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Infective Endocarditis :
Approach and
Management
Chaired by: Dr. Ardaman Singh
Presented by: Dr. Amith Kumar S.
Case
 32 year old male, a k/c/o RHD, who has
undergone mitral valve repair, presented
to emergency department with complaints
of fever (101 f), with chills and
rigor, myalgia and shortness of breath.
 On examination patient was
normotensive with tachycardia and was
febrile. Systemic examination revealed
PSM with thrill in mitral area, and
splenomegaly. Head to foot examination
showed splinter hemorrhages in nails and
red tender lesion over pulp of left middle
Pathogenesis
◦ Endothelial injury
 High velocity jet striking endothelium
 Flow from a high pressure to a low pressure
chamber
 Flow across a narrow orifice at a high
velocity
◦ Hypercoagulable state
◦ Virulent organisms may seed the
injured site directly
◦ Bacteremia seeds the sterile NBTE
Vegetations - Hallmark of IE
“…variably sized
amorphous mass of
platelets and fibrin
with abundant
enmeshed
microorganisms and
moderate
inflammatory cells…”
Native Valve Endocarditis
Acute NVE Subacute NVE
Site Normal/
damaged valves
Damaged valves
Course of
disease
Days to weeks
(aggressive)
Weeks to months
(Indolent)
Microbiology Staph. aureus
(MC)
Group B
streptococci
Viridans streptococci,
Enterococci,
Coagulase-negative
staphylococci,
Gram-negative
coccobacilli
Metastatic
infection
Often Rarely
Intravenous Drug Abusers
 Tricuspid valve (46 to 78%) MC involved
 Risk factor for recurrent NVE.
 Staph. aureus (>50% of IE occurring in IV
drug abusers overall)
 Streptococci, Enterococci, Pseudomona
s aeruginosa (Infection of right- and left-sided
heart valves)
 Fungi - left-sided heart valves
 Corynebacterium
species, Lactobacillus, Bacillus cereus
nonpathogenic Neisseria species
Prosthetic Valve Endocarditis
 Constitutes 10% to 30% of all cases of IE
in developed countries.
 Early
◦ Symptoms begin within 60 days of valve
surgery.
◦ Mostly due to complication of valve surgery.
◦ MC organism involved CoNS
 Late
◦ Onset thereafter
◦ Usually from later infection, most likely to be
community acquired
◦ MC organism Streptococci
Health Care – Associated
Endocarditis
 Includes..
◦ Nosocomial IE (54%)
◦ Arising in the community after a recent
hospitalization (44%)
◦ As a direct consequence of long-term
indwelling devices (such as central
venous lines and hemodialysis catheters).
Clinical Features
 Fever – almost universal
 Dyspnea, cough, and chest pain -
common with intravenous drug users.
 Cardiac murmurs
Classic peripheral
manifestations of IE
 Petechiae (most common)
found on the palpebral
conjunctiva, the buccal
and palatal
mucosa, and the
extremities.
 Splinter or subungual
hemorrhages are dark
red, linear, or
occasionally flame-
shaped streaks in the
proximal nailbed.
Classic peripheral manifestations
of IE – Contd…
 Osler nodes are small, tender
subcutaneous nodules in the pulp of the
digits, or occasionally more proximal, that
persist for hours to several days.
 Janeway lesions are small
erythematous or hemorrhagic macular
nontender lesions on the palms and soles
and are the consequence of septic embolic
events.
Infective endocarditis
 Embolic
infarcts in the
digits (common
in left-sided S.
aureus IE.)
 Roth
spots, oval
retinal
hemorrhages
with pale
centers.
