1. Shuktika Nandkeolyar, PGY2 5/29/2017
Acute Infective Bacterial Endocarditis Diagnosis and initial management
Shuktika Nandkeolyar, PGY2
5/29/2017

2. Objectives
Know the screening criteria (Duke’s criteria) for endocarditis
Know the initial work up of endocarditis
Common exam findings
Imaging modalities
Lab work

3. Vignette
26 y/o F PMHx IVDU (heroin) who presents with fevers, chills, nausea, vomiting and diarrhea for the past 3 weeks. She was febrile to 102.5F, HR 128, BP 91/62. CXR demonstrated multiple pulmonary lesions. On exam, 3/6 RLSB systolic murmur, remainder of the exam in unremarkable.
What work up would you order to diagnose endocarditis?

4. Predisposing factors to bacterial infective endocarditis
Dental manipulation and disease
Instrumentation (urinary tract, GI tract, IV infusions)
Cardiac surgery
Injection drug use
2) instrumentation: think gram positive bugs which could be introduced / cause transient bacteremia.

5. (Modified) Duke’s Criteria
Definitive IE (Clinical criteria)
2 major criteria OR 1 major and 3 minor criteria, OR 5 minor criteria
Possible IE
1 major and 1 minor, or 3 minor criteria
Pathological criteria: microorganisms demonstrated by culture or histological examination of a vegetation, embolized tissue specimen, or intracardiac abscess

6. Major Criteria
Major
Two Blood cultures positive with typical organisms:
Single positive blood culture for coxiella burnetti
Echocardiogram positive for IE
Persistently positive blood cultures defined as: at least 2 positive cultures of blood samples > 12h apart, or all 3 or a majority of >4 separate cultures of blood ) with first and last samples drawn at least 1h apart.
HACEK: Haemophilus, Arregregatibacter, cardiobacterium, eikenella, kingella
Typical organisms: strep Viridans, strep bovis, HACEK, S. aureus, community-acquired enterococci (in the absence of primary focus), microorganisms consistent with IE from persistently positive cultures

7. Minor Criteria Predisposition / predisposing heart condition, or IVDU
Fever, temperature >38C
Vascular phenomena:
Immunological phenomena:
Microbiological evidence: + blood culture that doesn’t meet major criteria
Our patient had fever, and septic pulmonary infarcts and was an IVDU. She met “probable endocarditis” even before doing any labs or imaging, based on Duke’s criteria
major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage, Janeway lesions
Immunologic criteria glomerulonephritis, Osler nodes, Roth spots, RF

8. Pretest Probability High risk patients (pretest probability > 4%):
prosthetic valves
congenital heart diseases
previous endocarditis
new murmur
(new onset) heart failure
Other stigmata of endocarditis (see next slide for physical exam).
Low Risk: EVERYONE ELSE!

9. Physical Exam findings
#1: Antibiotics, salicylates, steroids, severe CHF, uremia may mask temperature elevations. Can also consider hypoxemia in the setting of endocarditis causing valvular disease causing HF OR pulmonary emboli
Osler’s nodes: painful, erythematous, nodular lesions
Roth spot: oval retinal heorrhages with pale centers
Janeway lesions: erythematous blanching macules, nonpainful

10. Labs 3 sets of blood cultures from different sites
CBC w/ diff: looking for leukocytosis, bandemia, anemia
BMP: evidence of kidney disease
UA: if kidney disease, evaluate for hematuria/proteinuria
EKG: look for conduction abnormalities

11. When to get an Echo If
Either way, get TTE first! The urgency of the TEE depends on risk factors. High risk candidates are patients with prosthetic valves, congenital heart diseases, previous endocarditis, new murmur, heart failure, or other stigmata of endocarditis.
Our patient in our clinical vignette is high risk so we would go down high risk pathway for her (this means probable endocarditis )
A TTE is first line, regardless of high or low risk!
If your pretest probability is > 4%, or
Patient has probable endocarditis based on Duke’s criteria,
Consider TEE in addition to TTE.

12. Other Imaging If hypoxic, consider CXR or CT of chest
If focal neurologic deficits, consider CT of head for hemorrhagic stroke. MRI if looking for ischemic septic emboli.
CT head will change management if a surgery is in order – if hemorrhagic stroke, it can be a reason to delay valve surgery

13. Back to our vignette?
26 y/o F PMHx IVDU (heroin) who presents with fevers, chills, nausea, vomiting and diarrhea for the past 3 weeks. She was febrile to 102.5F, HR 128, BP 91/62. CXR demonstrated multiple pulmonary lesions. On exam, 3/6 RLSB systolic murmur, remainder of the exam in unremarkable.
What work up would you order to diagnose endocardits?

14. Consider the following:
Labs:
Blood cultures x3
CBC
BMP
Utox
EKG
Imaging:
CT chest
TTE
Initial management:
IVF resuscitation
Antibiotics
ID and Cardiology consult
CT chest given shortness of breath. Utox given IVDU history. EKG to ensure no conduction defects (unexpected in this young female).

15. Summary Duke’s criteria: High pretest probability (>4%)
Major: Positive blood cultures or TTE/TEE findings
Minor: fevers, IVDU, atypical cultures, vascular or immunologic phenomena
High pretest probability (>4%)
high risk behaviors
Hx prior valvular disease or congenital heart disease
probable endocarditis by Duke’s criteria
Labs: CBC, CMP, 3 sets of blood cultures
Imaging: TTE first! Consider other imaging based on symptoms or exam findings.

17. References
Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications, L. M. Baddour et al., Circulation. 2015
Uptodate.com
MKSAP17
Medcomic.com