Fingernails

Conjunctiva

Skin

CT ABDOMEN

MRI BRAIN

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 culturesViridans 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 InvolvementPositive 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

AbscessNew partial dehiscence of prosthetic valve

New Valvular RegurgitationIncrease or change in previous murmur not sufficient

Duke Criteria – MinorPredisposing condition

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 CVascular 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 pathogenRapid valvular damageRapid hematogenous seeding of

extracardiac sitesUntreated 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 StreptococcusPneumococcusEnterococcus, Coag negative Staph (less

commonly)

IE - Acute vs. Subacute Subacute

Indolent course.gradual valvular damageRarely 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 StreptococcusEnterococciCoagulase negative StaphHACEK

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 AbscessPerivalvular fistulaPericarditisVarying 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.

○ MRSANative valve

- Vanc for 4-6 weeksProsthetic valve

- Vanc plus gent plus rifampin for 6-8 weeks

○ MSSANative valve

- Naf/oxacillin/cefazolin 4-6 wks plus gent for 4-5 days, OR vanc for 4-6 weeks

Prosthetic valve- Naf/oxacillin for 6-8 weeks plus gent for 2 weeks

plus rifampin for 6-8 weeks

Treatment – Surgical

When to consider surgical therapyEmergent (same day):

○ aortic reguritation and preclosure of mitral valve

○ sinus of valsalva abscess rupture into right heart

○ rupture into pericardial sac

Treatment – SurgicalUrgent (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 – SurgicalElective (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 preplacementFungalAntibiotic resistant

Treatment – SurgicalAbx 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 longerIf 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 procedureIf 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