1
Q
What is endocarditis?
A
Infection of the heart valves and other endocardial tissue
2
Q
Endocarditis is most often seen in which patient populations? (2)
A
- Older adults (>50)
- Persons who inject drugs (PWID)
3
Q
What is the pathophysiology of endocarditis? (4)
A
- Altered endocardial surface produces a suitable site for bacterial attachment and colonization
- Trauma, turbulence, previously damaged valve - Formation of platelet-fibrin thrombus on the altered surface
- Get non-bacterial thrombotic endocarditis - Bacteremia
- Formation of vegetation of fibrin, platelets and bacteria
4
Q
What are the features of acute endocarditis? (5)
A
- Severe and rapid clinical course
- Often normal valves are involved
- History of bacteremia
- Requires early treatment (as valve may be destroyed in only a few days)
- Often Staphylococcus aureus
5
Q
What are the features of subacute endocarditis? (4)
A
- Illness often lasts months before diagnosed
- Usually some form of prior valve disease
- Often a history of dental work or procedures*
- Usually Streptococci or Enterococcal
6
Q
What is early onset prosthetic valve endocarditis? (4)
A
- Within 1 year of surgery
- Organisms introduced at time of surgery
- Usually Staphylococci
- Can be gram (-) bacili or fungal
7
Q
What is late onset prosthetic valve endocarditis? (2)
A
- After 1 year
- Same organisms as native valve endocarditis (i.e., Strep)
8
Q
What are the risk factors for endocarditis? (13 - know 5ish?)
A
- Age over 60 years
- Male
- Structural heart disease
- Prosthetic valve
- Prior infective endocarditits
- Intravenous drug use
- Diabetes mellitus
- Chronic hemodialysis
- Poor oral hygiene
- Intravascular catheter
- Indwelling cardiovascular device
- Skin infection
- Oral hygiene or dental pathology
9
Q
What are the 3 big bacteria groups that tend to cause endocarditis?
A
- Staphylococci
- Coagulase positive S. aureus
- Coagulase negative - Streptococci
- Viridans group Streptococci - Enterococci
10
Q
Where is Streptococci most likely to come from when it comes to endocarditis? (3)
A
- Mostly coming from oral and respiratory flora
- Dental or respiratory tract procedures may introduce bacteria into bloodstream
- Also group D strep - resides in the GIT
11
Q
Where is Staph aureus most likely to come from when it comes to endocarditis? (2)
A
Especially seen in IV drug use and early prosthetic valve endocarditis
12
Q
Where is Enterococci most likely to come from when it comes to endocarditis? (2)
A
- From gut or urinary tract
- GI/GU procedure may introduce into blood
13
Q
What are the common signs and symptoms of endocarditis? (9)
A
- Fever - 86-96% of cases - may be low grade
- Heart murmur - new (48%) or worsening of old murmur (20%)
- Fatigue
- Weakness
- Weight loss
- Arthralgias
- Myalgias
- Nightsweats
- Headache
14
Q
What are the more rare signs and symptoms of endocarditis? (5)
A
- Osler nodes
- Purplish SubQ nodules on tips of fingers and toes - Janeway lesions
- Erythematous, nonpainful macules on palms and soles - Splinter hemorrhages
- Petechiae
- Small, red, painless hemorrhagic lesions - eyeball pic - Vascular Embolic event (17%)
15
Q
IV drug use more often leads to _____ ______ endocarditis.
Often presents as a pulmonary syndrome with these 4 symptoms:
A
right sided
1. Fever
2. Cough
3. Hemoptysis (coughing up blood)
4. Pleuritic chest pain
16
Q
What type of anemia (morphology) is seen in endocarditis?
A
Usually normocytic, normochromic anemia
17
Q
How do the following change in endocarditis:
1. WBCs
2. ESR or CRP
3. RF
A
- Increased WBC
- May not be increased in subacute form - Increased ESR or CRP
- RF may be increased (in 50% of cases)
18
Q
How many blood cultures should be taken in endocarditis?
