2. CASE 1
32 years old male
โข PC:
โข Fever and generalized body stiffness for 12 days
โข Bed ridden for this period
โข Passing Cola-colored urine on day 5 of fever
โข PHx:
โข Hepatitis C
โข Psoriasis
โข Ex-IVDU: last used 6 years ago, now on Methadone
โข 2004: L arm abscess
โข 2005: R arm cellulitis (Group A, B hemolytic Strep on BC)
3. โข
FHx:
โข
โข
โข
SLE
Epilepsy
Social Hx:
โข
โข
Smoker
โข
โข
Lives with girlfriend and son
Denied heavy alcohol drinking
O/E:
โข
GCS: 15/15
โข
T 38.7, HR 108, BP 122/65, PO2sat 94% RA, RR 16
โข
Generalized Lymphadenopathy
โข
No rash
โข
Chest: clear (CXR: hilars LN enlargements)
โข
Heart: no murmur
โข
Abdo: generalized tenderness, hepatosplenomegaly (confirmed
by US), ?ascites
โข
CNS: neck stiffness, ?papilodema
18. CASE 2
โข 45 years old male presented with
โข fever, productive cough and SOB,
โข Hx of IVDU.
โข O/E: Temp 39 C, HR 100, BP 105/65
โข Chest: R basal crepitation
22. EPIDEMIOLOGY
โข Incidence: 2.6 - 7.0 cases / 100,000 population / year.
โข New Trends:
โข Mean age was 30 in 1926, now > 50% of patients are
over 60
โข Decline in incidence of rheumatic fever
โข More prosthetic valves
โข More nosocomial cases, injected drug use
โข More staphylococcal infection
โข Mitral valve alone 28-45% (MV > AV > TV)
23. PATHOLOGY
โข
Staphylococcus (40%) , NOT Streptococcus (34%) is now the leading
pathogen*, in the developed world.
โข
IVDU: may get unusual pathogen. Polymicrobial infection is common
โข
Risk of prosthetic (Mechanical = tissue) valve endocarditis is 4% first
year then decline to 1% per year.
โข
Regurgitation valve lesions are more susceptible than stenotic ones.
โข
Transvenous pacemaker lead and/or implanted defibrillator
associated endocarditis is usually nosocomial. Onset within weeks
of implantation.
โข
100% fatal if undiagnosed and untreated vs 20% fatal if diagnosed and
treated.
*Karchmer, Scientific American Medicine, 1999
24.
25. CLASSIFICATIONS
โข
Acute vs Subacute: causative microorganism is primarily responsible for the
temporal course.
โข
S.aureus๏ Acute
โข
Viridans Strep, Enterococcus Faecalis ๏ Subacute IE: classic PUO
โข
Bartonella species and the agent of Q fever, C. burnetii, is exceptionally
indolent
โข
Right vs Left sided heart: IVDU. May present as pneumonia
โข
Native vs Prostatic valve: IVDU
โข
Negative (5 - 15%) vs Positive blood culture
โข
Bad isolation/identification technique
โข
Fastidious isolate:
โข HACEK organisms: Haemophilusaphrophilus, H. paraphrophilus,
parainfluenzaeActinobacillusactinomycetemcomitansCardiobacteriumho
minisEikenellacorrodens, Kingellakingae
โข Bartonella species have now been established as an important cause
โข
Non-bacterial
โข
Antibiotics administration pre-culture: 1/3 - 1/2 of cases
26.
27. DIAGNOSIS
โข In 1994 investigators from Duke University modified
the von Reyn criteria (1981) to include:
โข Role of echocardiography
โข IVDU as risk factor
โข In 2000, further modification to include:
โข Role of TOE
โข Q fever (Coxiella brunetti)
28. MODIFIED DUKE CRITERIA
Major Criteria
โขIsolation of causative organism by two separate blood cultures at least
12hrs apart, or Three or more positive cultures taken at least one hour
apart
โขEndocardial involvement evidence by echo. Oscillating mass, prosthetic
valve dehiscence, abscess, new regurgitation.
Minor criteria
โขPredisposing lesion or IVDU
โขFever >38C
โขSigns of embolization: Janeway lesion, Intracranial infarct/ bleeding.
โขImmunologic phenomena: Glomerulonephritis, Oslers nodes,
Rheumatoid factor, Roths spots.
โขPositive blood culture not meeting major criteria.
โขEcho finding, but not meeting major criteria.
29. MODIFIED DUKE CRITERIA
Definite Infective Endocarditis
Pathologic criteria:
Microorganisms demonstrated by culture or histology in a vegetation or
embolus.
Clinical criteria:
2 major or
1 major + 3 minor or
5 minor
Possible endocarditis
Findings that are suggestive of IE but fall short of definite, but not rejected.
Rejected Infective Endocarditis
Firm, alternative diagnosis explaining the evidence suggesting infective
endocarditis.
Resolution of syndrome with antibiotic therapy in 4 days or less.
No pathologic evidence at surgery with Abx therapy of four days or less.
