Infective Endocarditis Matthew Leibowitz, MD David Geffen School of Medicine at UCLA Division of Infectious Diseases
Epidemiology <ul><li>10-20,000 cases per year in the US </li></ul><ul><li>Male:Female ratio 1.7:1 </li></ul><ul><li>New tr...
Epidemiology <ul><li>Mitral valve alone 28-45% </li></ul><ul><li>Aortic valve alone 5-36% (bicuspid valve in 20% of all na...
Classification <ul><li>OLD </li></ul><ul><ul><li>Subacute Bacterial Endocarditis </li></ul></ul><ul><ul><ul><li>Death in 3...
Pathogenesis <ul><li>Alteration of the valvular endothelial surface leading to deposition of platelets and fibrin </li></u...
Pathogenesis <ul><li>Low pressure side of structural lesion </li></ul><ul><ul><li>Atrial side of mitral valve (MR) </li></...
Pathogenesis <ul><li>Transient bacteremia </li></ul><ul><ul><li>Traumatization of mucosal surface colonized with bacteria ...
 
Microbiology <ul><li>Staphylococcus aureus  (30-40%) </li></ul><ul><li>Viridans group streptococci (18%) </li></ul><ul><li...
Characteristics of Causative Organisms <ul><li>Adherence factors critical for growth in the vegetation </li></ul><ul><ul><...
Risk Factors <ul><li>Structural heart disease </li></ul><ul><ul><li>Rheumatic, congenital, aging </li></ul></ul><ul><ul><l...
Clinical Manifestations <ul><li>Symptoms </li></ul><ul><ul><li>Fever, sweats, chills </li></ul></ul><ul><ul><li>Anorexia, ...
 
Cardiac Pathologic Changes <ul><li>Vegetations on valve closure lines </li></ul><ul><li>Destruction and perforation of val...
S. Aureus  mitral valve vegetation, anterior leaflet
 
Pathologic Changes <ul><li>Kidney </li></ul><ul><ul><li>Immune complex glomerulonephritis </li></ul></ul><ul><ul><li>Embol...
 
Pathologic Changes <ul><li>Splenic enlargement, infarction </li></ul><ul><li>Septic or bland pulmonary embolism </li></ul>...
 
 
 
 
Case Definition <ul><li>1977 Pelletier and Petersdorf criteria  </li></ul><ul><li>1981 von Reyn criteria </li></ul><ul><li...
Modified Duke Criteria <ul><li>Major Criteria </li></ul><ul><ul><li>Positive blood cultures with typical organisms </li></...
Modified Duke Criteria <ul><li>Minor Criteria </li></ul><ul><ul><li>Predisposition (valvular disease or IDU) </li></ul></u...
Modified Duke Criteria <ul><li>Definite IE </li></ul><ul><ul><li>Pathologic criteria </li></ul></ul><ul><ul><li>Clinical c...
Blood Cultures <ul><li>MULTIPLE BLOOD CULTURES BEFORE EMPIRIC THERAPY </li></ul><ul><li>If not critically ill </li></ul><u...
“Culture Negative” IE <ul><li>Less common with improved blood culture methods </li></ul><ul><li>Special media required </l...
HACEK <ul><li>H aemophilus aphrophilus, H. paraphrophilus, parainfluenzae </li></ul><ul><li>A ctinobacillus actinomycetemc...
Other microbiologic methods <ul><li>PCR </li></ul><ul><ul><li>Coxiella burnetii </li></ul></ul><ul><ul><li>Tropheryma whip...
Echocardiography <ul><li>Transthoracic </li></ul><ul><ul><li>Relatively low sensitivity </li></ul></ul><ul><ul><li>Good sp...
When to go to TEE first? <ul><li>Limited thoracic windows = TTE low sensitivity </li></ul><ul><li>Prosthetic valves </li><...
Other tests <ul><li>Electrocardiogram </li></ul><ul><ul><li>Conduction delays </li></ul></ul><ul><ul><li>Ischemia or infar...
Treatment of IE <ul><li>Native vs. Prosthetic Valve </li></ul><ul><li>Bactericidal therapy is necessary </li></ul><ul><li>...
Antimicrobial Therapy <ul><li>Most patients are afebrile in 3-5 days </li></ul><ul><li>Long duration of therapy (4-6 weeks...
Native Valve IE <ul><li>Viridans Streptococci and  S. bovis </li></ul><ul><ul><li>Aqueous Penicillin G 12-20 million units...
Native Valve IE <ul><li>Aminoglycosides for synergy </li></ul><ul><ul><li>Low concentrations are adequate (1-3 mcg/ml) </l...
Native Valve IE <ul><li>Enterococci, ampicillin sensitive </li></ul><ul><ul><li>High rates of failure </li></ul></ul><ul><...
Native Valve IE <ul><li>S. aureus </li></ul><ul><ul><li>Penicillinase-resistant semi-synthetic penicillin (oxacillin or na...
Native Valve IE <ul><li>Methicillin-resistant  S. aureus </li></ul><ul><ul><li>Vancomycin is bacteriostatic </li></ul></ul...
Native Valve IE <ul><li>HACEK </li></ul><ul><ul><li>Ceftriaxone 2 g IV q 24 x 4-6 weeks </li></ul></ul><ul><li>Fungal </li...
Native Valve IE <ul><li>Indications for surgery </li></ul><ul><ul><li>Refractory CHF </li></ul></ul><ul><ul><li>More than ...
Prosthetic Valve IE <ul><li>Staphylococci most common </li></ul><ul><ul><li>Coagulase negative staphylococci </li></ul></u...
Prosthetic Valve IE <ul><li>Risk is greatest in the first 3 months and first year (early PV IE) </li></ul><ul><ul><li>Coag...
Prosthetic Valve IE <ul><li>TEE should be used first </li></ul><ul><li>Staphylococci </li></ul><ul><ul><li>Vancomycin or o...
 