 Splenic abscess (3 to
5 %) – indicated by
persistent fever and
progressive
enlargement of lesion
during therapy
 Mycotic aneurysm (2
to 10%) – located
mostly in the territory
of MCA. Anticoagtn
therapy should be
avoided in those with
persistent mycotic
aneurysm
 Musculoskeletal symptoms
◦ Arthralgias and myalgias
◦ Occasional true arthritis
 Renal insufficiency
◦ Immune complex–mediated
glomeruonephritis (occurs in less than
15%)
◦ Embolic renal infarcts
 Congestive Cardiac Failure
 Embolic Stroke
 Intracranial
hemorrhage
 Cerebritis with
microabscess
 Purulent meningitis
Systemic Embolism
Chest X ray PA view showing septic emboli in
left lung fields in a patient with infective
endocarditis involving right heart valves
Work Up
◦ Complete hemogram
◦ CRP/ ESR
◦ BLOOD CULTURE
◦ Renal function tests
◦ Culture form the sites of septic emboli
◦ Electrocardiogram
◦ Echocardiogram
◦ Multislice CT with contrast
◦ Chest xray
Obtaining Blood Culture
 Three separate sets of
blood cultures, each
from a separate
venipuncture, after
proper aseptic
precautions, obtained
during 24 hours, are
recommended to
evaluate patients with
suspected endocarditis.
 Each set should include
a bottle containing an
aerobic medium and
one containing
thioglycollate broth
(anaerobic medium); at
least 10 mL of blood
should be placed into
each bottle.
Echocardiography
Aims
 Determine the presence, location and
size of vegetations
 Assess the damage to the valve
apparatus and determine the
haemodynamic effects.
 The dimensions and function of the
ventricles.
 Identify any abscess formation
 Need for surgical intervention.
Above: TEE shows a large mitral
vegetation (broken arrow) and a
perforation of anterior mitral
leaflet (arrowhead). LA, left
atrium; LV, left ventricle; RV, right
ventricle.
Below: TTE shows a large mitra
vegetation
TTE vs TEE
TTE TEE
Resoulution Poor Better
Minimum size of
vegetation seen
> 2mm <2mm
Sensitivity NVE 45% - 65% 85% - 95%
PVE 42% - 60% 82% - 96%
Indications for TEE
•Prosthetic valve endocarditis
•Poor trans thoracic views
•Continuing sepsis in spite of adequate antibiotic therapy
•New PR prolongation
•No signs of endocarditis on trans thoracic
echocardiography, but high clinical suspicion.
Infective endocarditis
Making the Diagnosis
 Pelletier and Petersdorf criteria (1977)
 Von Reyn criteria (1981)
 Duke criteria (1994)
Modified Duke Criteria
Major Criteria
◦ Positive Blood Culture
 Typical organism for IE from two separate
cultures (viridans strep, Strep bovis, HACEK
group or Staph aureus or community acquired
enterococci in the absence of primary focus) OR
 Persistently positive blood culture –
recovery of microorganism consistent with IE from
- Blood culture (>2) drawn more than 12
hrs apart OR
- All of the three or a majority of four or
more separate blood culture , with the first and the
last drawn at least one hr apart
 Single positive blood culture for Coxiella burnetti
or anti phase IgG antibody titer > 1:800
Major Criteria Contd…
◦ Evidence of Endocardial
Involvement
 Positive Echocardiogram
 Oscillating intracardiac mass,
 On valve or supporting structures
 In the path of regurgitant jets
 Implanted material , in the absence of an
alternative anatomic explanation
OR
 Abscess
OR
 New partial dehiscence of prosthetic valve
OR
 New valvular regurgitation
Minor Criteria
 Predisposition – predisposing heart
condition or IV drug use
 Fever (>100.4 F)
 Vascular phenomena
◦ Major arterial emboli
◦ Septic pulmonary infarcts
◦ Mycotic aneurysm
◦ Intracranial hemorrhage
◦ Conjunctival hemorrhage
◦ Janeway lesions
Minor Criteria - Contd
 Immunologic Phenomena
◦ Glomerulonephritis
◦ Osler Nodes
◦ Roth Spots
◦ Rheumatoid factor
 Microbiological Evidence
◦ Positive blood culture, but not meeting the
major criterion OR
◦ Serological evidence of active infection
with organism consistent with IE
Definitive Infective
Endocarditis
 Pathologic Criteria
◦ Micro-organisms
 demonstrated by culture or histology in a
vegetation OR
 in a vegetation that has embolized OR
 In an intracardiac abscess
OR
◦ Pathologic Lesions
 Vegetations or intracardiac abscess present
confirmed by histology showing active
endocarditis
Definitive Infective Endocarditis –
contd..
