Infective endocarditis

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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 ultrasound
  • FDG-PET cardiac imaging is a new imaging modality
    • Can be useful when TEE and CTA are inconclusive, and may be able to diagnose IE earlier than those other modalities
      • May be most helpful in cases of prosthetic valves or other cardiac hardware
    • However, it is non-specific, and cannot differentiate between infection and inflammation
      • In these cases, a tagged WBC scan with SPECT can be helpful
    • False positives with inadequate preparation, or other inflammatory disorders
      • Most commonly is patients getting glucose (including in IV therapies) during the fasting period
    • False negatives can be from very small lesion, or several weeks of antibiotics (needs to be off fo r2 to 4 weeks)
    • To request, should have TEE done beforehand, then fax special access request to Ottawa
      • Response within 24-48 hours, with imaging to be done at local PET (St. Joseph's)

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 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 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 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 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 3-4 MU IV q4h 4 weeks can use high dose if penicillin-resistant but without meningitis
NVE cefazolin 2 g IV q8h 4 weeks
NVE ceftriaxone 2 g IV/IM q24h 4 weeks
PVE penicillin 3-4 MU IV q4h 6 weeks can use high dose if penicillin-resistant but without meningitis
PVE cefazolin 2 g IV q8h 6 weeks
PVE ceftriaxone 2 g IV/IM q24h 6 weeks
Streptococcus pyogenes
NVE penicillin G 3-4 MU IV q4h 4 weeks can use high dose if penicillin-resistant but without meningitis
NVE ceftriaxone 2 g IV/IM q24h 4 weeks
PVE penicillin G 3-4 MU IV q4h 6 weeks can use high dose if penicillin-resistant but without meningitis
PVE ceftriaxone 2 g IV/IM q24h 6 weeks
Group B, C, or G Streptococcus
NVE penicillin G 3-4 MU IV q4h 4 weeks can use high dose if penicillin-resistant but without meningitis
± gentamicin 3 mg/kg IV/IM q24h 2 weeks
NVE ceftriaxone 2 g IV/IM q24h 4 weeks
± gentamicin 3 mg/kg IV/IM q24h 2 weeks
PVE penicillin G 3-4 MU IV q4h 6 weeks can use high dose if penicillin-resistant but without meningitis
± 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
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
      • This includes professional cleaning procedures
    • Procedures involving incision of respiratory mucosa, including tonsillectomy and bronchoscopic biopsy
    • Procedures on infected tissue (skin, bone, joint, etc)
  • Options
    • Amoxicillin 2 g PO once, 30-60 minutes prior to procedure
    • If allergy: clindamycin 600 mg PO once, 30-60 minutes prior to procedure

Further Reading

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