 
Prophylaxis of IE <ul><li>Uncertainty and controversy </li></ul><ul><li>No randomized trials </li></ul><ul><li>Indirect ev...
 
 
 
 
Clinical Case <ul><li>43 yo man ESRD, Cadaveric Renal Transplant 2004 </li></ul><ul><li>Recurrent UTIs, placement of nephr...
Clinical Case <ul><li>Urine with MRSA, 4/4 blood cultures with MRSA </li></ul><ul><li>Initial TTE: EF 35-45%, thickened AV...
Clinical case <ul><li>Renal allograft removed the following day with abscess </li></ul><ul><li>Replacement of AV and MV an...
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Endocarditis 2005 12

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Endocarditis 2005 12

  1. 1. Infective Endocarditis Matthew Leibowitz, MD David Geffen School of Medicine at UCLA Division of Infectious Diseases
  2. 2. Epidemiology <ul><li>10-20,000 cases per year in the US </li></ul><ul><li>Male:Female ratio 1.7:1 </li></ul><ul><li>New trends </li></ul><ul><ul><li>Mean age was 30 in 1926, now > 50% of patients are over 60 </li></ul></ul><ul><ul><li>Decline in incidence of rheumatic fever </li></ul></ul><ul><ul><li>More prosthetic valves </li></ul></ul><ul><ul><li>More nosocomial cases, injected drug use </li></ul></ul><ul><ul><li>More staphylococcal infection </li></ul></ul>
  3. 3. Epidemiology <ul><li>Mitral valve alone 28-45% </li></ul><ul><li>Aortic valve alone 5-36% (bicuspid valve in 20% of all native valve IE) </li></ul><ul><li>Both mitral and aortic valves 0-36% </li></ul><ul><li>Tricuspid valve 0-6% </li></ul><ul><li>Pulmonic valve <1% </li></ul><ul><li>Right and left sided 0-4% </li></ul>
  4. 4. Classification <ul><li>OLD </li></ul><ul><ul><li>Subacute Bacterial Endocarditis </li></ul></ul><ul><ul><ul><li>Death in 3-6 months </li></ul></ul></ul><ul><ul><li>Acute Bacterial Endocarditis </li></ul></ul><ul><ul><ul><li>Death in < 6 weeks </li></ul></ul></ul><ul><li>NEW </li></ul><ul><ul><li>Native Valve Endocarditis </li></ul></ul><ul><ul><li>Prosthetic Valve Endocarditis </li></ul></ul>
  5. 5. Pathogenesis <ul><li>Alteration of the valvular endothelial surface leading to deposition of platelets and fibrin </li></ul><ul><li>Bacteremia with seeding of non-bacterial thrombotic vegetation (NBTE) </li></ul><ul><li>Adherence and growth, further platelet and fibrin deposition </li></ul><ul><li>Extension to adjacent structures </li></ul><ul><ul><li>Papillary muscle, aortic valve ring abscess, conduction system </li></ul></ul>
  6. 6. Pathogenesis <ul><li>Low pressure side of structural lesion </li></ul><ul><ul><li>Atrial side of mitral valve (MR) </li></ul></ul><ul><ul><li>Ventricular side of aortic valve (AR, AS with R) </li></ul></ul><ul><ul><li>Congenital abnormality (MV prolapse, bicuspid AV) </li></ul></ul><ul><ul><li>Scarring from rheumatic heart disease or sclerosis as a consequence of aging </li></ul></ul><ul><ul><li>Prosthetic valves </li></ul></ul><ul><li>Other turbulence, high-velocity jets </li></ul><ul><ul><li>Ventricular septal defect </li></ul></ul><ul><ul><li>Stenotic valve </li></ul></ul><ul><li>Direct mechanical damage from catheters, pacemaker leads </li></ul>