 Clinical Criteria
◦ Two Major Criteria
OR
◦ One Major and Three Minor Criteria
OR
◦ Five Minor Criteria
Possible Infective
Endocarditis
 One major and one minor criteria
OR
 Three minor criteria
Rejected
 Firm alternative diagnosis for
manifestations of endocarditis
OR
 Sustained resolution of manifestations
of endocarditis, with antibiotic therapy
for 4 days or less
OR
 No pathologic evidence of IE at
surgery or autopsy after antibiotic
therapy for 4 days or less
Differential Diagnosis
 Atrial myxoma,
 Acute rheumatic fever,
 SLE or other collagen-vascular
disease,
 Marantic endocarditis,
 APLA syndrome,
 Carcinoid syndrome,
 Renal cell carcinoma
 TTP.
Treatment
Intiation
 In Acute IE and for those with
hemodynamic decompensation – Start
empirical therapy
 In hemodynamically stable patients -
delay of antibiotic therapy briefly
pending the results of the initial blood
cultures.
Empirical Treatment
Antimicrobial Therapy for
Specific Organisms
Antibiotic Dosage and Route[†] Duration
Aqueous
penicillin G
12-18 million units/24 hr IV either continuously or
every 4 hr in six equally divided doses
4 weeks
Or
Ceftriaxone 2 g once daily IV or IM 4 weeks
Aqueous
penicillin G
12-18 million units/24 hr IV either continuously or
every 4 hr in six equally divided doses
2 weeks
Or
Ceftriaxone 2 g once daily IV or IM 2 weeks
Plus
Gentamicin 3 mg/kg/day IM or IV as a single daily dose or divided
in equal doses every 8 hr
2 weeks
Vancomycin 30 mg/kg/24 hr IV in two equally divided doses, not to
exceed 2 g/24 hr unless serum levels are monitored
4 weeks
Treatment of Native Valve Endocarditis Caused by
Penicillin-Susceptible Viridans Streptococci and
Streptococcus gallolyticus (bovis)
Antibiotic Dosage and route[†] Duration
Aqueous
penicillin G
24 million units/24 hr IV either
continuously or every 4 hr in six equally
divided doses
4 weeks
or
Ceftriaxone 2 g once daily IV or IM 2 weeks
plus
Gentamicin 3 mg/kg/day IM or IV as a single daily
dose or divided in equal doses every 8 hr
2 weeks
Vancomycin 30 mg/kg/24 hr IV in two equally divided
doses, not to exceed 2 g/24 hr unless
serum levels are monitored
4 weeks
Treatment of Native Valve Endocarditis Caused by
Strains of Viridans Streptococci and Streptococcus
gallolyticus (bovis) Relatively Resistant to Penicillin G
Streptococcus Pyogenes, Streptococcus
Pneumoniae, and Group B, C, and G
Streptococci
 Refractory to antibiotic therapy or associated
with extensive valvular damage.
Dosage and Route Duration
Group A
streptococca
l
endocarditis
Penicillin G in a dose of 3 million
units intravenously every 4 hours
4 weeks
Gentamycin i/m First 2 weeks
Early cardiac Surgery
Dosage and Route
Pneumococci
(with or without
concomittant
meningitis)
Penicillin G 4 million units
intravenously every 4 hours
Ceftriaxone 2 g intravenously every
12 hours OR
Cefotaxime 4 g intravenously every 6
hours
In the absence of meningitis, these regimens are
effective for IE caused by pneumococci that are
relatively penicillin resistant
Antibiotic Dosage and route[†] Duration
Aqueous
penicillin G
18-30 million units/24 hr IV given
continuously or every 4 hr in six equally
divided doses
4-6 weeks
plus
Gentamicin 1 mg/kg IM or IV every 8 hr 4-6 weeks
Ampicillin 12 g/24 hr IV given continuously or every 4 hr
in six equally divided doses
4-6 weeks
plus
Gentamicin 1 mg/kg IM or IV every 8 hr 4-6 weeks
Vancomycin 30 mg/kg/24 hr IV in two equally divided
doses not to exceed 2 g/24 hr unless serum
levels are monitored
4-6 weeks
plus
Gentamicin 1 mg/kg IM or IV every 8 hr 4-6 weeks
Standard Therapy for Endocarditis
Caused by Enterococci*
Antibiotic Dosage and route* Duration
Methicillin-susceptible staphylococci†
Nafcillin or
oxacillin
2 g IV every 4 hr 4-6 weeks
or
Cefazolin 2 g IV every 8 hr 4-6 weeks
