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Infective endocarditits
- 2. 1. Positive blood culture Typical microorganism for infective endocarditis from two separate blood cultures or Persistent bactaeremia (two positive cultures >12 hours apart or three positive cultures or a majority of ≥4 culture positive results >1 hour apart) or Single positive blood culture for Coxiella burnetii or phase I IgG antibody titer of >1:800
- 4. 2. Evidence of endocardial involvement Positive echocardiogram 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 New valvular regurgitation (increase or change in preexisting murmur not sufficient)
- 6. Minor Criteria • 1. Predisposition: predisposing heart conditions 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 an organism consistent with infective endocarditis
- 11. Definite IE • Pathologically proven IE • Two major criteria • One major and three minor criteria • Five minor criteria
- 12. Possible IE • One major and one minor clinical criterion • Three minor clinical criteria
- 13. Rejected IE • Firm alternative diagnosis • Resolution of IE syndrome with antibiotic therapy for ≤4 days • No pathologic evidence of IE at surgery or autopsy with antibiotic therapy ≤4 days • Does not meet criteria for possible IE
- 14. Streptococci Penicillin- susceptible b streptococci, S. gallolyticus • Penicillin G (2–3 mU IV q4h for 4 weeks) • Ceftriaxone (2 g/d IV as a single dose for 4 weeks) • Vancomycin c (15 mg/kg IV q12h for 4 weeks) • Penicillin G (2–3 mU IV q4h) or ceftriaxone (2 g IV qd) for 2 weeks plus Gentamicin d (3 mg/kg qd IV or IM, as a single dose e or divided into equal doses q8h for 2 weeks) Relatively penicillin-resistant f • Penicillin G (4 mU IV q4h) or ceftriaxone (2 g IV qd) for 4 weeks plus Gentamicin d (3 mg/kg qd IV or IM, as a single dose e or divided into equal doses q8h for 2 weeks) • Vancomycin c as noted above for 4 weeks Moderately penicillin- resistant g streptococci, nutritionally variant organisms, or Gemella species • Penicillin G (4–5 mU IV q4h) or ceftriaxone (2 g IV qd) for 6 weeks plus Gentamicin d (3 mg/kg qd IV or IM as a single dose e or divided into equal doses q8h for 6 weeks) • Vancomycin c as noted above for 4 weeks Harrison's Principles of Internal Medicine, 19th Edition Textbook
- 15. Staphylococci MSSA infecting native valves (no foreign devices) • Nafcillin, oxacillin, or flucloxacillin (2 g IV q4h for 4–6 weeks) • Cefazolin (2 g IV q8h for 4–6 weeks) • Vancomycin c (15 mg/kg IV q12h for 4–6 weeks) MRSA infecting native valves (no foreign devices) • Vancomycin c (15 mg/kg IV q8–12h for 4–6 weeks) MSSA infecting prosthetic valves • Nafcillin, oxacillin, or flucloxacillin (2 g IV q4h for 6–8 weeks) plus Gentamicin d (1 mg/kg IM or IV q8h for 2 weeks) plus • Rifampin i (300 mg PO q8h for 6–8 weeks) MRSA infecting prosthetic valves • Vancomycin c (15 mg/kg IV q12h for 6–8 weeks) plus Gentamicin d (1 mg/kg IM or IV q8h for 2 weeks) plus Rifampin i (300 mg PO q8h for 6–8 weeks) Harrison's Principles of Internal Medicine, 19th Edition Textbook
- 16. Indications for Cardiac Surgical Intervention in Patients with Endocarditis Surgery Required for Optimal Outcome Moderate to severe congestive heart failure due to valve dysfunction Partially dehisced unstable prosthetic valve Persistent bacteremia despite optimal antimicrobial therapy Lack of effective microbicidal therapy (e.g., fungal or Brucella endocarditis) S. aureus prosthetic valve endocarditis with an intracardiac complication Relapse of prosthetic valve endocarditis after optimal antimicrobial therapy Harrison's Principles of Internal Medicine, 19th Edition Textbook
- 17. Indications for Cardiac Surgical Intervention in Patients with Endocarditis Surgery to Be Strongly Considered for Improved Outcome a Perivalvular extension of infection Poorly responsive S. aureus endocarditis involving the aortic or mitral valve Large (>10 mm in diameter) hypermobile vegetations with increased risk of embolism, particularly with prior embolic event or with significant valve dysfunction Persistent unexplained fever (≥10 days) in culture-negative native valve endocarditis Poorly responsive or relapsed endocarditis due to highly antibiotic-resistant enterococci or gram-negative bacilli Harrison's Principles of Internal Medicine, 19th Edition Textbook
- 18. TABLE 155-8High-Risk Cardiac Lesions for Which Endocarditis Prophylaxis Is Advised before Dental Procedures Prosthetic heart valves Prior endocarditis Unrepaired cyanotic congenital heart disease, including palliative shunts or conduits Completely repaired congenital heart defects during the 6 months after repair Incompletely repaired congenital heart disease with residual defects adjacent to prosthetic material Valvulopathy developing after cardiac transplantation a aNot a target population for prophylaxis according to recommendations of the European Society for Cardiology. Source: Table created using the guidelines published by the American Heart Association and the European Society of Cardiology (W Wilson et al: Circulation 116:1736, 2007; and G Habib et al: Eur Heart J 30:2369, 2009).
- 19. TABLE 155-7Antibiotic Regimens for Prophylaxis of Endocarditis in Adults with High-Risk Cardiac Lesions A. Standard oral regimen Amoxicillin: 2 g PO 1 h before procedure B. Inability to take oral medication Ampicillin: 2 g IV or IM within 1 h before procedure C. Penicillin allergy 1. Clarithromycin or azithromycin: 500 mg PO 1 h before procedure 2. Cephalexin c : 2 g PO 1 h before procedure 3. Clindamycin: 600 mg PO 1 h before procedure D. Penicillin allergy, inability to take oral medication 1. Cefazolin c or ceftriaxone c : 1 g IV or IM 30 min before procedure 2. Clindamycin: 600 mg IV or IM 1 h before procedure Source: Table created using the guidelines published by the American Heart Association and the European Society of Cardiology (W Wilson et al: Circulation 116:1736, 2007; and G Habib et al: Eur Heart J 30:2369, 2009).
- 20. Reference • Holland, Thomas L. et al. “Infective Endocarditis.” Nature reviews. Disease primers 2 (2016): 16059. PMC. Web. 8 July 2017. • Davidson's Principles and Practice of Medicine, 22nd Edition • Harrison's Principles of Internal Medicine, 19th Edition Textbook