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Epidemiology of Infective Endocarditis

Infective Endocarditis : Epidemiology, Diagnosis and Management Holger P. Salazar, MD, FACC Stern Cardiovascular Foundation No financial relation to disclose. Epidemiology of Infective Endocarditis. Epidemiology of Infective Endocarditis.

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Epidemiology of Infective Endocarditis

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  1. Infective Endocarditis: Epidemiology, Diagnosis and ManagementHolger P. Salazar, MD, FACCStern Cardiovascular FoundationNo financial relation to disclose

  2. Epidemiology of Infective Endocarditis

  3. Epidemiology of Infective Endocarditis • Annual incidence in USA 10,000-20,000 new cases, stable over past 30 years • Prosthetic valve endocarditis accounts for 15% of cases • Mortality is about 20%, due to CHF, valvular dysfunction, or uncontrolled infection • 50% over the age of 50

  4. Valvular Involvement in Infective Endocarditis Valve Percent of Cases Mitral 28-45% Aortic 5-36% Aortic + Mitral 0-35% Tricuspid 5% Combined right and left 0-4%

  5. Most Common Underlying Cardiac Lesions In Infective Endocarditis • Mitral valve prolapse • Degenerative valvular lesions • Calcified mitral annulus • Valve nodules • Bicuspid Aortic Valve • Prosthetic Valve

  6. Risk of Infective Endocarditis for Selected Groups Risk Factor Incidence* Injection Drug Use150-2000 Rheumatic heart disease 440 Bioprosthesis 383 Prior endocarditis 340-740 Mechanical prosthesis 308 VSD (Medical therapy) 220 *Cases per 105 patient-years

  7. Classification of Infective Endocarditis

  8. Infective Endocarditis: Classification Native Valve (75-90% of cases) • Acute -- ˃ 1 to 2 weeks • Subacute-- >2 week Prosthetic Valve (10-25% of cases) • Early Onset--˃ 12 months • Late Onset-- > 12 months

  9. Two Flavors of Infective Endocarditis: Native and Prosthetic Valves

  10. Clinical Manifestations of Endocarditis

  11. Fever 80 Chills 40 Weakness 40 Dyspnea 40 Sweats 25 Weight loss 25 Malaise 25 Stroke 20 Skin lesions 20 Headache 20 Achiness 20 Chest pain 15 Altered mental status 10-15 Back pain 10 Infective Endocarditis: Symptoms (%)

  12. Fever 90 Murmur 85 New 3-5 Changing 5-10 Emboli 50+ Splenomegaly 20-57 Metastatic 20 infection Retinal lesions 20 Skin manifestations 18-50 Petechiae 20-40 Splinters 15 Osler’s nodes 10-23 Janeway lesions <10 Native Valve Endocarditis: Signs (%)

  13. Cutaneous Findings of Endocarditis Janeway lesions are nontender macular lesions most commonly involving the palms and soles and are caused by septic emboli Osler’s nodes are small raised, swollen, painful erythematous lesions the size of a pea, on pads of fingers or toes Splinter hemorrhages

  14. Roth’s Spots and Endocarditis Round or oval retinal hemorrhages with white spots seen in the retina early in the course of IE, caused by complex mediated vasculitis

  15. Microbiology of Endocarditis

  16. Microbiology of Native Valve Endocarditis Organism Percent of Cases Viridans streptococci 30-40% Other streptococci 15-25% Staphylococcus aureus10-27% Enterococcus species 5-18% Gram negative bacilli2-13%

  17. Microbiology of Prosthetic-Valve Endocarditis Organism Percentage of Cases Early Onset Late Onset (> 12 m) Coagulase negative staph30-35%15% Staphylococcus aureus 17-23% 20% Gram negative bacilli 10% 5% Streptococci 5-10% 33% Fungi 10% 2%

  18. Causes of Culture-Negative Endocarditis • Coxiella burnetti (Q fever) • Bartonella species (cat scratch disease) • HACEK organisms* • Legionella species • Aspergillus species • Lactobacillus species * Haemophilus species; Actinobacillus actinomycetemcomitans; Cardiobacteriumhominis; Eikenella corrodens; and Kingella kingae

  19. Echocardiography and Diagnosis of Endocarditis

  20. Transthoracic Echocardiography and Endocarditis • No technological advance has had as much impact on approach to patients with IE • Rapid, non-invasive and specific for vegetations (98%) • May be inadequate in 20% of patients because of obesity, COPD, or chest-wall deformities • TTE should be used in the evaluation of those with suspected native valve IE who are good candidates for imaging