or
Vancomycin 15 to 20 mg/kg actual body
weight, IV every 8 to 12 hr
4-6 weeks
Methicillin-resistant staphylococci‡
Vancomycin[?] 15 to 20 mg/kg actual body
weight, IV every 8 to 12 hr
4-6 weeks
Treatment of Staphylococcal Endocarditis
in the Absence of Prosthetic Material
Antibiotic Dosage and route* Duration
Regimen for methicillin-resistant staphylococci†
Vancomycin 15 to 20 mg/kg actual body weight, IV every 8
to 12 hr
≥6 weeks
Plus
Rifampin 300 mg PO every 8 hr ≥6 weeks
And
Gentamicin 1.0 mg/kg IM or IV every 8 hr 2 weeks
Regimen for methicillin-susceptible staphylococci
Nafcillin or
oxacillin
2 g IV every 4 hr ≥6 weeks
Plus
Rifampin 300 mg PO every 8 hr ≥6 6weeks
And
Gentamicin 1.0 mg/kg IM or IV every 8 hr 2 weeks
Treatment of Staphylococcal Endocarditis in the Presence of a
Prosthetic Valve or Other Prosthetic Material
Antibiotic Dosage and route[†] Duration
Ceftriaxone 2 g once daily IV or IM 4 weeks
or
Ampicillin-
sulbactam
12 g/24 hr IV given every
4 hr in six equally divided
doses
4 weeks
Treatment of Endocarditis Caused by
HACEK Microorganisms*
Organisms Drugs
Candida IE Amphotericin desoxycholate or liposomal amphotericin
formulation, at full doses, often combined with 5-
fluorocytosine. Surgical intervention shortly after
beginning of medical treatment is advised.
Sporadic
Candida PVE
and NVE
Caspofungin, with prolonged or indefinite oral azole therapy
has been advocated for patients treated either medically or
surgically.
Corynebacteria
(diphtheroids) IE
Penicillin combined with aminoglycosides OR
vancomycin
Corynebacterium
jeikeium IE
Often resistant to penicillin and aminoglycosides, is sensitive to
vancomycin.
Pseudomonas
aeruginosa IE
Tobramycin (8 mg/kg/day intravenously once daily plus
piperacillin, ceftazidime, or cefipime.
Coxiella burnetii
IE
Doxycycline (100 mg twice daily) combined with a quinolone
for at least 4 years. Treatment with doxycycline combined
with hydroxychloroquine for 18 to 48 months may be more
Culture-Negative Endocarditis
 Recommended therapy
Suspected IE Received confounding antibiotic
therapy
NVE Ampicillin-sulbactam plus
gentamicin (3 mg/kg/day) or
vancomycin plus gentamicin and
ciprofloxacin
PVE Vancomycin plus gentamicin,
cefepime, and rifampin.
Anticoagulant therapy in IE
 Patients with PVE involving devices that
necessitates maintenance
anticoagulation
 Anticoagulant therapy in patients with
NVE is limited to patients for whom
there is a clear indication and no
increased risk for intracranial
hemorrhage.
Monitoring Therapy
 ~70% of patients with NVE or PVE are
afebrile, by one week of therapy
 Blood cultures should be repeated
daily until sterile, and rechecked if
there is recrudescent fever and
performed again 4 – 6 weeks after
therapy.
Relapse and Recurrence
 Relapse of IE usually occurs within 2
months of discontinuation of
antibiotic treatment.
 IV drug abuse is now the most
common predisposing factor for
recurrent IE
Surgery in IE - Indications
 Congestive Heart Failure
 Unstable Prosthesis
 Uncontrolled infection or unavailable
effective therapy
 Staph aureus PVE
 Perivalvular invasive infection
 Left sided Staph aureus IE
 Unresponsive culture negative IE
 Large vegetations (>10mm)
Cardiac Conditions Associated with the Highest Risk of
Adverse Outcome from Endocarditis for Which
Prophylaxis with Dental Procedures Is Recommended
Regimens for Prophylaxis Against
Endocarditis: Use with Dental, Oral, and
Upper Respiratory Tract Procedures
Future Perspectives
 Staphylococcal vaccines
 Against Staph aureus surface carbohydrates
 poly-N-acetylglucosamine or poly-N-succinylglucosamine
(PNSG)
 Newer Antibiotics
◦ Linezolid,
◦ Quinupristin-dalfopristin,
◦ Daptomycin
Heal the world, make it a better place, for
you and for me and the entire human
race…..

