History – things to ask at “Risk” (6)
- Dental
- Endoscopic procedures
- Operative procedures
- IVDU
- Tatoo
- Previous valvular disease / Rheumatic fever / valve operations / immunosuppression
Two bacerial organisms associated Endocarditis and Colorectal cancer?
- Streptococcus Bovis (Gallolyticus)*
- Clostrium Septicus*
How would you invesigate for suspected endocardis?
- Confrim the diagnosis
- At least 3 sets of blood cultures (ideally 6) in 24 hours
- Transthoracic echocardiogram - valvular involvement + abscess?
- Immunological markers: RhF, urine RBCs for dysmorphic cells
- Severiy
- WCC, CRP, ESR
- Review ECHO to assess valvular function
- Complicaiton - end organ damage
- ECG to look for conduction defect, heart block
- CXR - heart failure
- EUC - renal failure
- FBC to look for anaemia
- Urine MCS - ?haematuria
Common causative organisms for infective endocarditis? (4 categories)
- Streptococcus - 50%
- Strep - viridans (sanguinis, mitis, gordonii)
- Strep faecalis
- Strep bovis
- Staph (aureus, epidermidis)
- HACEK (rare)
- Fungal (candida, aspergillus) - suspect in drug addicts and immSx
HACEK?
Haemophilus
Actinobacillus
Cardiobacterium hominis
Eikonella
Kingella
Causes of culture-negative bacterial endocarditis? (5)
What is your general comment when answering this question?
I would be very cautious of making this diagnosis as it condemns a patient to prolonged IV Abx
Q-fever
Brucella
Histoplasma
Candida
Haemophilus parainfluenzae
What are the Duke’s criteria for endocarditis (3 majors)?
- Blood culture (typical organisms in at least 2 separate blood cultures at least 12 hours apart, or persistent) - for common skin contaminants - +ve culture in the majority of ≥4)
- Echocardiogram (abscess, new valvular regurgitaion, mobile intra-cardiac mass)
- Single positive blood culture for Coxiella Burnettii (Q-fever) or IgG titre >1:800
What are the minor criteria (5) for endocarditis (Modified Duke’s, 5)
- Predisposition
- Heart conditions that predispose to regurg / tubulent blood flow: prosthetic valve)
- IVDU
- Microbiologic evidence: +ve culture but does not meet criteria for Major
- Vascular: embolic - mycotic aneurysm, pulmonary infarct…etc
- Immunological phenomenon - RhF, dysmorphic RBCs (GN), Roth spots, Osler’s
- Fever ≥38
How would you manage this patient who has suspected endocarditis?
Goal:
- Eradication of the causative organism
- Prevent complications
- Prevent future occurrences
Associations:
- Source control - e.g. lines, infected prosthesis or devices - remove where possible
Non-pharmacological
- Education - 1) keeping the PICC line clean, 2) importance of adherence to minimise development of resistance, 3) avoiding risky behaviors to minimise future occurrences
- Early Cardiothoracics and Cardiology referral
Pharmacological
- ABx based on sensitivities - 4-6 weeks IV for most, 6-8 weeks for prosthetic valves
Surgical
- Valve replacement if indicated
Follow-up
- Reiterate importance of dental hygiene + prophylactic ABx before dental procedures
- Remove PICC as early as possible
- Blood tests - inflammatory markers (new baseline reference)
- TTE: assess valve appearance, the severity of regurgitation, LV function
What are the indications for surgery? (5)
Significant valvular dysfunction (e.g. acute severe AR)
Persistent positive blood cultures despite appropriate ABx
Resistant organisms (e.g. fungi)
Invasive paravalvular infection: causing conduction disturbances or paravalvular abscess or fistula
Recurrent embolic phenomena (controversial)
Endocarditis - poor prognostic indicators? (4 categories, 9 factors)
How sick they are
- Shock
- CCF
Extensiveness
- Multiple valves or AV involvement
- Multiple organisms
Those with risk factors
- Prosthetic valve involvement
- Extreme age
More virulent bugs
- Staph aureus
- Gram-negatives
- Fungal
- Culture negative microorganisms
The differential diagnosis for infective endocarditis? (4)
Tumour: atrial myxoma or occult malignant neoplasm, metastasis
SLE: Libman-Sacks endocarditis (non-bacterial, thrombotic)
Cardiac thrombus
Fibrin
Difference between prophylaxis between IE vs Rheumatic fever?
Rheumatic fever prophylaxis - long term, low dose ABx
Endocarditis - short term, high dose ABx
What are the indications for prophylaxis against endocarditis? (5)
Previous IE
Prosthetic heart valve
Congenital heart disease
- Cyanotic heart disease - unrepaired or repaired but residual defects
- Those with residual shunts or artificial materials
Cardiac transplant with valve disease
Aboriginal patients with intermediate-high risk lesions
So what is your prophylaxis regime for
- Dental procedures or oral surgery
- GI or GU procedures? (e.g. endoscopy, cystoscopy)
Dental:
Amoxycillin 2g (or Cephalexin 2g) 1h before procedure (PO) or;
Ampicillin IV 15-30min before the proedure or;
