Infective endocarditis resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farman Khan, MD, MRCP [2]; Mohamed Moubarak, M.D. [3]; Rim Halaby, M.D. [4]

Synonyms and keywords: Infective Endocarditis (IE), subacute bacterial endocarditis (SBE), acute bacterial endocarditis, fungal endocarditis, nosocomial infective endocarditis, intravenous drug abuse endocarditis, intravenous drug abuse infective endocarditis, prosthetic valve endocarditis, endocardial infection, native valve endocarditis, HACEK endocarditis, bloodstream infection

Infective endocarditis Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
FIRE
Complete
Treatment
Do's
Don'ts

Overview

Infective endocarditis is the infection of the endothelium of the heart including but not limited to the valves. While acute bacterial endocarditis is caused by an infection with a virulent organism such as staphylococcus aureus, group A or other beta-hemolytic streptococci, subacute bacterial endocarditis is an indolent infection with less virulent organisms like streptococcus viridans. Patients with unexplained fever for more than 48 hours and who are at high risk for infective endocarditis and patients among whom valve regurgitation is newly diagnosed should undergo a diagnostic workup to rule out endocarditis. The diagnosis of endocarditis depends on a thorough history an physical exam as well as on the results of blood cultures and transthoracic echocardiogram. The modified Duke criteria is used to establish the diagnosis of endocarditis. Endocarditis is initially treated with empiric antibiotic therapy until the causative agent is identified.

Causes

Life Threatening Causes

Acute endocarditis can be a life-threatening condition and must be treated as such irrespective of the underlying cause.

Common Causes

Dignosis

First Initial Rapid Evaluation of Suspected Endocarditis

Shown below is an algorithm depicting the First Initial Rapid Evaluation (FIRE) of suspected syncope.

Boxes in red signify that an urgent management is needed.

 
 
 
 
 
 
 
 
Identify cardinal signs and symptoms that increase the pretest probability of endocarditis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Identify alarming signs or symptoms
 
 

Complete Diagnostic Approach to Endocarditis

Shown below is an algorithm depicting the management of infective endocarditis.[1][2]

Characterize the symptoms:

❑ Onset of the symptoms

❑ Acute
❑ Subacute

Fever
Chills
Rigors
Sweats
Fatigue
Pleuritic chest pain
Back pain
Weakness
Myalgias
Arthralgias
Anorexia
Shortness of breath
Hemoptysis
Productive cough
Seizures (suggestive of septic emboli)
❑ Focal neurological deficits due to stroke (suggestive of septic emboli)
❑ Reversible focal neurological deficits due to transient ischemic attack (suggestive of septic emboli)

 
 
 
 
 
 
 
 
 
 
 
 
Identify existing risk factors:

❑ History of rheumatic heart disease
Prosthetic valves
Intravenous drug use

❑ Substances used in the mixture
❑ Sharing the equipment
❑ The process of cleaning the equipment

❑ Previous infective endocarditis
Cardiac transplantation with valvular abnormality
Congenital heart diseases with a shunt
Acquired heart diseases

Immunodeficiency
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

Vitals
Temperature

Fever

Blood pressure

❑ Wide pulse pressure (suggestive of aortic insufficiency)
❑ Narrow pulse pressure (suggestive of left ventricular failure)

Skin

❑ Petechiae
❑ Splinter hemorrhages
❑ Osler's nodes
❑ Janeway lesions

Dental examination
Teeth
Gingiva

Eyes

Conjunctival hemorrhage
Roth's spots in the retina

Cardiovascular examination

Heart murmur

Aortic insufficiency (early diastolic, decrescendo, best heard in the left sternal border)
Tricuspid regurgitation (holosystolic, best heard over the fourth intercostal area at left sternal border)
Mitral regurgitation (holosystolic, best heard at the apex)

Respiratory examination

Rales (suggestive of heart failure)

Abdominal examination

Reduced bowel sounds (suggestive of mesenteric embolization or ileus)
Abdominal pain

Flank pain (suggestive of embolus to the kidney)
❑ Left upper quadrant pain (suggestive of splenic infarct)

Splenomegaly

Extremities

Janeway lesions (painless hemorrhagic cutaneous lesions on the palms and soles)
Gangrene of fingers
Splinter hemorrhages
Osler's nodes (painful subcutaneous lesions in the distal fingers)

Neurological examination

❑ Full neurological exam

❑ Focal deficits (suggestive of stroke or brain abscess)
 
 
 
 
 
 
 
 
 
 
 
 
If the patient has any of the following proceed with tests:

❑ Unexplained fever for more than 48 hours and high risk for infective endocarditis, OR
❑ Newly diagnosed valve regurgitation

 
 
 
 
 
 
 
 
 
 
 
 
Order tests:

Blood culture (at least two sets)
❑ Order a TTE
❑ Order a TEE if one or more of the following is present