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Infective endocarditis

  • 1. Infective Endocarditis : Approach and Management Chaired by: Dr. Ardaman Singh Presented by: Dr. Amith Kumar S.
  • 2. Case  32 year old male, a k/c/o RHD, who has undergone mitral valve repair, presented to emergency department with complaints of fever (101 f), with chills and rigor, myalgia and shortness of breath.  On examination patient was normotensive with tachycardia and was febrile. Systemic examination revealed PSM with thrill in mitral area, and splenomegaly. Head to foot examination showed splinter hemorrhages in nails and red tender lesion over pulp of left middle
  • 3. Pathogenesis ◦ Endothelial injury  High velocity jet striking endothelium  Flow from a high pressure to a low pressure chamber  Flow across a narrow orifice at a high velocity ◦ Hypercoagulable state ◦ Virulent organisms may seed the injured site directly ◦ Bacteremia seeds the sterile NBTE
  • 4. Vegetations - Hallmark of IE “…variably sized amorphous mass of platelets and fibrin with abundant enmeshed microorganisms and moderate inflammatory cells…”
  • 5. Native Valve Endocarditis Acute NVE Subacute NVE Site Normal/ damaged valves Damaged valves Course of disease Days to weeks (aggressive) Weeks to months (Indolent) Microbiology Staph. aureus (MC) Group B streptococci Viridans streptococci, Enterococci, Coagulase-negative staphylococci, Gram-negative coccobacilli Metastatic infection Often Rarely
  • 6. Intravenous Drug Abusers  Tricuspid valve (46 to 78%) MC involved  Risk factor for recurrent NVE.  Staph. aureus (>50% of IE occurring in IV drug abusers overall)  Streptococci, Enterococci, Pseudomona s aeruginosa (Infection of right- and left-sided heart valves)  Fungi - left-sided heart valves  Corynebacterium species, Lactobacillus, Bacillus cereus nonpathogenic Neisseria species
  • 7. Prosthetic Valve Endocarditis  Constitutes 10% to 30% of all cases of IE in developed countries.  Early ◦ Symptoms begin within 60 days of valve surgery. ◦ Mostly due to complication of valve surgery. ◦ MC organism involved CoNS  Late ◦ Onset thereafter ◦ Usually from later infection, most likely to be community acquired ◦ MC organism Streptococci
  • 8. Health Care – Associated Endocarditis  Includes.. ◦ Nosocomial IE (54%) ◦ Arising in the community after a recent hospitalization (44%) ◦ As a direct consequence of long-term indwelling devices (such as central venous lines and hemodialysis catheters).
  • 9. Clinical Features  Fever – almost universal  Dyspnea, cough, and chest pain - common with intravenous drug users.  Cardiac murmurs
  • 10. Classic peripheral manifestations of IE  Petechiae (most common) found on the palpebral conjunctiva, the buccal and palatal mucosa, and the extremities.  Splinter or subungual hemorrhages are dark red, linear, or occasionally flame- shaped streaks in the proximal nailbed.
  • 11. Classic peripheral manifestations of IE – Contd…  Osler nodes are small, tender subcutaneous nodules in the pulp of the digits, or occasionally more proximal, that persist for hours to several days.  Janeway lesions are small erythematous or hemorrhagic macular nontender lesions on the palms and soles and are the consequence of septic embolic events.
  • 13.  Embolic infarcts in the digits (common in left-sided S. aureus IE.)  Roth spots, oval retinal hemorrhages with pale centers.