A
Obtain 3 samples at different times or sites
- May be negative due to previous antibiotic use or difficult to culture organisms
19
Q
Using the Modified Duke criteria, what is a definite diagnosis of endocarditis? (3)
A
- 2 major; or
- 1 major and 3 minor; or
- 5 minor
20
Q
Using the Modified Duke criteria, what is a possible diagnosis of endocarditis? (2)
A
- 1 major and 1 minor; or
- 3 minor
21
Q
What are the major criteria of the Modified Duke Criteria? (2)
A
- Positive blood culture(s)
- Evidence of endocardial involvement
22
Q
What are the minor criteria of the Modified Duke Criteria? (5)
A
- Predisposition for endocarditis
- Fever
- Vascular phenomenon
- Immunologic phenomenon
- (+) blood culture (not meeting major criteria)
23
Q
What are the complications associated with endocarditis? (6)
A
- Destruction of valve tissue, fibrosis, abscess
- HF
- Cardiomyopathy
- Septic emboli
- Glomerulonephritis
- Stroke
24
Q
What are 2 things to know about how bacteria grows which should be taken into account when treating endocarditis?
A
- Vegetation protects bacteria from antibodies, macrophages and antibiotics
- Bacteria are in high density with a slow rate of growth within biofilms and low microorganism metabolic activity
- Dense bacteria will produce beta-lactamase at higher concentrations
- Slow growth means fewer active penicillin-binding proteins
- Efficacy of drug varies depending on the degree of penetration into the vegetation, pattern of distribution within, and the size - mechanical barriers
25
What are 4 treatment principles to know for endocarditis?
i.e., what type of treatment?
What type of antibiotics? (2)
TDM (kind of)?
1. Treatment is generally IV for 4-6 weeks, although courses as short as 2 weeks in certain circumstances
2. Must be bactericidal; sufficient doses
3. Often synergistic combinations are used
- Note: there is synergy of Pen G and AMG against viridans group Streptococci, Group D Strep, and Enterococci species
4. Doses acknowledge ratios of drug exposure (AUC) and minimum inhibitory concentrations (MIC) of drug to be
- Bactericidal and
- Above the MIC for long enough time
26
Empiric antibiotics depends on patient history and requires Infectious Disease consultation immediately; however, with unknown source and native valve, what are our empiric antibiotic choices? (2)
1. Penicillin G or ampicillin + AMG
2. If highly suspicious of S. aureus, add cloxacillin or use vancomycin + AMG
27
What are some clues that would point to S. aureus being the causative organism of an endocarditis infection? (8)
1. Intravenous drug user
2. Indwelling cadriovascular medical devices
3. Chronic skin disorders
4. Burns
5. Diabetes mellitus
6. Prosthetic valve replacement
7. AIDS
8. Solid organ transplantation
28
Endocarditis pathogen directed therapy: What are the first line antibiotic choices for a Streptococci infection? (2)
How long is therapy for native valve and prosthetic valve?
Generally highly sensitive to penicillin, so
- Crystalline Penicillin G or ceftriaxone for 4 weeks (native valve) or 6 weeks (prosthetic valve)
29
Endocarditis pathogen directed therapy: What are the alternative antibiotic choices for a Streptococci infection? (2)
How long?
What is done for more resistant strains? (antibiotic and duration)
Alternative:
- Pencillin G or ceftriaxone with gentamicin for 2 weeks in certain patients
For more resistant strains:
- 4 weeks of penicillin; first 2 weeks add gentamicin OR ceftriaxone alone
30
Endocarditis pathogen directed therapy: Staphylococci.
If S. aureus, treatment depends on whether MSSA or MRSA suspected.
What antibiotic group is first line in MSSA? What is an alternative?
1. Beta lactams
2. Cefazolin can be used instead of cloxacillin in non-anaphylactic penicillin allergy
31
Endocarditis pathogen directed therapy: Staphylococci.
