Infective endocarditis: Difference between revisions

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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]]


=== Antimicrobial Selection ===
===Antimicrobial Selection===
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!Valve
!Valve
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=== Indications for Surgery ===
===Indications for Surgery===


* Early valve surgery (that is, before discharge and completion of antibiotics) is recommended in some scenarios
*Early valve surgery (that is, before discharge and completion of antibiotics) is recommended in some scenarios
* Left-sided endocarditis
*Left-sided endocarditis
** Acute heart failure
**Acute heart failure
** Fungal endocarditis
**Fungal endocarditis
** Highly-resistant organisms
**Highly-resistant organisms
** Heart block, annular or aortic abscess, or perforating valve lesion
**Heart block, annular or aortic abscess, or perforating valve lesion
** Bacteremia or fever lasting more than 5-7 days despite appropriate antimicrobials
**Bacteremia or fever lasting more than 5-7 days despite appropriate antimicrobials
** Severe valvular regurgitation and mobile vegetations >1 cm
**Severe valvular regurgitation and mobile vegetations >1 cm
** Prosthetic valve endocarditis with recurrent emboli despite appropriate antimicrobials
**Prosthetic valve endocarditis with recurrent emboli despite appropriate antimicrobials
** Relapsed prosthetic valve endocarditis
**Relapsed prosthetic valve endocarditis
* Right-sided endocarditis
*Right-sided endocarditis
** Severe tricuspid valve regurgitation with right heart failure despite medical therapy
**Severe tricuspid valve regurgitation with right heart failure despite medical therapy
** Persistent infection with difficult-to-treat organisms
**Persistent infection with difficult-to-treat organisms
** Tricuspid valve vegetation >2 cm
**Tricuspid valve vegetation >2 cm
** Recurrent pulmonary emboli despite appropriate antimicrobials
**Recurrent pulmonary emboli despite appropriate antimicrobials


== Prevention ==
==Prevention==


* Prophylaxis is recommended for high-risk patients who are undergoing higher-risk procedures
*Prophylaxis is recommended for high-risk patients who are undergoing higher-risk procedures
* Patient characteristics
*Patient characteristics
** Prosthetic heart valve
**Prosthetic heart valve
** Previous infective endocarditis
**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
**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
**Cardiac transplantation with valvulopathy
* Procedures
*Procedures
** Dental procedures with manipulation of the gingiva, perforation of mucosa, or periapical region of teeth
**Dental procedures with manipulation of the gingiva or periapical region of teeth, perforation of mucosa
** Procedures involving incision of respiratory mucosa, including tonsillectomy and bronchoscopic biopsy
**Procedures involving incision of respiratory mucosa, including tonsillectomy and bronchoscopic biopsy
** Procedures on infected tissue (skin, bone, joint, etc)
**Procedures on infected tissue (skin, bone, joint, etc)


[[Category:Cardiac infections]]
[[Category:Cardiac infections]]

Revision as of 00:29, 19 August 2020

Background

  • Infection of endocardium, generally involving the heart valves, either prosthetic or native

Microbiology

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

Subacute Bacterial Endocarditis

  • Insidious onset with more pronounced constitutional symptoms progressing over weeks to months

Differential Diagnosis

Diagnosis

  • Based on a combination of clinical exam, laboratory investigations, and imaging
  • Refer to Modified Duke criteria

Management

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 or periapical region of teeth, perforation of mucosa
    • Procedures involving incision of respiratory mucosa, including tonsillectomy and bronchoscopic biopsy
    • Procedures on infected tissue (skin, bone, joint, etc)