Fingernails

Conjunctiva

Skin

CT ABDOMEN

MRI BRAIN

Infective Endocarditis

Duke Criteria Definative: 2 major, 1 major and 3 minor, 5 minor Possible: 1 major and 1 minor OR 3 minor crieria met

Duke Criteria Major: Positive Blood culture: Evidence of endocardial involvement

Duke Criteria – Major Positive Blood culture: Typical microorganism for infective endocarditis from two separate blood cultures Viridans Streptococci, streptococcus bovis, HACEK group, staph aureas, Community acquired enterococcus in absence of a primary focus OR Persistently positive blood culture (3/4 cultures or 2 cultures >12 hours apart) Single positive for coxiella bunetti, or phase I IgG titer of >1:800

Duke Criteria – Major Endocardial Involvement Positive Echo: Oscillating intracardiac mass on valve or supporting structures in the path of regurgitant jet or in implanted material in the absence of an alternative anatomic explanation Abscess New partial dehiscence of prosthetic valve New Valvular Regurgitation Increase or change in previous murmur not sufficient

Duke Criteria – Minor Predisposing condition Fever ≥38.0 C Abnormal valve (prior endocarditis, rheumatic valvular disease, Aortic Valvular disease, complex cyanotic lesions, prosthesis Abnormal risk (IVDU, indwelling catheters, poor dentition, hemodialysis, DM Fever ≥38.0 C Vascular Phenomena: Major arterial emboli, septic pulmonary infarctions, mycotic aneurism, intracranial hemorrhage, conjunctival hemorrhages, Janeway lesions

Duke Criteria – Minor Immunologic Phenomena: Glomerulonephritis, Osler;s nodes, Roth’s sports, rheumatoid factor Microbiologic evidence: Positive blood culture but not meeting major criteria Usu: gnr’s Serologic evidence of active infection with organism consistent with infective endocarditis

IE - Acute vs. Subacute Acute More virulent pathogen Rapid valvular damage Rapid hematogenous seeding of extracardiac sites Untreated leads to death in days to weeks Typical exam findings of vascular phenomenon: Janeway lesions, emboli, mycotic aneurisms

IE - Acute vs. Subacute Acute Organisms Staphylococcus Aureas (MRSA and MSSA) Beta Hemolytic Streptococcus Pneumococcus Enterococcus, Coag negative Staph (less commonly)

IE - Acute vs. Subacute Subacute Indolent course. gradual valvular damage Rarely has seeding of extracardiac sites Generally has more signs of rhematologic activation: roth spots, RF+, osler’s nodes, GN

IE - Acute vs. Subacute Subacute Organisms Viridan’s Streptococcus Enterococci Coagulase negative Staph HACEK haemophilus ssp., actinobaciullus actinomycetemcomitans, cadiobacterium hominis, eikenella corrodens, kingella ssp. Strep Bovis with colon cancer.

Age old Debate - TTE vs. TEE

Cardiac Complications CHF – 30-40% Consequence of valvular disease Perivalvular Abscess Perivalvular fistula Pericarditis Varying degrees of heart block Mitral: may interrupt the AV node, or bundle of his Aortic: non-cardiac or right sinus: upper interventricular system.

Extra-cardiac Findings Musculoskeletal Septic and reative arthritis, bone infarctions, back pain, Skin Subungual hemorrhages, janeway lesions, osler’s nodes, Eyes: Roth’s spots, conjunctival petichiae, Neuro: CVA in up to 40%, aseptic and purulent meningitis, intracranial hemorrhage, seizures, encephalopathy, microabscesses in brain and meninges, Renal: Immune complex deposition in GBM, embolic infarcts, abscesses Embolic: Any organ can be involved but most often are skin, kidneys, spleen, skeletal system, brain and meninges

Treatment Medical Management: Difficult to eradicate bacteria from the valve. Should use long course of IV bacteriocidal antibiotics and static antibiotics should be avoided. Antibiotic management should be held for cultures to be drawn. Either 4 over the course of an hour, or 2 and 2 12 hours apart. Even with appropriate management some may continue to spike fevers and have + BC