  21. Transesophageal Echocardiography and Endocarditis • More costly and invasive but increases the sensitivty (from 75% to 95%) while maintaining specificity (85-98%) • More sensitive for defining perivalvular extension, perforation of valves, and myocardial abscess • A negative TEE has a negative predictive value for IE of > 92%

  22. TTE or TEE or Both? • Recent guidelines suggest that among patients with suspected endocarditis appropriate use of echocardiography depends on prior probability of IE • If this probability is < 4% , a negative TTE is cost effective and satisfactory in ruling out IE • If this probability is 4 to 60%, initial use of TEE is more cost effective and efficient than initial TTE followed by TEE (if former negative) Mylonakis & Calderwood NEJM 2001;345:1318

  23. Limitations of Echocardiography in the Diagnosis of Endocarditis • Falsely negative early in disease • False positive diagnosis with thickened valve leaflets, valve nodules or tumors • Inability to distinguish healed from active vegetations • Lower sensitivity in those with mechanical prostheses • Blood cultures remain the test of choice for patients with suspected endocarditis

  24. Duke Criteria for Diagnosis of Endocarditis

  25. Duke Criteria for Diagnosis of Infective Endocarditis: Major Criteria • Positive blood culture for typical organism (from 2 separate cultures or Staphylococcus aureusor enterococcalbacteremia without a primary focus) or • Persistent bacteremia for any organism > 12 hrs apart or • All of 3 or majority of 4 BC positive drawn > 1 hr apart • Echocardiographic criteria - Oscillating mass, abscess or new dehiscence of prosthesis - New valvular regurgitation

  26. Duke Criteria for Diagnosis of Infective Endocarditis: Minor Criteria • Predisposing heart condition or injection drug use • Fever greater than or equal to 38o C • Immunologic phenomena: GN, Osler’s nodes, Roth Spots, RF • Echo consistent, but not meeting major criteria • Vascular phenomena: arterial embolism, septic PE, mycotic aneurysm, intracranial hemorrhage, Janeway lesions • Microbiologic evidence: positive BC not meeting major criteria or serology indicating active infection with consistent organism

  27. Duke Criteria for Diagnosis of Infective Endocarditis Definite endocarditis: Pathologic criteria • Organisms by culture or histology in vegetation, embolus, or cardiac abscess or • Pathologic lesion such as vegetation or cardiac abscess Clinical criteria • 2 major, or 1 major plus 3 minor, or 5 minor criteria

  28. Right Sided Endocarditis in Injection Drug Users

  29. Right-sided Endocarditis in Injection Drug Users 46 y/o man injection drug user (heroin) with fevers, sweats and right sided pleuritic chest pain. Blood cultures grew penicillin- susceptible S. aureus and echocardiogram showed 1 mm Tricuspid valve vegetation. HIV negative and in hospital for 7 days with oxacillin and gentamicin followed by 21 days of outpatient ceftriaxone (2 gms/ day). Multiple peripheral septic emboli with cavitation

  30. Right-Sided Endocarditis in Injection Drug Users • Common complication with overall favorable prognosis • Vegetations > 2 cm associated with higher mortality (33% vs 1.3%) • S. aureus most common pathogen (>80%) than Viridans streptococci • >50% with septic emboli on chest radiographs Hecht SR and Berger M Ann Int Med 1992;117:560

  31. Right Sided Endocarditis in Injection Drug Users: Treatment • Two week regimen (nafcillin or oxacillin + gentamicin) for susceptible isolates • Oral therapies still controversial • Exclusion to “short-course” protocol: • Extracardiac complications of IE • Fever for > 7 days • HIV infection • Vegetation > 1-2 cm Chambers HF Ann Intern Med 1988;109:619

  32. AHA Guidelines for Treatment of Endocarditis

  33. Aortic Versus Mitral Valve Endocarditis Overall incidence Surgical Patients Aortic ~55% ~75% Mitral ~85% ~40% Pulmonary ~1% Tricuspid ~20% Acute aortic regurgitation is poorly tolerated because the LV is less compliant than the LA resulting higher LV wall stress! Watch out for abrupt deterioration!

