Morning Report: Infectious Endocarditis

Here’s Dr. Abram with today’s Morning Report!

Infectious Endocarditis  – infection of endothelium of heart, valves, septal defect.

Generally fatal without treatment, leading to valvular insufficiency, congestive heart failure and myocardial abscess.

20% from rheumatic heart disease. 6% of those with rheumatic dz get IE. 50% elderly have calcific aortic stenosis.

Bacteria seeding –

Dental procedures – 40-100%

TURP – 20-40%

Endoscopy/colonoscopy/TEE – 0-20%

Subtypes:

Native – acute – aggressive, usually S. aureus and GBS, maybe lacking structural heart disease

Native – subacute – less aggressive, typically only abnormal valves, Alpha-hemolytic strep, enterococci

Prosthetic valve – 5 % of implanted valves, first 3 months mechanical more common, after one year bioprosthetic more common. Mitral valve most common.

Early – within 60 days of implant, staph, gram neg bacilli, candida MC

Late – after 60 days, alpha-hemolytic strep, staph, enterococci MC

IVDU – 75% normal valves, 50% tricuspid valve, Staph aureus

Nosocomial IE – from e.g. central lines

Pacemaker IE – Similar to Prosthetic valve – infected usually within 3 months, MC in generator pocket, proximal leads, distal leads

Signs: Fever (50%), Heart murmur (85%), Petechiae, Osler nodes, splinter hemorrhages, Janeway lesions, Roth spots

Systemic Signs: Embolic stroke/neurologic defects (20%), intracerebral hemorrhage, multiple microabscesses

Symptoms: (if subacute) low-grade fever, weight loss, anorexia, influenza-like sx, polymyalgia sx, pleuritic pain, rheumatic syndromes (fever, HA, delirium), abdominal symptoms

Diagnosis:

Cultures: blood cultures x 2 with typical IE bacteria, 3 or more separate blood cultures from 1 or more hours apart (one culture is worse than none? Some say draw 3-5 over 60-90 min before abx)

Major Echo findings: Echo positive for IE/vegetation, Myocardial abscess, partial dehiscence of prosthetic valve, new valvular regurgitation

Minor IE criteria:

1. heart condition/IVDU
2. fever
3. vascular findings (emboli, infarcts, hemorrhage, Janeway)
4. immunologic findings (glomerulonephritis, Osler nodes, Roth spots, RF+)
5. blood cultures unusual organism
6. echo positive but unusual findings

dx: 2 major

1 major +3 minor

5 minor

Treatment:

Native valve – pen G + gentamycin (now use vancomycin with MRSA), can also use 2g CTx

Prosthetic valve – add Rifampin to penetrate biofilm

Can use linezolid or daptomycin if can’t have vancomycin

If subacute can wait until cultures grow (?)

Anticoagulation is controversial

Prognosis: 40-98% depending on organism

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Brian

Kings County Hospital | SUNY Downstate Emergency Medicine Resident -Clinical Monster Webmaster

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