Endocarditis

Definition: Infection involving the inner lining of the heart, often involving the valves.

TUH In-Hospital Mortality- ~23%

5-Year Mortality- 40%

Risk Factors: Prosthetic valve, history of IE, intracardiac devices, rheumatic heart disease, age, hemodialysis, IV drug abuse, HIV (?), diabetes

Valves affected (TUH): Aortic 34%,Mitral 36%, Tricuspid 33%, Pulmonic 2%

Microbiology (TUH): S. aureus 58%, Viridans strep 9%, Coag. neg staph 5.5%, Enterococcus 6%

Clinical and Laboratory Findings on Admission (most common): Fever >38C, Elevated ESR/CRP, Worsening of old murmur, New murmur, Vascular embolic event, Hematuria

Complications: Cerebral (CVA, TIA, brain abscess, meningitis), Intracardiac abscess, CHF, conduction abnormalities, Osteomyelitis/Distant abscesses

Modified Duke Criteria:

Major-

  • Positive blood culture for typical IE
  • Echo with intracardiac mass, abscess, prosthetic valve dehiscence, new valvular regurgitation

Minor-

  • Predisposing heart condition
  • IV drug abuse
  • Temp >100.4
  • Vascular phenomena: arterial emboli, pulm infarcts, Janeway lesion
  • Immunologic phenomena: Osler nodes, Roth spots
  • Other positive blood cultures

Diagnosis:

  • Blood cultures (2 sets)
  • CXR
  • ECG
  • Echo (TTE vs. TEE)
    • Especially with S. aureus
  • CBC, Basic met, Coags
  • ID consult, +/- CT surgery and cardiology

Treatment:

Empiric coverage- Vancomycin

MRSA-

  • Vancomycin 30mg/kg BID x 4 weeks

Viridans strep-

  • Penicillin G q4h x 4 weeks
  • Ceftriaxone 2g daily x 4 weeks
  • Penicillin G q4h PLUS Gentamicin q8h x 2 weeks
  • Pen-Allergic Patients: Vancomycin 30mg/kg BID x 4 weeks

MSSA-

  • Oxacillin 2g q4h x 4-6 weeks
  • Cefazolin 2g q8h x 4-6 weeks
  • Pen-Allergic Patients: Cefazolin 2g q8h x 4-6 hour OR Vancomycin 30mg/kg BID x 4-6 weeks

Enterococcus-

  • Penicillin G q4h PLUS Gentamicin q8h x 2 weeks
  • Ampicillin 2mg q4h PLUS Gentamicin q8h x 4 weeks
  • Vancomycin 30mg/kg BID x 4 weeks PLUS Gentamicin q8h x 4 weeks
  • Ampicillin PLUS Ceftriaxone

HACEK-

  • Ceftriaxone 2g IV daily x 4 weeks
  • Ampicillin 2g q6h PLUS Gentamicin q8h x 4 weeks

Prosthetic Valve Endocarditis- Viridans Strep

  • Penicillin G x 6 weeks +/- Gentamicin x 2 weeks
  • Ampicillin x 6 weeks +/- Gentamicin x 2 weeks
  • Vancomycin 30mg/kg BID x 6 weeks

Prosthetic Valve Endocarditis- S. aureus

  • MSSA
    • Oxacillin 2g q6h x 6 weeks PLUS Gentamicin x 2 weeks PLUS Rifampin 300mg q8h x 6 weeks
  • MRSA
    • Vancomycin 30mg/kg BID x 6 weeks PLUS Gentamicin x 2 weeks PLUS Rifampin 300mg q8h x 6 weeks

Prosthetic Valve Endocarditis- Enterococcus

  • Ampicillin 2g q6h x 6 weeks PLUS Gentamicin x 6 weeks
  • Penicillin G x 6 weeks PLUS Gentamicin x 6 weeks
  • Vancomycin 30mg/kg BID x 6 weeks PLUS Gentamicin x 6 weeks

Valve Replacement Indications

  • Major
    • Heart Failure
    • Uncontrolled Infection
    • Prevention of Embolic Events
  • Other Indications
    • Fungal
    • Pseudomonas species
    • Perivalvular abscess
    • Valve Dehiscence

Prophylaxis

  • Prosthetic cardiac valve
  • Previous episode of IE
  • Unrepaired cyanotic congential heart disease
  • Heart transplant recipients with cardiac valvulopathy