  34. AHA Guidelines for Antibiotic Therapy in Native Valve Endocarditis Organism Regimen Weeks PCN-sensitive PCN G 12-18 MI qdor 4Ceftriaxone 2 g qdor 4Ceftriaxone 2 g qd + 2 Gentamicin 3 mg/kg qdor Vancomycin 1 g bid 4 PCN-insensitive PCN G 18 MI qd + 4 Gentamicin 1 mg/kg tid2 or Vancomycin 1 g bid 4 Doses assume normal renal function

  35. AHA Guidelines for Antibiotic Therapy in Native Valve Endocarditis Organism Regimen Weeks MSSA Oxacillin or Nafcillin 2 g q4h 4-6 or Cefazolin 2 g tid 4-6 both +/- Gentamicin 1 mg/kg tid 3-5d or Vancomycin 1 g bid +/- Gent MRSA Vancomycin 1 g bid 4-6 +/- Gentamicin 1 mg/kg tid 4-6 Doses assume normal renal function

  36. AHA Guidelines for Antibiotic Therapy in Native Valve Endocarditis Organism Regimen Weeks Enterococci (VSE)PCN + Gentamicinor 6Vancomycin + Gentamicin 6 as above HACEK Ceftriaxone 2 g qdor 4 Ampicillin 2 g q4h + 4 Gentamicin 1 mg/kg tid 4 Doses assume normal renal function

  37. AHA Guidelines for Antibiotic Therapy in Prosthetic Valve Endocarditis Organism Regimen Weeks MSSA or MSSE Oxacillin or Nafcillin 2 g q4h 6+ + Gentamicin 1 mg/kg tid 2 + Rifampin 300 mg tid 6+ MRSA or MRSE Vancomycin 1 g bid 6+ + Gentamicin 1 mg/kg tid 2 + Rifampin 300 mg tid 6+ Doses assume normal renal function

  38. Steel: Often the Best Antimicrobial Agent In Treating Infective Endocarditis

  39. Medical versus Surgical therapy • Surgery is always in addition to medical therapy • The vast majority of the operated patients would die if not operated • Some medically treated patients are “inoperable”

  40. Refractory CHF > 1 serious embolic event Uncontrolled infection Physiologically significant valve dysfunction by echo Fungal endocarditis Ineffective antimicrobial therapy Mycotic aneurysm Most cases of PVE due to antibiotic resistant pathogens Local cardiac suppurative complications Surgical Indications in Endocarditis

  41. Persistent vegetations after a major embolus Large (> 1 cm) mitral valve vegetation Increasing vegetation size after 4 weeks of antimicrobial therapy Acute mitral insufficiency Valve perforation or rupture Periannular extension of infection AHA Committee on Endocarditis Echocardiographic Features Predicting Need for Surgery in Endocarditis

  42. Homograft or Prosthetic Valve Replacement for Aortic Valve IE • There are no and probably will be no randomized studies! • Good results are possible to obtain with either • However, an increasing number of publications favor homografts • Technically easier and safer • Lower risk of heart block • Lower infection and re-infection rate • Homograft does not require anticoagulation • Limited supply of homografts • Limited durability of homograft

  43. Timing of Surgery 30% require surgery in the acute phase another 20-40% will require surgery later • Main principle: Don’t postpone an indicated operation, however: • Pts with strokes: Postpone surgery, if possible 1-3 weeks, particularly if evidence of hemorrhage • If valve repair is planned: 1 week of preop antibiotic treatment • Re-infection rate is lower after surgery for healed endocarditis

  44. Early Surgery Versus Conventional Treatment for IE Kaplan–Meier Curves for Cumulative Probabilities of Death and Composite End Point at 6 Months Kang DH, et al: NEJM 2012; 366:2466

  45. Early Surgery Versus Conventional Treatment for IE Clinical End Points Early Surgery Versus Conventional Treatment for Infective Endocarditis Kang D et al. N Engl J Med 2012;366:2466-2473. Kang DH, et al: NEJM 2012; 366:2466

  46. Special Surgical Considerations Related to Location • Aortic valve IE: Be aggressive! • Acute aortic regurgitation is poorly tolerated • Mitral valve IE: Repair whenever possible, consider risk of embolism • Right-sided IE: Be conservative! • Repair, excision, (replacement) • Pulmonary valve IE is very uncommon

  47. Aortic Root Endocarditis With Vegetation and Fistula to Right Atrium

  48. The infection penetrates through to the floor of the Right atrium just about to destroy the A-V node

  49. Ventricular Assist Device Associated Endocarditis

  50. LVAD and Endocarditis

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