Infective endocarditis: Difference between revisions
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*Any cause of fever or consitutional symptoms |
*Any cause of fever or consitutional symptoms |
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==Diagnosis== |
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*Based on a combination of clinical exam, laboratory investigations, and imaging |
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*Refer to [[Modified Duke criteria]] |
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==Management== |
==Management== |
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*In patients who are in [[acute heart failure]], may need to consider [[antibiotics in sodium restriction|the sodium content of the antibiotics used]] |
*In patients who are in [[acute heart failure]], may need to consider [[antibiotics in sodium restriction|the sodium content of the antibiotics used]] |
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=== Antimicrobial Selection === |
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!Valve |
!Valve |
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=== Indications for Surgery === |
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* Early valve surgery (that is, before discharge and completion of antibiotics) is recommended in some scenarios |
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* Left-sided endocarditis |
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** Acute heart failure |
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** Fungal endocarditis |
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** Highly-resistant organisms |
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** Heart block, annular or aortic abscess, or perforating valve lesion |
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** Bacteremia or fever lasting more than 5-7 days despite appropriate antimicrobials |
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** Severe valvular regurgitation and mobile vegetations >1 cm |
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** Prosthetic valve endocarditis with recurrent emboli despite appropriate antimicrobials |
|||
** Relapsed prosthetic valve endocarditis |
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* Right-sided endocarditis |
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** Severe tricuspid valve regurgitation with right heart failure despite medical therapy |
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** Persistent infection with difficult-to-treat organisms |
|||
** Tricuspid valve vegetation >2 cm |
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** Recurrent pulmonary emboli despite appropriate antimicrobials |
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== Prevention == |
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* Prophylaxis is recommended for high-risk patients who are undergoing higher-risk procedures |
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* Patient characteristics |
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** Prosthetic heart valve |
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** Previous infective endocarditis |
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** Unrepaired cyanotic congenital heart disease, or repaired within the past six months with prosthetic material in situ, or repaired with residual defect and with material in situ |
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** Cardiac transplantation with valvulopathy |
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* Procedures |
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** Dental procedures with manipulation of the gingiva, perforation of mucosa, or periapical region of teeth |
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** Procedures involving incision of respiratory mucosa, including tonsillectomy and bronchoscopic biopsy |
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** Procedures on infected tissue (skin, bone, joint, etc) |
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[[Category:Cardiac infections]] |
[[Category:Cardiac infections]] |
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Revision as of 00:28, 19 August 2020