❑ Non diagnostic TTE in a suspected infective endocarditis (Class I, level of evidence B)
❑ Clinical complications (Class I, level of evidence B)
❑ Intracardiac device leads (Class I, level of evidence B)
Staphylococcus aureus bacteremia without a known cause (Class IIa, level of evidence B)
❑ Prosthetic valve with persistent fever without bacteremia (Class IIa, level of evidence B)
❑ Prosthetic valve with a new murmur (Class IIa, level of evidence B)
❑ Nosocomial Staphylococcus aureus bacteremia with known extra-cardiac port of entry (Class IIb, level of evidence B)
 
 
 
 
 
 
 
 
 
 
 
 
Evaluate the Modified Duke Criteria for infective endocarditis:[3]
Probability of infective endocaritis Characteristics
Definite diagnosis by pathological criteria❑ Microorganisms demonstrated by culture or histological examination
of a vegetation, OR
❑ Pathological lesions; vegetation or intracardiac abscess confirmed by histological
examination showing active endocarditis
Definite diagnosis by clinical criteria❑ 2 major criteria, OR

❑ 1 major criterion and 3 minor criteria, OR

❑ 5 minor criteria
Possible diagnosis❑ 1 major criterion and 1 minor criterion, OR
❑ 3 minor criteria
Rejected diagnosis❑ Firm alternative diagnosis explaining evidence of IE, OR

❑ Resolution of IE syndrome with antibiotic therapy for 4 days, OR
❑ No pathological evidence of IE at surgery or autopsy, with antibiotic therapy for 4 days, OR

❑ Does not meet criteria for possible IE as above
 
 
 
 

Treatment

Shown below is an algorithm depicting the management of infective endocarditis.[1][2]

Once the diagnosis of infective endocarditis is confirmed, initiate the treatment:

❑ Begin antibiotic treatment
❑ Order blood cultures very 24-48 hours until no bacteremia can be detected
❑ Temporarily discontinue anticoagulation if one of the following is present

❑ Signs and symptoms of CNS involvement consistent with embolism or stroke (Class IIa, level of evidence B)
❑ Vitamin K antagonist administration (Class IIb, level of evidence B)

❑ Schedule early surgery during hospitalization before completion of the antibiotics course if one of the following is present

Heart failure due to the valve dysfunction (Class I, level of evidence B)
❑ Left sided infective endocarditis due to staphylococcus aureus, fungal or highly resistant organisms (Class I, level of evidence B)
Heart block, annular or aortic abscess or destructive lesions (Class I, level of evidence B)
❑ Persistent bacteremia or fever 5 to 7 following the initiation of the antibiotics (Class I, level of evidence B)

❑ Remove the pacemaker of the defibrillator system if one of the following is present

❑ Documented infection of the device or leads (Class I, level of evidence B)
❑ Valvular infective endocarditis by Staphylococcus aureus or fungi in the absence of documented infection of the device or leads (Class IIa, level of evidence B)
❑ Patient scheduled for valve surgery (Class IIa, level of evidence C)
❑ Persistent vegetations and recurrent emboli despite the antibiotic regimen (Class IIa, level of evidence B)
 
 
 
 
 
 
 
 
 
 
 
 
Manage the patient with a multidisciplinary team:
❑ Consult an infectious disease specialist
❑ Consult a cardiologist
❑ Consult a cardiac surgeon
 
 
 
 
 
 
 
 
 
 
 
 
Follow up the patient:

❑ Repeat TTE before discharge
❑ Refer for cessation of drug abuse (if applicable)
❑ Educate the patient about the signs and symptoms of infective endocarditis
❑ Recommend a thorough dental examination
❑ Monitor for complications

❑ Relapse (fever, chills)
❑ New or worsening heart failure
❑ Antibiotic toxicity
❑ Vestibular toxicity
Diarrhea or colitis
 
 
 
 
 
 
 
 
 
 
 
 
Reevaluate the patient with TTE and/or TEE if one of the following is present:

❑ Change in clinical signs and symptoms

❑ New murmur
Embolism
❑ Persistent fever
Heart failure
Abscess
❑ Atrioventricular heart block

❑ High risk of complications

❑ Large vegetations on echocardiogram
❑ Staphylococcus, enterecoccal, or fungal infections
 
 
 
 

TEE: Transesophageal echocardiocardiography; TTE: Transthoracic echocardiocardiography

Antibiotic Regimens

A complete list of pathogen specific antibiotics regimens with appropriate dosages and duration of treatment is available here.

Modified Duke Criteria

Shown below is a table summarizing the major and minor Modified Duke Criteria.[3]

Modified Duke Criteria
Major criteria Minor criteria
1- Positive Blood Culture for Infective Endocarditis

❑ Typical microorganism consistent with infective endocarditis from 2 separate blood cultures, in the absence of a primary focus:

Viridans streptococci, streptococcus bovis
HACEK group
❑ Community-acquired staphylococcus aureus
Enterococci


OR

❑ Microorganisms consistent with infective endocarditis from persistently positive blood cultures defined as:

❑ At least 2 positive cultures of blood samples drawn >12 hours apart, or
❑ All of 3 or a majority of 4 separate cultures of blood (with first and last sample drawn 1 hour apart)


OR

❑ Single positive blood culture for Coxiella burnetii or anti–phase 1 IgG antibody titer >1:800