If S. aureus, treatment depends on whether MSSA or MRSA suspected.
What antibiotic is first line in MRSA? How does that differ between native and prosthetic valve?
Vancomycin (or daptomycin) x 6 weeks
- For native valve endocarditis, no need to add AMG
- For prosthetic valve endocarditis, add an aminoglycoside (monitor b/c of increased renal risk) and rifampin
32
Treatment of Staphylococci induced endocarditis takes how long typically?
6 weeks
33
Endocarditis pathogen directed therapy: What are the first line antibiotic choices for an Enterococci infection? (2) Know the duration too
What to use in first-line resistance?
1. 4-6 weeks of penicillin or ampicillin plus AMG
2. Ampicillin plus ceftriaxone
3. If penicillin resistant, use vancomycin
34
When might oral therapy be used in endocarditis?
Partial Oral Treatment of Endocarditis (POET) trial, changing to oral antimicrobial therapy after at least 10 days of IV therapy was non-inferior to continuing IV antimicrobial therapy in patients with left-sided native or PVE caused by streptococci, Enterococcus faecalis, S. auerus (not MRSA), or coagulase-negative staphylococci
35
What are the recommendations when it comes to anticoagulation use in endocarditis? (3)
1. Ds/c of all forms of anticoagulation in pts with mechanical valve IE who have experienced a CNS embolic event for at least 2 weeks is reasonable
2. Initiation of aspirin or other antiplatelet agents as adjunctive therapy in IE is not recommended
3. The continuation of long-term antiplatelet therapy at the time of development of IE with no bleeding complications may be considered
36
Monitoring of endocarditis therapy is based on what you know about the disease and what antibiotics. In general though, what should be monitored? (6)
1. Blood cultures
- Done every 24h until negative
2. Drug specific monitoring
3. Patient's signs and symptoms
4. Signs and symptoms of HF (SOB, edema, weight gain)
5. The heart murmur will not go away, but worsening may be a poor sign
6. Embolic phenomenon
37
What is the most important advice when it comes to endocarditis prophylaxis?
Maintain excellent oral health and daily oral hygiene
38
What are the cardiac conditions associated with the highest risk of adverse outcomes from endocarditis for which prophylaxis with dental procedures is reasonable? (4)
1. Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
2. Previous IE
3. Congenital heart disease
4. Cardiac transplantation recipients who develop cardiac valvulopathy
39
Should know the dental procedures for which endocarditis prophylaxis is reasonable
All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa
40
When should dental procedure prophylaxis of endocarditis be started? What happens if forgotten?
1. 30-60 minutes before procedure
2. If forgotten, can be up to 2h after procedure
41
What is the medication used in dental procedure prophylaxis of endocarditis? (1)
What about if there is an allergy? (4)
1. Amoxicillin
If allergy:
1. Cephalexin
2. Clindamycin
3. Azithromycin
4. Clarithromycin
42
When is prophylaxis for endocarditis in respiratory tract procedures recommended?
Only recommended for those who undergo an invasive procedure of the respiratory tract that involves incision or biopsy of the respiratory mucosa (tonsillectomy, adenoidectomy)
43
When is prophylaxis for endocarditis in skin infection or MSK tissue procedures recommended?
If a procedure involves infected skin, skin structure, or musculoskeletal tissue, the regimen used to treat this should include coverage for staphylococci and streptococci
(Note: this does NOT include vaginal delivery, hysterectomy, tattoos, or body piercing)
44
When is prophylaxis for endocarditis in GI or GU tract procedures recommended?
Prophylaxis no longer recommended for any scopes over concerns of resistance
45
If a patient is already on antibiotics for whatever reason and needs to do prophylaxis for endocarditis for a procedure, what should they do? (3)
1. Choose a different class than what they are currently receiving
2. Consider delaying procedure until course is finished if possible
3. If currently being treated for endocarditis and procedure is unavoidable, dose 30-60 mins before procedure