  • 14.  Splenic abscess (3 to 5 %) – indicated by persistent fever and progressive enlargement of lesion during therapy  Mycotic aneurysm (2 to 10%) – located mostly in the territory of MCA. Anticoagtn therapy should be avoided in those with persistent mycotic aneurysm
  • 15.  Musculoskeletal symptoms ◦ Arthralgias and myalgias ◦ Occasional true arthritis  Renal insufficiency ◦ Immune complex–mediated glomeruonephritis (occurs in less than 15%) ◦ Embolic renal infarcts  Congestive Cardiac Failure
  • 16.  Embolic Stroke  Intracranial hemorrhage  Cerebritis with microabscess  Purulent meningitis Systemic Embolism
  • 17. Chest X ray PA view showing septic emboli in left lung fields in a patient with infective endocarditis involving right heart valves
  • 18. Work Up ◦ Complete hemogram ◦ CRP/ ESR ◦ BLOOD CULTURE ◦ Renal function tests ◦ Culture form the sites of septic emboli ◦ Electrocardiogram ◦ Echocardiogram ◦ Multislice CT with contrast ◦ Chest xray
  • 19. Obtaining Blood Culture  Three separate sets of blood cultures, each from a separate venipuncture, after proper aseptic precautions, obtained during 24 hours, are recommended to evaluate patients with suspected endocarditis.
  • 20.  Each set should include a bottle containing an aerobic medium and one containing thioglycollate broth (anaerobic medium); at least 10 mL of blood should be placed into each bottle.
  • 21. Echocardiography Aims  Determine the presence, location and size of vegetations  Assess the damage to the valve apparatus and determine the haemodynamic effects.  The dimensions and function of the ventricles.  Identify any abscess formation  Need for surgical intervention.
  • 22. Above: TEE shows a large mitral vegetation (broken arrow) and a perforation of anterior mitral leaflet (arrowhead). LA, left atrium; LV, left ventricle; RV, right ventricle. Below: TTE shows a large mitra vegetation
  • 23. TTE vs TEE TTE TEE Resoulution Poor Better Minimum size of vegetation seen > 2mm <2mm Sensitivity NVE 45% - 65% 85% - 95% PVE 42% - 60% 82% - 96% Indications for TEE •Prosthetic valve endocarditis •Poor trans thoracic views •Continuing sepsis in spite of adequate antibiotic therapy •New PR prolongation •No signs of endocarditis on trans thoracic echocardiography, but high clinical suspicion.
  • 25. Making the Diagnosis  Pelletier and Petersdorf criteria (1977)  Von Reyn criteria (1981)  Duke criteria (1994)
  • 27. Major Criteria ◦ Positive Blood Culture  Typical organism for IE from two separate cultures (viridans strep, Strep bovis, HACEK group or Staph aureus or community acquired enterococci in the absence of primary focus) OR  Persistently positive blood culture – recovery of microorganism consistent with IE from - Blood culture (>2) drawn more than 12 hrs apart OR - All of the three or a majority of four or more separate blood culture , with the first and the last drawn at least one hr apart  Single positive blood culture for Coxiella burnetti or anti phase IgG antibody titer > 1:800
  • 28. Major Criteria Contd… ◦ Evidence of Endocardial Involvement  Positive Echocardiogram  Oscillating intracardiac mass,  On valve or supporting structures  In the path of regurgitant jets  Implanted material , in the absence of an alternative anatomic explanation OR  Abscess OR  New partial dehiscence of prosthetic valve OR  New valvular regurgitation
  • 29. Minor Criteria  Predisposition – predisposing heart condition or IV drug use  Fever (>100.4 F)  Vascular phenomena ◦ Major arterial emboli ◦ Septic pulmonary infarcts ◦ Mycotic aneurysm ◦ Intracranial hemorrhage ◦ Conjunctival hemorrhage ◦ Janeway lesions
  • 30. Minor Criteria - Contd  Immunologic Phenomena ◦ Glomerulonephritis ◦ Osler Nodes ◦ Roth Spots ◦ Rheumatoid factor  Microbiological Evidence ◦ Positive blood culture, but not meeting the major criterion OR ◦ Serological evidence of active infection with organism consistent with IE
  • 31. Definitive Infective Endocarditis  Pathologic Criteria ◦ Micro-organisms  demonstrated by culture or histology in a vegetation OR  in a vegetation that has embolized OR  In an intracardiac abscess OR ◦ Pathologic Lesions  Vegetations or intracardiac abscess present confirmed by histology showing active endocarditis
  • 32. Definitive Infective Endocarditis – contd..  Clinical Criteria ◦ Two Major Criteria OR ◦ One Major and Three Minor Criteria OR ◦ Five Minor Criteria
  • 33. Possible Infective Endocarditis  One major and one minor criteria OR  Three minor criteria
  • 34. Rejected  Firm alternative diagnosis for manifestations of endocarditis OR  Sustained resolution of manifestations of endocarditis, with antibiotic therapy for 4 days or less OR  No pathologic evidence of IE at surgery or autopsy after antibiotic therapy for 4 days or less
  • 35. Differential Diagnosis  Atrial myxoma,  Acute rheumatic fever,  SLE or other collagen-vascular disease,  Marantic endocarditis,  APLA syndrome,  Carcinoid syndrome,  Renal cell carcinoma  TTP.