2-Echocardiographic evidence of endocardial involvement
❑ Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomic explanation, or
❑ Abscess, or
❑ New partial dehiscence of prosthetic valve, or
❑ New valvular regurgitation

1- Predisposition

❑ Predisposing heart condition or intravenous drug use


2- Fever
❑ Temperature > 38.0° C (100.4° F)


3- Vascular phenomena
Major arterial emboli
❑ Septic pulmonary infarcts
Mycotic aneurysm
Intracranial hemorrhage
Conjunctival hemorrhage
Janeway lesions


4- Immunologic phenomena
Glomerulonephritis
Osler's nodes
Roth spots
Rheumatoid factor


5- Microbiological evidence
❑ Positive blood culture but does not meet a major criterion as noted above

OR

❑ Serological evidence of active infection with organism consistent with infectious endocarditis


Prophylaxis

Shown below is an algorithm depicting the general prophylactic approaches of infective endocarditis.[4][1]

Identify high risk patients: (Class IIa, Level of evidence B)

Prosthetic valves patients
❑ Previous infective endocarditis
Cardiac transplant recipients with valves regurgitation due to structurally abnormal valve
Congenital heart diseases

❑ Unrepaired cyanotic congenital heart diseases
❑ Completely repaired defect with prosthetic material or device
❑ Repaired with residual defects
 
 
 
 
 
 
Identify high risk procedures:

Dental procedures

❑ Manipulation of gingival tissue, or
❑ Manipulation of the periapical region of teeth, or
❑ Perforation of the oral mucosa

Respiratory tract procedures involving incision of the respiratory tract mucosa

Tonsillectomy
Adenoidectomy

Gastrointestinal (GI) and genitourinary (GU) procedures only if GI or GU tract infection is present

 
 
 
 
 
 
❑ Administer prophylaxis
 

Antibiotic Prophylaxis

Shown below is a table depicting the prophylaxis antibiotic regimes for infective endocarditis.[1]

Infective Endocarditis Antibiotic Prophylaxis
Oral treatment is tolerated
Not allergic to penicillin Allergic to penicillin
Amoxicillin 2 g Ampicillin 2 g IM or IV
OR
Cefazolin 1 g IM or IV
OR
Ceftriaxone 1 g IM or IV
Oral treatment is not tolerated
Not allergic to penicillin Allergic to penicillin
Cefalexin 2 g
OR
Clindamycin 600 mg
OR
Azithromycin 500 mg
OR
Clarithromycin 500 mg
Cefazolin 1 g IM or IV
OR
Ceftriaxone 1 g IM or IV
OR
Clindamycin 600 mg IM or IV

Do's

  • Elicit a full medical history to identify the minor Duke criteria for the diagnosis.
  • Consider alternative diagnoses for bacteremia and fever by searching for focus of infections.
  • Initiate antibiotic therapy after withdrawing blood for culture (Class I, level of evidence B).[1]
  • If HACEK bacteremia is detected without any focus of infection, suspect the presence of infective endocarditis even in the absence of the typical signs and symptoms.[2]
  • Consider ordering a cardiac CT scan when echocardiography does not provide clear details about the cardiac anatomy in the context of suspected paravalvular infections (Class IIa, level of evidence B).[1]

Don'ts

  • Don't administer prophylaxis for infective endocarditis in patients with valvular heart disease who are at risk infective endocarditis for procedures such as TEE, cystoscopy, esophagogastroduodenoscopy or colonoscopy without any evidence of active infection (Class III; level of evidence B).[1]
  • Do not administer infective endocarditis prophylaxis for the following dental procedures:
    • Anesthetic injections in noninfected tissue
    • Dental radiographs
    • Shedding of deciduous teeth
    • Placement of orthodontic brackets
    • Placement or removal of prosthodontic or orthodontic appliances
    • Adjustment of orthodontic appliances
    • Bleeding following trauma to the oral mucosa or lips[5]
  • Do not administer infective endocarditis prophylaxis for procedures involving the respiratory tract unless they involve incision of the respiratory tract mucosa.[5]

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary". Retrieved 4 March 2014.
  2. 2.0 2.1 2.2 2.3 Baddour, LM.; Wilson, WR.; Bayer, AS.; Fowler, VG.; Bolger, AF.; Levison, ME.; Ferrieri, P.; Gerber, MA.; Tani, LY. (2005). "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. 111 (23): e394–434. doi:10.1161/CIRCULATIONAHA.105.165564. PMID 15956145. Unknown parameter |month= ignored (help)
  3. 3.0 3.1 Li JS, Sexton DJ, Mick N, Nettles R, Fowler VG, Ryan T; et al. (2000). "Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis". Clin Infect Dis. 30 (4): 633–8. doi:10.1086/313753. PMID 10770721.
  4. Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M; et al. (2007). "Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group". Circulation. 116 (15): 1736–54. doi:10.1161/CIRCULATIONAHA.106.183095. PMID 17446442.
  5. 5.0 5.1 Bonow RO, Carabello BA, Chatterjee K; et al. (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines 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 (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Unknown parameter |month= ignored (help)


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