Background
- Infection of endocardium, generally involving the heart valves, either prosthetic or native
Microbiology
- Bacteria
- Fungi
- Culture-negative endocarditis
Risk Factors
- Cardiac
- Prior endocarditis
- Prosthetic heart valve or implanted device
- Congenital heart disease, especially unrepaired cyanotic congenital heart disease
- Valve abnormalities
- Non-cardiac
- Intravenous drug use
- Indwelling intravenous lines
- Immunosuppression
- Recent dental work or surgical procedure associated with bacteremia
Clinical Manifestations
- In general, symptoms are fever, chills, and malaise in a patient at risk for endocarditis
- Tends to progress rapidly
- May have a new murmur, stroke syndrome, pulmonary embolism, arthralgias
- Specific organisms may be associated with specific risk factors
- Injection drug use: Viridans group streptococci and Pseudomonas aeruginosa
- Colon cancer: Streptococcus gallolyticus subspecies gallolyticus and Clostridium septicum
Subacute Bacterial Endocarditis
- Insidious onset with more pronounced constitutional symptoms progressing over weeks to months
Differential Diagnosis
- Non-infectious causes of endocarditis
- Any cause of fever or consitutional symptoms
Diagnosis
- Based on a combination of clinical exam, laboratory investigations, and imaging
- Refer to Modified Duke criteria
Management
- Varies by causative organism and prosthetic vs. native valve
- In patients who are in acute heart failure, may need to consider the sodium content of the antibiotics used
Antimicrobial Selection
| Valve | Antibiotic | Dose | Duration | Notes |
|---|---|---|---|---|
| MSSA and other oxacillin-susceptible Staphylococcus | ||||
| NVE | oxacillin | 2 g IV q4h | 6 weeks | can treat for 2 weeks in uncomplicated right-sided NVE |
| NVE | cefazolin | 2 g IV q8h | 6 weeks | in patients with non-anaphylactoid penicillin allergy |
| PVE | oxacillin | 2 g IV q4h | ≥6 weeks | use cefazolin or vancomycin if allergy |
| + rifampin | 300 mg IV/PO q8h | |||
| + gentamicin | 1 mg/kg IV/IM q8h | 2 weeks | ||
| MRSA and other oxacillin-resistant Staphylococcus | ||||
| NVE | vancomycin | 15 mg/kg IV q12h | 6 weeks | target trough 10-20 μg/mL |
| NVE | daptomycin | ≥8 mg/kg/dose | 6 weeks | |
| PVE | vancomycin | 15 mg/kg IV q12h | ≥6 weeks | target vancomycin trough of 10-20 μg/mL |
| + rifampin | 300 mg IV/PO q8h | |||
| + gentamicin | 1 mg/kg IV/IM q8h | 2 weeks | ||
| Enterococcus susceptible to penicillin and gentamicin | ||||
| NVE/PVE | ampicillin | 2 g IV q4h | 4-6 weeks | 4 weeks if symptoms <3 months; 6 weeks if symptoms >3 months or if PVE |
| + gentamicin | 1 mg/kg IV q8h | |||
| NVE/PVE | ampicillin | 2 g IV q4h | 6 weeks | alternative regimen if CrCl <50 |
| + ceftriaxone | 2 g IV q12h | |||
| Enterococcus susceptible to penicillin and resistant to aminoglycosides | ||||
| NVE/PVE | ampicillin | 2 g IV q4h | 6 weeks | |
| + ceftriaxone | 2 g IV q12h | |||
| Enterococcus resistant to penicillin and susceptible to vancomycin and aminoglycosides | ||||
| NVE/PVE | vancomycin | 15 mg/kg IV q12h | 6 weeks | |
| + gentamicin | 1 mg/kg IV/IM q8h | |||
| Enterococcus resistant to penicillin, aminoglycosides, and vancomycin | ||||
| NVE/PVE | linezolid | 600 mg IV/PO q12h | >6 weeks | |
| NVE/PVE | daptomycin | 10-12 mg/kg IV q24h | >6 weeks | |
| Viridans Streptococcus or Streptococcus gallolyticus highly susceptible to penicillin (MIC ≤0.12 μg/mL) | ||||
| NVE | crystalline penicillin G | 3-4 MU IV q4h | 4 weeks | |
| NVE | ceftriaxone | 2 g IV/IM q24h | 4 weeks | |
| NVE | penicillin or ceftriaxone | as above | 2 weeks | |
| + gentamicin | 3 mg/kg IV/IM q24h | |||
| NVE | vancomycin | 15 mg/kg IV q12h | 4 weeks | use if allergy, target 10-15 μg/mL |
| PVE | crystalline penicillin G | 6 MU IV q4h | 6 weeks | |
| ± gentamicin | 3 mg/kg IV/IM q24h | 2 weeks | ||
| PVE | ceftriaxone | 2 g IV/IM q24h | 6 weeks | |
| ± gentamicin | 3 mg/kg IV/IM q24h | 2 weeks | ||
| PVE | vancomycin | 15 mg/kg IV q12h | 6 weeks | use if allergy |
| Viridans Streptococcus or Streptococcus gallolyticus relatively resistant to penicillin (MIC >0.12 μg/mL) | ||||
| NVE | crystalline penicillin G | 6 MU IV q4h | 4 weeks | |