  • 36. Treatment Intiation  In Acute IE and for those with hemodynamic decompensation – Start empirical therapy  In hemodynamically stable patients - delay of antibiotic therapy briefly pending the results of the initial blood cultures.
  • 39. Antibiotic Dosage and Route[†] Duration Aqueous penicillin G 12-18 million units/24 hr IV either continuously or every 4 hr in six equally divided doses 4 weeks Or Ceftriaxone 2 g once daily IV or IM 4 weeks Aqueous penicillin G 12-18 million units/24 hr IV either continuously or every 4 hr in six equally divided doses 2 weeks Or Ceftriaxone 2 g once daily IV or IM 2 weeks Plus Gentamicin 3 mg/kg/day IM or IV as a single daily dose or divided in equal doses every 8 hr 2 weeks Vancomycin 30 mg/kg/24 hr IV in two equally divided doses, not to exceed 2 g/24 hr unless serum levels are monitored 4 weeks Treatment of Native Valve Endocarditis Caused by Penicillin-Susceptible Viridans Streptococci and Streptococcus gallolyticus (bovis)
  • 40. Antibiotic Dosage and route[†] Duration Aqueous penicillin G 24 million units/24 hr IV either continuously or every 4 hr in six equally divided doses 4 weeks or Ceftriaxone 2 g once daily IV or IM 2 weeks plus Gentamicin 3 mg/kg/day IM or IV as a single daily dose or divided in equal doses every 8 hr 2 weeks Vancomycin 30 mg/kg/24 hr IV in two equally divided doses, not to exceed 2 g/24 hr unless serum levels are monitored 4 weeks Treatment of Native Valve Endocarditis Caused by Strains of Viridans Streptococci and Streptococcus gallolyticus (bovis) Relatively Resistant to Penicillin G
  • 41. Streptococcus Pyogenes, Streptococcus Pneumoniae, and Group B, C, and G Streptococci  Refractory to antibiotic therapy or associated with extensive valvular damage. Dosage and Route Duration Group A streptococca l endocarditis Penicillin G in a dose of 3 million units intravenously every 4 hours 4 weeks Gentamycin i/m First 2 weeks Early cardiac Surgery
  • 42. Dosage and Route Pneumococci (with or without concomittant meningitis) Penicillin G 4 million units intravenously every 4 hours Ceftriaxone 2 g intravenously every 12 hours OR Cefotaxime 4 g intravenously every 6 hours In the absence of meningitis, these regimens are effective for IE caused by pneumococci that are relatively penicillin resistant
  • 43. Antibiotic Dosage and route[†] Duration Aqueous penicillin G 18-30 million units/24 hr IV given continuously or every 4 hr in six equally divided doses 4-6 weeks plus Gentamicin 1 mg/kg IM or IV every 8 hr 4-6 weeks Ampicillin 12 g/24 hr IV given continuously or every 4 hr in six equally divided doses 4-6 weeks plus Gentamicin 1 mg/kg IM or IV every 8 hr 4-6 weeks Vancomycin 30 mg/kg/24 hr IV in two equally divided doses not to exceed 2 g/24 hr unless serum levels are monitored 4-6 weeks plus Gentamicin 1 mg/kg IM or IV every 8 hr 4-6 weeks Standard Therapy for Endocarditis Caused by Enterococci*
  • 44. Antibiotic Dosage and route* Duration Methicillin-susceptible staphylococci† Nafcillin or oxacillin 2 g IV every 4 hr 4-6 weeks or Cefazolin 2 g IV every 8 hr 4-6 weeks or Vancomycin 15 to 20 mg/kg actual body weight, IV every 8 to 12 hr 4-6 weeks Methicillin-resistant staphylococci‡ Vancomycin[?] 15 to 20 mg/kg actual body weight, IV every 8 to 12 hr 4-6 weeks Treatment of Staphylococcal Endocarditis in the Absence of Prosthetic Material
