1. Update on Endocarditis Dr Catherine Berry May 2012

2. Endocarditis Pathological characteristics of an episode of GBS AV endocarditis Pathological characteristics of an episode of GBS AV endocarditis Group B streptococcus in endocarditis Group B streptococcus in endocarditis What we know about endocarditis in 21 st century? What we know about endocarditis in 21 st century? Review of endocarditis at JHH, 2011 Review of endocarditis at JHH, 2011 Recent guidelines Recent guidelines Case Case

3. Valve… From : www.clevelandclinicmeded.com

4. History 1554 - First described pathologically by Jean François Fernel 1554 - First described pathologically by Jean François Fernel 1646 – Riverius noted thrill with valvular “outgrowths” at autopsy 1646 – Riverius noted thrill with valvular “outgrowths” at autopsy 1816 – 1 st stethoscope 1816 – 1 st stethoscope 1835 – Bouillaud named disease endocarditis 1835 – Bouillaud named disease endocarditis 1884 – Gram stain reported 1884 – Gram stain reported 1885 – Osler’s Gulstonian lectures – attempted classification and clinical features 1885 – Osler’s Gulstonian lectures – attempted classification and clinical features 1890’s – 1 st routine blood cultures 1890’s – 1 st routine blood cultures 1930 – 1 st clinical cures with penicillin 1930 – 1 st clinical cures with penicillin 1966 – “Infective Endocarditis in the antibiotic era” NEJM 1966 – “Infective Endocarditis in the antibiotic era” NEJM Miller B, EID 2004 Jun

5. Osler’s simple vs malignant endocarditis “.. the simple being those with few or slight symptoms, and which run a favourable course; the malignant, the cases with severe constitutional disturbance and extensive valve- lesions, whether ulcerative or vegetative, the term being more clinical than anatomical.” “.. the simple being those with few or slight symptoms, and which run a favourable course; the malignant, the cases with severe constitutional disturbance and extensive valve- lesions, whether ulcerative or vegetative, the term being more clinical than anatomical.” J R Soc Med. 1985 December; 78(12): 1039–1046.

6. What do we know about endocarditis in the 2000’s? ICE –PCS 2000-5 (Arch Int Med 2009) N=2781 - Nth/Sth America, Europe, Australasia N=2781 - Nth/Sth America, Europe, Australasia Median age 56.5; Incidence 3-10/100,000 Median age 56.5; Incidence 3-10/100,000 Acute disease Acute disease 77% in 1 st month; Osler’s nodes 3% (prev 11-23%) 77% in 1 st month; Osler’s nodes 3% (prev 11-23%) Risk factor Rate Pre-existing valve dx.. 70% 70% RHD RHD3.3% Prosthetic valve 22.2% IVDU9.8% Chronic venous access device ~10% Health care assoc. 25%

7. 2 Archives of Internal Medicine. 169(5):463&hyhen;473, March 9, 2009. DOI: 10.1001/archinternmed.2008.603 

8. What do we know about endocarditis in the 2000’s? Outcomes Outcomes 17.7% in hospital mortality 17.7% in hospital mortality 48.2% required surgery 48.2% required surgery Risk factors for death Risk factors for death SA or CoNS SA or CoNS Pulmonary oedema Pulmonary oedema Prosthetic valve Prosthetic valve Paravalvular dx. Paravalvular dx. NB. Surgery assoc with OR for death of 0.6 NB. Surgery assoc with OR for death of 0.6

9. Group B streptococcus S. agalactiae S. agalactiae 1 st recognised in cows 1 st recognised in cows 20-35% colonisation 20-35% colonisation Previously- peripartum, neonatal dx. Previously- peripartum, neonatal dx. Now – elderly, health-care assoc., DM Now – elderly, health-care assoc., DM Mostly Skin/Soft tissue infections, Mostly Skin/Soft tissue infections, spontaneous bacteraemia

10. GBS endocarditis Epidemiology Epidemiology complicates 2-9% of invasive GBS complicates 2-9% of invasive GBS 1.7  2.8% of all endocarditis in recent series 1.7  2.8% of all endocarditis in recent series Rapid onset 6-9 days Rapid onset 6-9 days Clinical features Clinical features Presentation with heart failure 70% Presentation with heart failure 70% Embolisation 37% Embolisation 37% Surgical management 40% Surgical management 40% Death 41 - 47% Death 41 - 47% ?Gentamicin ?Gentamicin Retrospective analysis of additive gent  increased rates HF (n=54) Retrospective analysis of additive gent  increased rates HF (n=54) No improvement in mortality. No improvement in mortality.

11. Endocarditis @ JHH, 2011 20 cases

12. Mortality 2011 – 40%

13. Morbidity or Mortality – 55%

14. Endocarditis 2011 male - 70% male - 70% Median age - 54.5 Median age - 54.5 >65 yrs (5 died) - 35% >65 yrs (5 died) - 35% inter-hospital transfers - 40% inter-hospital transfers - 40% surgical mmt. - 25% surgical mmt. - 25% IVDU - 40% IVDU - 40% prosthetic valves - 25% prosthetic valves - 25%

15. Guidelines ACC/AHA 2006 (Circulation)* ACC/AHA 2006 (Circulation)* ECS 2009 (European Heart Journal) ECS 2009 (European Heart Journal) BSAC 2012 (Journal of Antimicrobial chemo) BSAC 2012 (Journal of Antimicrobial chemo) Whats new and ongoing controversies Whats new and ongoing controversies Most recommendations remain on “C” level evidence Most recommendations remain on “C” level evidence 16S PCR on valve tissue 16S PCR on valve tissue Significance of Bartonella & Q-fever in culture neg IE Significance of Bartonella & Q-fever in culture neg IE Optimal surgical timing Optimal surgical timing Combination therapy in staphylococcal IE Combination therapy in staphylococcal IE MRSA abx selection MRSA abx selection

