Endocarditis
Grant Whitebloom
Michael Kaminski
Etiology & Pathogenesis
- Endothelial injury > fibrin-platelet vegetation > bacteremia > infected vegetation
- Common organisms: S. aureus, VGS, Enterococci (faecalis>faecium), CoNS (prosthetic valves), HACEK, Candida. Uncommon organisms: Coxiella, Brucella, Bartonella, Chlamydia, Legionella, Mycoplasma, T whipplei, C. acnes, Aspergillus
- Culture Negative: most commonly recent abx, also Non-infectious (marantic endocarditis, Libman-Sacks Endocarditis)
- Risk factors: IVDU, intracardiac devices, prosthetic valves, poor dentition, iHD, DM, immunosuppression
Presentation
- Acute (days of rapid valve destruction, sepsis, emboli) vs Subacute (weeks to months of lowgrade fever, malaise, weight loss)
- Fever, murmur, splenomegaly, splinter hemorrhages, Janeway lesions, Osler nodes, Roth spots
- Complications: CHF, stroke, PE, mycotic aneurysm, perivalvular abscess +/- heart block
Diagnostics & Workup
- Workup: ESR/CRP, UA (hematuria), BCxs (≥3 sets from separate sites before abx, then q24h until clearance), EKG and Tele, TTE (vs TEE if prosthetic valve, high suspicion, or c/f perivalvular abscess), CT/MRI brain (for left sided IE or if neuro signs), Bartonella/Coxiella/Brucella serology; PCR (16S rRNA) on valve tissue if available
- ID Consult for all pts to guide abx, OPAT, fu
- Consider repeat TTE after treatment for new baseline
Duke Criteria
Definite IE (2 major, OR 1 major+3 minor, OR 5 minor) vs Possible IE (1 major+1 minor, OR 3 minor) vs Rejected (firm alternate diagnosis, resolution of evidence with <4d of abx, or absence of pathologic evidence with <4d of abx)
| Acute NVE (days) | Vanc + CTX |
| Subacute NVE (weeks) | Vanc + CTX |
| PVE <1 year post-op | Vanc + CTX +/- Rifampin +/- Gent (discuss with ID) |
| PVE >1 year post-op | Vanc + CTX (discuss with ID) |
Empiric Treatment
| Acute NVE (days) | Vanc + CTX |
| Subacute NVE (weeks) | Vanc + CTX |
| PVE <1 year post-op | Vanc + CTX +/- Rifampin +/- Gent (discuss with ID) |
| PVE >1 year post-op | Vanc + CTX (discuss with ID) |
Definitive Therapy by Organism
- All regimens listed below should be managed together with ID assistance.
Organism |
Native Valve (NVE) |
Prosthetic Valve (PVE) |
|---|---|---|
| MSSA | Cefazolin ×6W | Cefazolin + Rifampin ≥6W + Gent ×2W |
| MRSA | Vanc OR Dapto ×6W | Vanc + Rifampin ≥6W + Gent ×2W |
| E. faecalis (PCN-susc) | Amp + CTX ×6W (preferred) OR Amp + Gent ×4-6W |
Same |
| VGS |
PCN MIC ≤0.12: CTX ×4W PCN MIC >0.12–≤0.5: CTX ×4W + Gent ×2W |
CTX ×6W ± Gent ×2W CTX ×6W + Gent ×6W |
| HACEK | CTX ×4W | CTX ×6W |
| Candida | Ampho +/- Flucytosine + surgery | Same |
Indications for Early Surgery
- Class I: HF from valve dysfunction; persistent bacteremia >5–7 days on appropriate Abx; heart block/annular abscess/penetrating lesion; fungal or resistant organisms
- Class IIa: Recurrent emboli + persistent vegetation; severe regurg + mobile vegetation >10 mm
- Stroke/intracranial hemorrhage: delay surgery ≥4 weeks; ischemic without hemorrhage