30. painful, nodules found in the
pulp of fingers and toes and
are seen more often in
subacute IE
Macular, blanching, nonpainful, e
rythematous lesions on the
palms and soles
36. TRANSTHORACIC (TTE) VSTRANSOESOPHAGEAL
(TOE) ECHOCARDIOGRAPHY
โข TTE does not detect vegetations <2 mm in
diameter
โข TOE is 90% sensitive (vs 60% in TTE) in
detecting vegetations and is particularly
useful for identifying valve ring abscesses as
well as prosthetic valve endocarditis
โข However, TTE may be used in pts with a low
pretest likelihood of endocarditis (<5%).
39. โECHO SHOULD BE DONE IN ALL
CASES OF SUSPECTED
ENDOCARDITIS.โ
(This is not all patients with fever or positive blood cultures).
Circulation 1997; 95: 1686-1784
40. COMPLICATIONS
โข CARDIAC COMPLICATIONS:
โข Heart failure- acute or insidious
โข Paravalvular abscesses- esp aortic,
increased in IVDU
โข Heart block
โข Other extravalvular complicationspericarditis, fistulas
41. โข
EMBOLIZATION: Vegetations >10 mm in diameter and those
located on the mitral valve are more likely to embolize:
โข Stroke
โข Blindness
โข Painful ischemic or frankly gangrenous extremities
โข Unusual pain syndromes (eg, due to splenic or renal
infarction)
โข Hypoxia (due to pulmonary emboli in right-sided
endocarditis)
โข Paralysis (due to embolic infarction of either the brain or
spinal cord)
โข Effect of antibiotic therapy on embolic risk- decreases,
but can occur wks after initiation
โข Predictors of embolization- strep bovis, saureus, L sided,
seen on TTE, not just TOE
42. โข
NEUROLOGIC COMPLICATIONS
โข Acute encephalopathy
โข Meningoencephalitis
โข Purulent or aseptic meningitis
โข Embolic stroke
โข Cerebral hemorrhage (due to stroke or a
ruptured mycotic aneurysm)
โข Brain abscess or cerebritis
โข Seizures (secondary to abscess or embolic
infarction)
43.
44.
45. โข
MYCOTIC ANEURYSMS (most feared)
โข cerebral and systemic
โข
RENAL DISEASE
โข renal infarction due to emboli
โข drug induced acute interstitial nephritis
โข glomerulonephritis due to deposition of immunoglobulins
and complement in the glomerular membrane- pre
commencement of antibiotics
โข
METASTATIC ABSCESSES
โข rare- kidneys, spleen, brains, soft tissues
โข
MUSCULOSKELETAL COMPLICATIONS
โข osteomyelitis- esp vertebral (staph aureus)
โข
COMPLICATIONS OF MEDICAL OR SURGICAL THERAPY
โข Aminoglycoside-induced ototoxicity or nephrotoxicity
46. POOR PROGNOSTIC MARKERS:
โข Low serum albumin
โข Infection with S. aureus
โข Heart failure
โข Diabetes mellitus
โข Apache II score
โข Embolic events
โข Paravalvular abscess
โข Vegetation size
โข Female sex
49. EMPIRICAL TREATMENT IN
FULMINANT INFECTION
At least three blood cultures (no more than one
from each venipuncture) must be obtained
before therapy is commenced:
โข benzylpenicillin 1.8 g IV, 4-hourly
PLUS
โข di/flucloxacillin 2 g IV, 4-hourly
PLUS
โข gentamicin 4 to 6 mg/kg IV, for 1 dose, then
determine dosing interval for a maximum of
either 1 or 2 further doses based on renal
function
50. ALTERNATIVE EMPIRICAL
TREATMENT
โข vancomycin 1.5 IV, 12-hourly (adjust initial dosage for
renal function and monitor blood concentrations
PLUS
โข
gentamicin 4 to 6 mg/kg IV, for 1 dose, then determine
dosing interval for a maximum of either 1 or 2 further
doses based on renal function
โข Indications:
โข prosthetic cardiac valve, pacemaker or intra-cardiac device
โข health careโassociated infection
โข penicillin hypersensitivity
โข MRSA is suspected
51. NON FULMINANT INFECTION
WAIT FOR BLOOD CULTURE RESULT
โข methicillin-susceptible staphylococci
โข di/flucloxacillin 2 g IV, 4-hourly for 4 to 6
weeks
โข methicillin-resistant staphylococci
โข vancomycin 1.5 g IV, 12-hourly for 6 weeks
+/- Rifampicin & Fusidic Acid
52. โข Viridans streptococci susceptible to benzylpenicillin
โข benzylpenicillin 1.8 g IV, 4-hourly for
โข 2 weeks (uncomplicated endocarditis)
โข 4 weeks (complicated endocarditis)
PLUS
โข gentamicin 1 mg/kg IV, 8-hourly for 2 weeks
โข Viridans streptococci resistant to benzylpenicillin
โข vancomycin 1.5 g IV, 12-hourly for 4 - 6 weeks
PLUS
โข gentamicin 1 mg/kg IV, 8-hourly for for 4 - 6 weeks
53.