16. Indications for cardiac surgery in the management of infective endocarditis (IE) adapted from the European Society for Cardiology guidelines49 and the American Heart Association.50. Gould F K et al. J. Antimicrob. Chemother. 2012;67:269-289

17. The dilemma Recurrent embolisation is 4.8/1000 pt days (1 st week)  1.7/1000 days Recurrent embolisation is 4.8/1000 pt days (1 st week)  1.7/1000 days Surgical mortality 15% mortality 1 st week (n=95) Surgical mortality 15% mortality 1 st week (n=95) 12% recurrence 12% recurrence 7% valvular dysfunction 7% valvular dysfunction Mortality 5-7% if delayed in non-perivalvular disease. Mortality 5-7% if delayed in non-perivalvular disease.

18. AHA/European guidelines No delay if TIA or clinically silent embolisation No delay if TIA or clinically silent embolisation Immediate indications should not be delayed in ischaemic CVA episodes unless Immediate indications should not be delayed in ischaemic CVA episodes unless coma coma ICH ICH Severe neurological dx. Severe neurological dx. Severe co-morbidities Severe co-morbidities Overall 70% survivors complete recovery Overall 70% survivors complete recovery Peri-operative neurological risk (3-6%) Peri-operative neurological risk (3-6%)

19. Case - Mr DB P/w back pain and “run out of medication” to Manning Base. P/w back pain and “run out of medication” to Manning Base. Bkd Bkd Anxiety Anxiety “Prev.” IVDU “Prev.” IVDU Chronic back pain – on jurnista Chronic back pain – on jurnista Hypotensive requiring inotropic support Hypotensive requiring inotropic support Plt 16; INR 1.4; WCC 11.1; Cr 136; CRP 179 Plt 16; INR 1.4; WCC 11.1; Cr 136; CRP 179

20. Mr DB Definite endocarditis (mod. Duke’s) Definite endocarditis (mod. Duke’s) Blood cultures x 3 positive for Group B streptococcus Blood cultures x 3 positive for Group B streptococcus Echo – moderate to severe AR. Echo – moderate to severe AR. 14/11 - T/f’d JHH ?need for Sx. 14/11 - T/f’d JHH ?need for Sx.

21. ECG

22. Mr DB Management plan Management plan IV penicillin IV penicillin HDU for inotropes HDU for inotropes APS/D+A for pain management APS/D+A for pain management Cardio BPT r/v  TOE Cardio BPT r/v  TOE

23. Mr DB 15/11 15/11 Off inotropes; plt recovered  CCU Off inotropes; plt recovered  CCU BP 90/60; HR 110 BP 90/60; HR 110 16/11 16/11 S/B Cardiologist – Await TOE, for medical mmt. S/B Cardiologist – Await TOE, for medical mmt. TOE TOE

25. Mr DB 17/11- 8pm 17/11- 8pm Rapid response for RR 40; HR 140 Rapid response for RR 40; HR 140 “APO” “APO” Responded to morphine; olanzapine; frusemide Responded to morphine; olanzapine; frusemide Attempted contact with cardiologist – no response Attempted contact with cardiologist – no response

27. Mr DB

28. 18/11- 22/11 18/11- 22/11 Transferred to ward Transferred to ward CRP/obs stable. CRP/obs stable. Escalating HF rx. Escalating HF rx. Digoxin Digoxin Frusemide Frusemide ACEi ACEi Ongoing pain mmt Ongoing pain mmt

29. Mr DB 23/11 - pm 23/11 - pm increased tachypnoea, desaturating off O 2 increased tachypnoea, desaturating off O 2 ID AMO non-contactable ID AMO non-contactable Handed over to after hours medical staff Handed over to after hours medical staff 24/11 1.20am 24/11 1.20am Found dead and unable to be revived Found dead and unable to be revived 14 days presentation to death 14 days presentation to death

37. Final diagnosis: Final diagnosis: Aortic valve vegetative endocarditis. Aortic valve vegetative endocarditis. Left heart failure. Left heart failure. Splenomegaly. Splenomegaly. Splenic infarction, splenic septic emboli. Splenic infarction, splenic septic emboli.

38. Mr DB Comments.. Comments..

39. RCA recommendations – Endocarditis protocol An agreement on AMO1 An agreement on AMO1 Consults should have outcome with intended follow-up time-frame and frequency documented ?consult form Consults should have outcome with intended follow-up time-frame and frequency documented ?consult form How results of TOE’s should be conveyed How results of TOE’s should be conveyed CTS should be aware of all IE patients in the hospital. CTS should be aware of all IE patients in the hospital. Documentation requirements by all members of treating teams Documentation requirements by all members of treating teams Process and person responsible to re-engage Cardiology and CTS if the pt is not improving. Process and person responsible to re-engage Cardiology and CTS if the pt is not improving.

40. Conclusions Endocarditis has the same morbidity and mortality it did 30 years ago! Endocarditis has the same morbidity and mortality it did 30 years ago! Aetiology and presentation is evolving Aetiology and presentation is evolving GBS endocarditis has an acute and fulminant natural hx. GBS endocarditis has an acute and fulminant natural hx. A co-ordinated, multi-disciplinary approach is required to optimise outcomes A co-ordinated, multi-disciplinary approach is required to optimise outcomes

41. "Medicine is a science of uncertainty and an art of probability.” - William Osler (1849–1919)