck.com/mrkshared/mmanual/section16/chapter208/208a.jsp.Jassal
    21. Jassal DS, Embil M. CME workshop - infective endocarditis: prophylaxis, diagnosis and management. Can J CME. 2002 Feb;14:33-48. http://www.stacommunications.com/journals/cme/2002/02-Feb/cmefeb02Workshop.pdf
    22. Keys TF. The Cleveland Clinic Disease Management Project: infective endocarditis. http://clinicmeded.com/diseasemanagement/infectiousdisease/infectendo/infectendo.htm. Jun 2003
    23. Keys TF. The Cleveland Clinic Disease Management Project: infective endocarditis. http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/infectious-disease/infective-endocarditis/. Aug 2010
    24. Lawrence L. Pelletier, Jr. Infective endocarditis. http://www.merckmanuals.com/professional/cardiovascular_disorders/endocarditis/infective_endocarditis.html. Feb 2012
    25. McFarland S. Rheumatology. In: Robertson J, Shilkofski N, eds. The Harriet Lane handbook: a manual for pediatric house officers. 17th. Philadelphia: Mosby, Elsevier; 2005
    26. Li JS, Sexton DJ, Mick N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis. 2000 Apr;30(4):633-638. PMID: 10770721
    27. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011 Feb 1;52(3):e18-55. doi: 10.1093/cid/ciq146. Accessed 02 Dec 2013. PMID: 21208910
    28. Malaysian Society of Infectious Diseases and Chemotherapy, Academy of Medicine of Malaysia, Ministry of Health Malaysia. Consensus Guidelines on the Management of Staphylococcus Aureus Infections. http://www.acadmed.org.my/view_file.cfm?fileid=202. Mar 2000
    29. Marill, K. Endocarditis. eMedicine. http://www.emedicine.com/emerg/topic164.htm. 2004
    30. Martin RP. The recognition and treatment of infective endocarditis. Curr Paediatr. 2002 Jun;12(3):212-219
    31. Ministry of Health Malaysia. National antibiotic guideline 2014, 2nd edition. Pharmaceutical Services Divisions, Ministry of Health Malaysia. http://www.pharmacy.gov.my/v2/en/documents/national-antibiotic-guideline-nag-2nd-edition.html. Dec 2014.
    32. Mylonakis E, Calderwood SB. Infective endocarditis in adults. N Engl J Med. 2001 Nov;345(18):1318-1330. PMID: 11794152
    33. Nishimura RA, Carabello BA, Faxon DP, et al. ACC/AHA 2008 guideline update on valvular heart disease: focused update on infective endocarditis: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Jul 28, 2008. Circulation. 2008 Aug;118(8):887-896. http://www.ncbi.nlm.nih.gov/pubmed/18663090. PMID: 18663090
    34. Nishimura RA, Otto CM, Bonow RO, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2014 AHA/ACC guideline 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. J Am Coll Cardiol. 2014 Jun 10;63(22):e57-185. doi: 10.1016/j.jacc.2014.02.536. Accessed 06 Apr 2015. PMID: 24603191
    35. Peńa AC, Tria R, Chua JA. Infective endocarditis at the Philippine Heart Center. Phil J Microbiol Infect Dis. 1995;24(2):37-42
    36. Pierce D, Calkins BC, Thornton K. Infectious endocarditis: diagnosis and treatment. Am Fam Physician. 2012 May 15;85(10):981-986. http://www.aafp.org/afp/2012/0515/p981.pdf. Accessed 07 Apr 2015. PMID: 22612050
    37. Porter RS. The Merck manual of diagnosis and therapy. Whitehouse Station: Merck & Co., Inc; 2008. http://www.merck.com/mmpe/sec07/ch077/ch077b.html#sec07-ch077-ch077a-1418
    38. Prendergast BD. Diagnosis of infective endocarditis. BMJ. 2002 Oct;325(7369):845-846. PMID: 12386011
    39. Sachdev M, Peterson GE, Jollis JG. Imaging techniques for diagnosis of infective endocarditis. Infect Dis Clin North Am. 2002 Jun;16(2):ix,319-337. PMID: 12092475
    40. Wilson WR, Karchmer AW, Dajani AS, et al. Antibiotic treatment of adults with endocarditis due to streptococci, enterococci, staphylococci and HACEK microorganisms. JAMA. 1995 Dec;274(21):1706-1713. PMID: 7474277
    41. Working Party of the British Society for Antimicrobial Chemotherapy. Antibiotic treatment of streptococcal, enterococcal, and staphylococcal endocarditis. Heart. 1998 Feb;79(2):207-210. PMID: 9538323