54. HITH CRITERIA
(MUST FULFILL ALL)
โข afebrile for at least 72 hours with negative blood cultures
โข no evidence of cardiac failure (or if cardiac failure
present, stable and well controlled with medical therapy)
โข vegetations less than 10 mm and no intracardiac abscess on
transoesophageal echocardiogram
โข no new cardiac conduction abnormalities
โข no neurological findings that may result from cerebral embolism
or mycotic aneurysm
โข continuing supervision by a cardiologist, and an infectious
diseases physician or clinical microbiologist
56. โข Anticoagulation is contraindicated in native
valve endocarditis because increases the risk of
intracerebral bleed.
โข โIf anticoagulation is indicated for another
reason, it should be continued, with INR at low
therapeutic range.
โข Anticoagulation does not prevent embolization
due to IE.โ
ACC guidelines on Diagnosis and Management of Infective Endocarditis .
57.
58.
59.
60. RELAPSES
โข Mostly occur within 1-2 months after completion
of therapy.
โข Obtaining one or two blood cultures during this
period is prudent .
66. PROPHYLAXIS
โข No randomised controlled trial has been
performed to decide the role of antibiotic prophylaxis
and there are no human studies showing that it can
prevent endocarditis.
โข Guidelines produced in different parts of the world
rely on expert consensus and consequently can
differ in their recommendations.
โข Australian guidelines follow the lead of the
American Heart Association
67. Antibiotic prophylaxis is recommended in patients with the
following cardiac conditions if undergoing a specified dental or other
procedure
โข
prosthetic cardiac valve or prosthetic material used for cardiac valve
repair
โข
previous infective endocarditis
โข
congenital heart disease but only if it involves:
โข unrepaired cyanotic defects, including palliative shunts and
conduits
โข completely repaired defects with prosthetic material or
devices, whether placed by surgery or catheter
intervention, during the first 6 months after the procedure (after
which the prosthetic material is likely to have been
endothelialised)
โข repaired defects with residual defects at or adjacent to the site
of a prosthetic patch or device (which inhibit endothelialisation)
โข
cardiac transplantation with the subsequent development of cardiac
valvulopathy
โข
rheumatic heart disease in Indigenous Australians only
70. ARE DENTISTS INNOCENT?
โข โToothbrushing for 1 year has a greater risk of producing
bacteraemia than a single extractionโ
Roberts GJ 1999 Pediatr Cardiol 20:317-325
Dentists are innocent!
โข First and most important โ proper oral hygiene & Regular
dental review
71.
72.
73. STANDARD PROPHYLAXIS
โข
amoxycillin 2 g orally, 1 hour before the procedureโจoramoxy/ampicillin 2
g IV, just before the procedureโจoramoxy/ampicillin 2 g IM, 30 minutes
before the procedure.
โข
hypersensitive to penicillin
โข
clindamycin 600 mg orally, 1 hour before the
procedureโจorclindamycin 600 mg IV over at least 20 minutes, just
before the procedure
OR
โข
lincomycin 600 mg IV over at least 1 hour, just before the procedure
OR
โข
vancomycin 25 mg/kg up to 1.5 g IV, ending the infusion just before
the procedure
74. MCQ1
โข A 60 year old male has a previous rash whist talking
flucoxacillin. He presents with aortic valve endocarditis with
Staphylococcus Aureus sensitive to flucoxacillin. He is treated
with IV Cephazolin 2g every 8 hours for the past week. He
develops pulmonary oedema and a new early diastolic murmur
in the aortic area.
What is the best management ?
A. Add Gentamycin to Cephazolin
B. B. Start flucoxacillin after rapid desensitisation
C. Change to Vancomycin and Rifampin
D. Transfer to ICU for Intra-aortic balloon pump insertion
E. Urgent aortic valve repair.
75. MCQ2
โข 60 years old man presents with a Streptococcus Bovis
endocarditis which is adequately diagnosed and treated.
which of the following is the next most appropriate
investigation?
A. Iron Studies
B. Small bowel series
C.
Gallium scan
D.
Colonoscopy
E. HIV antibody test
76. ANSWER MCQ2
D โ colonoscopy
Strep bovis typically comes from the gut
and is associated with bowel polyps and
carcinoma
77. WHAT DO WE NEED TO KNOW?
โข IE is rare but serious disease, with high mortality rate
โข IVDU and the elderly are at greatest risk of developing IE.
โข Every case of PUO should be suspected for IE
โข The signs and symptoms of IE are nonspecific and
varied.
โข A thorough but timely evaluation (including serial blood
cultures, adjunct labs, and an echo) is crucial to
accurately diagnose and treat IE.
โข Beware of life-threatening complications.
โข Antibiotics prophylaxis is reserved for high risk patients
78. MANY THANKS
โข For your attendance and attention
โข To Department of Medicine for the support:
โข Dr Bassi
โข Dr Vidyarantna
โข Debbie Hobbs & Kim Adams
โข And all others
โข Frankston Hospital Library staff
โข Finally not to forget our hard working interns,
Linda and Victor