| + gentamicin | 3 mg/kg IV/IM q24h | 2 weeks | ||
| NVE | vancomycin | 15 mg/kg IV q12h | 4 weeks | use if allergy, target 10-15 μ/mL |
| PVE | crystalline penicillin G | 6 MU IV q4h | 6 weeks | |
| + gentamicin | 3 mg/kg IV/IM q24h | |||
| PVE | ceftriaxone | 2 g IV/IM q24h | 6 weeks | |
| + gentamicin | 3 mg/kg IV/IM q24h | |||
| PVE | vancomycin | 15 mg/kg IV q12h | 6 weeks | use if allergy |
| Streptococcus pneumoniae | ||||
| NVE | penicillin | 4 weeks | ||
| NVE | cefazolin | 4 weeks | ||
| NVE | ceftriaxone | 4 weeks | ||
| PVE | penicillin | 6 weeks | ||
| PVE | cefazolin | 6 weeks | ||
| PVE | ceftriaxone | 6 weeks | ||
| Streptococcus pyogenes | ||||
| NVE | crystalline penicillin G | 4 weeks | ||
| NVE | ceftriaxone | 4 weeks | ||
| PVE | crystalline penicillin G | 6 weeks | ||
| PVE | ceftriaxone | 6 weeks | ||
| Group B, C, or G Streptococcus | ||||
| NVE | crystalline penicillin G | 4 weeks | ||
| ± gentamicin | 2 weeks | |||
| NVE | ceftriaxone | 4 weeks | ||
| ± gentamicin | 2 weeks | |||
| PVE | crystalline penicillin G | 6 weeks | ||
| ± gentamicin | 2 weeks | |||
| PVE | ceftriaxone | 6 weeks | ||
| ± gentamicin | 2 weeks | |||
| HACEK bacterium | ||||
| NVE | ceftriaxone | 2 g IV/IM q24h | 4 weeks | |
| PVE | ceftriaxone | 2 g IV/IM q24h | 6 weeks | |
| NVE/PVE | ciprofloxacin | 500 mg PO q12h | 6 weeks | |
Indications for Surgery
- Early valve surgery (that is, before discharge and completion of antibiotics) is recommended in some scenarios
- Left-sided endocarditis
- Acute heart failure
- Fungal endocarditis
- Highly-resistant organisms
- Heart block, annular or aortic abscess, or perforating valve lesion
- Bacteremia or fever lasting more than 5-7 days despite appropriate antimicrobials
- Severe valvular regurgitation and mobile vegetations >1 cm
- Prosthetic valve endocarditis with recurrent emboli despite appropriate antimicrobials
- Relapsed prosthetic valve endocarditis
- Right-sided endocarditis
- Severe tricuspid valve regurgitation with right heart failure despite medical therapy
- Persistent infection with difficult-to-treat organisms
- Tricuspid valve vegetation >2 cm
- Recurrent pulmonary emboli despite appropriate antimicrobials
Prevention
- Prophylaxis is recommended for high-risk patients who are undergoing higher-risk procedures
- Patient characteristics
- Prosthetic heart valve
- Previous infective endocarditis
- Unrepaired cyanotic congenital heart disease, or repaired within the past six months with prosthetic material in situ, or repaired with residual defect and with material in situ
- Cardiac transplantation with valvulopathy
- Procedures
- Dental procedures with manipulation of the gingiva, perforation of mucosa, or periapical region of teeth
- Procedures involving incision of respiratory mucosa, including tonsillectomy and bronchoscopic biopsy
- Procedures on infected tissue (skin, bone, joint, etc)
References
- ^ Kasper Iversen, Nikolaj Ihlemann, Sabine U. Gill, Trine Madsen, Hanne Elming, Kaare T. Jensen, Niels E. Bruun, Dan E. Høfsten, Kurt Fursted, Jens J. Christensen, Martin Schultz, Christine F. Klein, Emil L. Fosbøll, Flemming Rosenvinge, Henrik C. Schønheyder, Lars Køber, Christian Torp-Pedersen, Jannik Helweg-Larsen, Niels Tønder, Claus Moser, Henning Bundgaard. Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis. New England Journal of Medicine. 2019;380(5):415-424. doi:10.1056/nejmoa1808312.
- ^ John A Wildenthal, Andrew Atkinson, Sophia Lewis, Sena Sayood, Nathanial S Nolan, Nicolo L Cabrera, Jonas Marschall, Michael J Durkin, Laura R Marks. Outcomes of Partial Oral Antibiotic Treatment for Complicated Staphylococcus aureus Bacteremia in People Who Inject Drugs. Clinical Infectious Diseases. 2022;76(3):487-496. doi:10.1093/cid/ciac714.
- ^ Sarah Freling, Noah Wald-Dickler, Josh Banerjee, Catherine P Canamar, Soodtida Tangpraphaphorn, Dara Bruce, Kusha Davar, Fernando Dominguez, Daniel Norwitz, Ganesh Krishnamurthi, Lilian Fung, Ashley Guanzon, Emi Minejima, Michael Spellberg, Catherine Spellberg, Rachel Baden, Paul Holtom, Brad Spellberg. Real-World Application of Oral Therapy for Infective Endocarditis: A Multicenter, Retrospective, Cohort Study. Clinical Infectious Diseases. 2023;77(5):672-679. doi:10.1093/cid/ciad119.
