Infective endocarditis resident survival guide
For infective endocarditis prevention resident survival guide click here.
|Infective endocarditis Resident Survival Guide Microchapters|
Infective endocarditis is an infection in the endothelium of the heart, including but not limited to the valves. While acute bacterial endocarditis is caused by an infection with a virulent organism such as staphylococcus aureus, group A or other beta-hemolytic streptococci, subacute bacterial endocarditis is an indolent infection with less virulent organisms like streptococcus viridans. Patients with unexplained fever for more than 48 hours and who are at high risk for infective endocarditis and patients among whom valve regurgitation is newly diagnosed should undergo a diagnostic workup to rule out endocarditis. The diagnosis of endocarditis depends on a thorough history and physical exam as well as the results of blood cultures and the findings on transthoracic echocardiogram or transesophageal echocardiogram. The modified Duke criteria is used to establish the diagnosis of endocarditis. Endocarditis is initially treated with empiric antibiotic therapy until the causative agent is identified.
Life Threatening Causes
Acute endocarditis is a life-threatening condition and must be treated as such irrespective of the underlying cause.
FIRE: Focused Initial Rapid Evaluation
Boxes in salmon color signify that an urgent management is needed.
Abbreviations: CT: Computed tomography ; CTA: Computed tomography angiography; MRA: Magnetic resonance angiography; MRI: Magnetic resonance imaging; TEE: Transesophageal echocardiography; TTE: Transthoracic echocardiography
Identify cardinal signs and symptoms that increase the pretest probability of endocarditis
❑ Order blood cultures (at least 2 sets)
❑ Order TTE, or
❑ Order a TEE if one or more of the following is present
❑ Evaluate the modified Duke criteria
Does the patient have any findings suggestive of complications of endocarditis that require urgent intervention?
Yes, the patient has cardiac complications
Yes, the patient has extra cardiac complications
No, the patient does not have any complications
|❑ Order abdominal CT scan or MRI|
Embolism to the brain
❑ Consider valve replacement surgery
❑ Evaluate medical vs surgical intervention
❑ Consider surgical ligation of the involved artery
Complete Diagnostic Approach
Characterize the symptoms:
❑ Onset of the symptoms
Identify existing risk factors for endocarditis:
❑ Previous infective endocarditis
Examine the patient:
❑ Heart murmur: New or change in the character of a previous murmur
❑ Full neurological exam
Evaluate the Modified Duke Criteria for infective endocarditis:
Consider alternative diagnoses:
❑ Culture negative endocarditis
❑ Cellulitis (skin inflammatory skin)
Once the diagnosis of infective endocarditis is confirmed, initiate the treatment:
❑ Manage the patient with a multidisciplinary team
Does the patient have any of the following conditions that require an early valve replacement surgery during hospitalization?
❑ Heart failure due to the valve dysfunction (Class I, level of evidence B)
|❑ Schedule for early surgery|
Follow up the patient:
❑ Repeat TTE before discharge
Reevaluate the patient with TTE and/or TEE if one of the following is present:
❑ Change in clinical signs and symptoms
❑ High risk of complications
A complete list of pathogen specific antibiotics regimens with appropriate dosages and duration of treatment is available here.
Modified Duke Criteria
Shown below is a table summarizing the major and minor Modified Duke Criteria.
- Elicit a full medical history to identify the minor Duke criteria for the diagnosis.
- Consider alternative diagnoses for bacteremia and fever by searching for the cause of the infection.
- Initiate antibiotic therapy after withdrawing blood for culture (Class I, level of evidence B).
- If the blood cultures are negative in a patient suspected to have infective endocarditis, suspect HACEK infection and ask the laboratory to retain the blood cultures for more than two weeks.
- If HACEK bacteremia is detected without any focus of infection, suspect the presence of infective endocarditis even in the absence of the typical signs and symptoms.
- Do a transesophageal echocardiography intraoperatively among patients scheduled for valve surgery for infective endocarditis (Class I, level of evidence B).
- Consider ordering a cardiac CT scan when echocardiography does not provide clear details about the cardiac anatomy in the context of suspected paravalvular infections (Class IIa, level of evidence B).
- Suspect intraventricular septal abscess as a complication of endocarditis when the ECG is significant for a gradual increase in the PR interval or a new left bundle branch block.
- Don't administer prophylaxis for infective endocarditis in patients with valvular heart disease who are at risk infective endocarditis for procedures such as transesophageal echocardiography, cystoscopy, esophagogastroduodenoscopy or colonoscopy without any evidence of active infection (Class III; level of evidence B).
- Do not administer infective endocarditis prophylaxis for the following dental procedures:
- Do not administer prophylaxis for infective endocarditis for procedures involving the respiratory tract unless they involve incision of the respiratory tract mucosa.
- Do not administer cephalosporins in subjects with a previous history of anaphylaxis, angioedema, or urticaria following penicillin or ampicillin use.
- "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary". Retrieved 4 March 2014.
- Baddour, LM.; Wilson, WR.; Bayer, AS.; Fowler, VG.; Bolger, AF.; Levison, ME.; Ferrieri, P.; Gerber, MA.; Tani, LY. (2005). "Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America". Circulation. 111 (23): e394–434. doi:10.1161/CIRCULATIONAHA.105.165564. PMID 15956145. Unknown parameter
- Weinstein L (1986). "Life-threatening complications of infective endocarditis and their management". Arch Intern Med. 146 (5): 953–7. PMID 3516105.
- Frontera JA, Gradon JD (2000). "Right-side endocarditis in injection drug users: review of proposed mechanisms of pathogenesis". Clin Infect Dis. 30 (2): 374–9. doi:10.1086/313664. PMID 10671344.
- Harrison DW, Walls RM (1990). ""Cotton fever": a benign febrile syndrome in intravenous drug abusers". J Emerg Med. 8 (2): 135–9. PMID 2362114.
- Lockhart PB, Brennan MT, Thornhill M, Michalowicz BS, Noll J, Bahrani-Mougeot FK; et al. (2009). "Poor oral hygiene as a risk factor for infective endocarditis-related bacteremia". J Am Dent Assoc. 140 (10): 1238–44. PMC 2770162. PMID 19797553.
- Li JS, Sexton DJ, Mick N, Nettles R, Fowler VG, Ryan T; et al. (2000). "Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis". Clin Infect Dis. 30 (4): 633–8. doi:10.1086/313753. PMID 10770721.
- Bonow RO, Carabello BA, Chatterjee K; et al. (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Unknown parameter