1. Infective Endocarditis
경희대학교 의과대학
감염내과
박기호

2. Modified Duke Criteria
Definite IE
Possible IE
2 major criteria (blood cultures + echo)
1 major criteria
+ 3 minor criteria
5 minor criteria
1 major + 1 minor
3 minors
Rejection criteria
Resolution of endocarditis syndrome with antibiotic therapy for 4 days

3. Modified Duke Criteria
Major Criteria 
1. Positive blood culture
  A) Typical microorganism for infective endocarditis from two separate blood cultures
     Viridans streptococci, Streptococcus gallolyticus, HACEK group, Staphylococcus aureus, or
      Community-acquired enterococci in the absence of a primary focus, or
Persistently positive blood culture, defined as recovery of a microorganism consistent
with infective endocarditis from:
가) Blood cultures drawn >12 h apart; or
나) All of 3 or a majority of 4 separate blood cultures, with first and last drawn
at least 1 h apart
C)  Single positive blood culture for Coxiella burnetii or phase I IgG antibody titer of >1:800
2. Evidence of endocardial involvement
  A) Positive echocardiogramb
Oscillating intracardiac mass on valve or supporting structures or in the path of regurgitant jets or in implanted material, in the absence of an alternative anatomic explanation, or
     Abscess, or
     New partial dehiscence of prosthetic valve, or
  B) New valvular regurgitation (increase or change in preexisting murmur not sufficient)

4. Modified Duke Criteria
Minor Criteria 
1. Predisposition: predisposing heart condition or injection drug use
2. Fever 38.0°C (100.4°F)
3. Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, Janeway lesions
4. Immunologic phenomena: glomerulonephritis, Osler's nodes, Roth's spots, rheumatoid factor
5. Microbiologic evidence: positive blood culture but not meeting major criterion as noted previously or serologic evidence of active infection with organism consistent with infective endocarditis

5. Etiology of Native Valve Endocarditis
AMC from 2000 through 2009 (Duke definite IE:328 cases)
Unpublished

6. Musculoskeletal symptom
Musculoskeletal manifestation: 84 (44%) of 192 cases of bacterial endocarditis
Churchill MA, Jr., et al. Ann Intern Med 1977; 87: 754-9

7. Splenic septic emboli in endocarditis
patients with left sided endocarditis
Splenic infarcts and abscess: 19% (20/108)
Incidental finding of splenic infarct: 38% (11/29)
Splenectomy in 50% (10/20)
Persistent sepsis in 60% (n = 6), large (>2cm) in 30%, splenic rupture in 10% (n=1)
perioperative mortality: 33% (3/10)
Ting W, et al. Circulation 1990; 82: IV105-9

8. Baddour LM, et al. Circulation 2005; 111: e394-434

9. Aminoglycoside toxicity
Figure 1. % of auditory toxicity, represented as a function of age
Gatell JM, et al. Antimicrob Agents Chemother 1987; 31:

10. Gavalda. et al. Ann Intern Med 2007; 146: 574-9

11. Habib G, et al. Eur Heart J 2009; 30: 2369-41
c(i) linezolid mg/day i.v. or orally for 8 weeks (IIa, C), (ii) quinupristin–dafopristin mg/kg/day for 8 weeks (IIa, C), (iii) b-lactam combinations including imipenem plus ampicillin or ceftriaxone plus ampicillin for 8 weeks (IIb, C).
Habib G, et al. Eur Heart J 2009; 30:

12. Ampicillin and ceftriaxone
159 patients with Enterococcal faecalis IE Ampicillin-ceftriaxone (AC) and Ampicillin-aminoglycoside (AA) Three-month mortality (8% vs 7%, P = 0.72). Renal failure (23% vs. 0%, P<0.001).
Fernandez-Hidalgo N, et al. Clin Infect Dis 2013; 56:

13. Summary Musculosketal Sx: common (immunologic or embolic)
Enterococcal endocarditis: PCN/AMP + AG
AG: nephrotoxicity + ototoxicity
Audiometry monitoring: AG combination
New treatment for enterococcal infection
- Double beta-lactam (Ampicillin + Ceftriaxone)