Treatment – Medical Mgmt. Strep ssp.: Pen sensitive: Penicillin G, ceftriaxone, vanc for 4 wks, OR penicilin/ceftr plus gent for 2 weeks Pen resistant: Penicillin G plus gent for 4-6wks OR Vanc 4 weeks Enterococcus: Pen g plus gen for 4-6 weeks, OR Amp plus gent for 4-6 weeks, OR vank plus gent for 4-6 weeks HACEK: Ceftriaxone for 4 weeks OR Amp/Sulbactam 4 weeks

Treatment – Medical Mgmt. MRSA Native valve Vanc for 4-6 weeks Prosthetic valve Vanc plus gent plus rifampin for 6-8 weeks MSSA Naf/oxacillin/cefazolin 4-6 wks plus gent for 4-5 days, OR vanc for 4-6 weeks Naf/oxacillin for 6-8 weeks plus gent for 2 weeks plus rifampin for 6-8 weeks

Treatment – Surgical When to consider surgical therapy Emergent (same day): aortic reguritation and preclosure of mitral valve sinus of valsalva abscess rupture into right heart rupture into pericardial sac

Treatment – Surgical Urgent (1-2 days): Valve obstruction by vegitation Unstable prosthesis Ao regurgitation with NYHA 3-4 CHF Septal perforation Perivalvular infection Lack of effective antibiotic therapy Major embolus plus persisting large vegetation (evidence conflicting but concensus opinion)

Treatment – Surgical Elective (earlier usually preferred): Progressive paravalvular prothetic regurgitation Valve dysfuntion plus persistent infection after 7-10 days of Abx Fungal endocarditis (specifically mold) Prosthetic vave: With staph <2 moths after preplacement Fungal Antibiotic resistant

Treatment – Surgical Abx after surgery: If native valve and uncomplicated with negative valve cultures: 2 weeks of post operative antibiotics OR a total full duration of above regimen whichever is longer If complicated by perivalvular abscess, partially treated prosthetic valve infection or cases with culture positive valves: Full course of antibiotics after surgery

Complication rate: Mortality with staph aureas: 70% with medical management - decreases to 25% with surgical intervention Splenic abscess 3-5% Should be treated with drain placement Mycotic aneurisms: 2-15%, 50% in cerebral vasculature Some resolve with Abx so monitor with cerebral angiography recommended Persistent enlarging or periferal aneurisms should be resected surgically if possible Vegitations 50% remain unchanged 3 months after cure is achieved, and 25% have slight improvement

Prophylaxis: Indications: Prosthetic heart valves Prior endocarditis Unrepaired cyanotic congenital heart disease Completely repaired congential heart disease <6 months after repair) Incompletely repaired congenital heart diease with residual defects adjacent to prosthetic material Valvulopathy developing after cardiac transplantation

Prophylaxis: Regimens: Standard: amoxicillin 2.0 g PO 1 hour prior to procedure If pen allergic: clarithromycin or azithro 500 mg prior to procedure Cefalexin 2.0 g PO prior to procedure Clindamycin 600 mg prior to procedure

Bibliography Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service. American Journal of Medicine. 96(3):200-9, 1994. Jennifer S. Li, Daniel J. Sexton, Nathan Mick, Richard Nettles, Vance G. Fowler, Jr., Thomas Ryan, Thomas Bashore, G. Ralph Corey . Proposed Modifications to the Duke Criteria for the Diagnosis of Infective Endocarditis. Clinical Infectious Diseases, Vol. 30, No. 4 (Apr., 2000), pp. 633-638 Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, Loscalzo J. (2008). Harrison's principles of internal medicine (17th ed.). Pp.789-798; New York: McGraw-Hill Medical Publishing Division Fuster, O’rourke, Walsh, Poole-Wilson. (2008). Hurst’s The heart Manual of Cardiology (12th ed.). 1975-2004. New York: McGraw-Hill Medical Publishing Division