  • 45. Antibiotic Dosage and route* Duration Regimen for methicillin-resistant staphylococci† Vancomycin 15 to 20 mg/kg actual body weight, IV every 8 to 12 hr ≥6 weeks Plus Rifampin 300 mg PO every 8 hr ≥6 weeks And Gentamicin 1.0 mg/kg IM or IV every 8 hr 2 weeks Regimen for methicillin-susceptible staphylococci Nafcillin or oxacillin 2 g IV every 4 hr ≥6 weeks Plus Rifampin 300 mg PO every 8 hr ≥6 6weeks And Gentamicin 1.0 mg/kg IM or IV every 8 hr 2 weeks Treatment of Staphylococcal Endocarditis in the Presence of a Prosthetic Valve or Other Prosthetic Material
  • 46. Antibiotic Dosage and route[†] Duration Ceftriaxone 2 g once daily IV or IM 4 weeks or Ampicillin- sulbactam 12 g/24 hr IV given every 4 hr in six equally divided doses 4 weeks Treatment of Endocarditis Caused by HACEK Microorganisms*
  • 47. Organisms Drugs Candida IE Amphotericin desoxycholate or liposomal amphotericin formulation, at full doses, often combined with 5- fluorocytosine. Surgical intervention shortly after beginning of medical treatment is advised. Sporadic Candida PVE and NVE Caspofungin, with prolonged or indefinite oral azole therapy has been advocated for patients treated either medically or surgically. Corynebacteria (diphtheroids) IE Penicillin combined with aminoglycosides OR vancomycin Corynebacterium jeikeium IE Often resistant to penicillin and aminoglycosides, is sensitive to vancomycin. Pseudomonas aeruginosa IE Tobramycin (8 mg/kg/day intravenously once daily plus piperacillin, ceftazidime, or cefipime. Coxiella burnetii IE Doxycycline (100 mg twice daily) combined with a quinolone for at least 4 years. Treatment with doxycycline combined with hydroxychloroquine for 18 to 48 months may be more
  • 48. Culture-Negative Endocarditis  Recommended therapy Suspected IE Received confounding antibiotic therapy NVE Ampicillin-sulbactam plus gentamicin (3 mg/kg/day) or vancomycin plus gentamicin and ciprofloxacin PVE Vancomycin plus gentamicin, cefepime, and rifampin.
  • 49. Anticoagulant therapy in IE  Patients with PVE involving devices that necessitates maintenance anticoagulation  Anticoagulant therapy in patients with NVE is limited to patients for whom there is a clear indication and no increased risk for intracranial hemorrhage.
  • 50. Monitoring Therapy  ~70% of patients with NVE or PVE are afebrile, by one week of therapy  Blood cultures should be repeated daily until sterile, and rechecked if there is recrudescent fever and performed again 4 – 6 weeks after therapy.
  • 51. Relapse and Recurrence  Relapse of IE usually occurs within 2 months of discontinuation of antibiotic treatment.  IV drug abuse is now the most common predisposing factor for recurrent IE
  • 52. Surgery in IE - Indications  Congestive Heart Failure  Unstable Prosthesis  Uncontrolled infection or unavailable effective therapy  Staph aureus PVE  Perivalvular invasive infection  Left sided Staph aureus IE  Unresponsive culture negative IE  Large vegetations (>10mm)
  • 53. Cardiac Conditions Associated with the Highest Risk of Adverse Outcome from Endocarditis for Which Prophylaxis with Dental Procedures Is Recommended
  • 54. Regimens for Prophylaxis Against Endocarditis: Use with Dental, Oral, and Upper Respiratory Tract Procedures
  • 55. Future Perspectives  Staphylococcal vaccines  Against Staph aureus surface carbohydrates  poly-N-acetylglucosamine or poly-N-succinylglucosamine (PNSG)  Newer Antibiotics ◦ Linezolid, ◦ Quinupristin-dalfopristin, ◦ Daptomycin
  • 56. Heal the world, make it a better place, for you and for me and the entire human race…..