Infective Endocarditis

Infective Endocarditis

Empiric –(waiting for sensitivity)–> Specific

· Best 1˚: Vanco + Gentamicin

· If pt doesnt respond? add aminoglycosides

· If pt has prosthetic valve and staph? add rifampin

When Is Surgery the Answer?

· CHF or ruptured valve or chordae tendineae

· Prosthetic valves

· Fungal endocarditis

· Abscess – AV block

👾	Tx
Viridans	Ceftriaxone for 4 weeks
S.aureus (MSSA)	Oxacillin, nafcillin, or cefazolin
Fungal	Amphotericin and valve replacement
S.epidermidis/MRSA	Vancomycin
Enterococci	Ampicillin and gentamicin
HACEK	Ampicillin-Sulbactam

PPx

Who need PPx?

1. Significant cardiac defect: Prosthetic valve / Previous endocarditis / Unrepaired cyanotic heart disease

2. Risk of bacteremia: Dental work with blood / Respiratory tract surgery that produces bacteremia

What to give them? Amoxicillin prior to the procedure. (If allergic: clindamycin, azithromycin)

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Procedures that do not need prophylaxis are: ✳️

· Flexible endoscopies, even with biopsy

· Obstetrical and gynecologic procedures

· Urology procedures (including prostate biopsy)

· GI procedures including ERCP

· Valvular heart disease including MVP, even with a murmur ·

· MR/MS, AR/AS, HOCM, ASD

Vascular & immunologic features of infective endocarditis
Vascular phenomena	· Systemic emboli (cerebral, pulmonary, or splenic infarcts) · Mycotic aneurysm · Janeway lesions – Macular, erythematous, nontender lesions on the palms & soles
Immunologic phenomena	· Osler nodes – Tender, violaceous nodules seen on the fingertips & toes · Roth spots – Edematous & hemorrhagic lacerations of the retina

Bacteria in infective endocarditis
S.Aureus	Prosthetic valves IV catheters Pacemaker/defibrillator IVDU
S.Viridans	Gingival manipulation
S. epidermidis	Prosthetic valves IV line
Enterococci	Nosocomial UTI
Streptococcus gallolyticus (S bovis)	Colon carcinoma IBD
Fungi – Candida	Immunocompromised IV catheters Prolonged Abx use

Infective endocarditis in IV drug users

· HIV infection increases IE risk in intravenous drug users

· Staphylococcus aureus the most common organism

· Tricuspid valve involvement (right-sided) more common than aortic valve

· Holosystolic murmur increases with inspiration indicating tricuspid involvement

· Septic pulmonary emboli common

· Fewer peripheral IE manifestations (eg, splinter hemorrhages, Janeway lesions)

· Heart failure more common in aortic valve involvement but rare with tricuspid valve disease

IE- Modified Duke criteria
Dx	Major criteria • Culture +ve for typical organism (S.aureus, Enterococcus, viridans) • Echocardiogram showing valvular vegetation
	Minor criteria • Predisposing cardiac lesion • IVID • FEVER >38 • Embolic phenomena • Immunologic phenomena (GN) • Culture +ve for atypical organisms
	Definite IE: 2 major OR (1 major + 3 minor)
	Possible IE: (I major + I minor) / (3 minor)

Infective Endocarditis Complications
Cardiac	• Valvular insufficiency – common cause of death • Perivalvular abscess • Conduction anomalies • Mycotic aneurysm
Neurologic	• Embolic stroke • Cerebral hemorrhage • Brain abscess • Acute encephalopathy or meningoencephalitis
Renal	• Renal infarction • Glomerulonephritis • Drug induced acute interstitial nephritis from therapy
MSK	• Vertebral osteomyelitis • Septic arthritis • MSK abscess

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