  7. 7. Pathogenesis <ul><li>Transient bacteremia </li></ul><ul><ul><li>Traumatization of mucosal surface colonized with bacteria (oral, GI) </li></ul></ul><ul><ul><li>Low grade, cleared in 15-30 minutes </li></ul></ul><ul><ul><li>Susceptibility to complement-mediated bacterial killing </li></ul></ul><ul><li>Leads to concept of prophylaxis </li></ul>
  8. 9. Microbiology <ul><li>Staphylococcus aureus (30-40%) </li></ul><ul><li>Viridans group streptococci (18%) </li></ul><ul><li>Enterococci (11%) </li></ul><ul><li>Coagulase-negative staphylococci (11%) </li></ul><ul><li>Streptococcus bovis (7%) </li></ul><ul><li>Other streptococci (5%) </li></ul><ul><li>Non-HACEK Gram negatives (2%) </li></ul><ul><li>HACEK Organisms (2%) </li></ul><ul><li>Fungi (2%) </li></ul><ul><li>“ Culture negative” (2-20%) </li></ul>
  9. 10. Characteristics of Causative Organisms <ul><li>Adherence factors critical for growth in the vegetation </li></ul><ul><ul><li>Can adhere to damaged valves (Staph, Strep and Enterococci have adhesins that mediate attachment) </li></ul></ul><ul><ul><li>Staph adhesin binds fibrinogen and fibronectin </li></ul></ul><ul><ul><li>Bacteria trigger tissue-factor production from local monocytes and induce platelet aggregation so the organisms become enveloped in the vegetation </li></ul></ul><ul><ul><li>Protection from immune clearance leads to large numbers of bacteria (10 9 -10 10 per g of tissue) </li></ul></ul>
  10. 11. Risk Factors <ul><li>Structural heart disease </li></ul><ul><ul><li>Rheumatic, congenital, aging </li></ul></ul><ul><ul><li>Prosthetic heart valves </li></ul></ul><ul><li>Injected drug use </li></ul><ul><li>Invasive procedures (?) </li></ul><ul><li>Indwelling vascular devices </li></ul><ul><li>Other infection with bacteremia (e.g. pneumonia, meningitis) </li></ul><ul><li>History of infective endocarditis </li></ul>
  11. 12. Clinical Manifestations <ul><li>Symptoms </li></ul><ul><ul><li>Fever, sweats, chills </li></ul></ul><ul><ul><li>Anorexia, malaise, weight loss </li></ul></ul><ul><li>Signs </li></ul><ul><ul><li>Anemia (normochromic, normocytic) </li></ul></ul><ul><ul><li>Splenomegaly </li></ul></ul><ul><ul><li>Microscopic hematuria, proteinuria </li></ul></ul><ul><ul><li>New or changing heart murmur, CHF </li></ul></ul><ul><ul><li>Embolic or immunologic dermatologic signs </li></ul></ul><ul><ul><li>Hypergammaglobulinemia, elevated ESR, CRP, RF </li></ul></ul>
  12. 14. Cardiac Pathologic Changes <ul><li>Vegetations on valve closure lines </li></ul><ul><li>Destruction and perforation of valve leaflet </li></ul><ul><li>Rupture of chordae tendinae, intraventricular septum, papillary muscles </li></ul><ul><li>Valve ring abscess </li></ul><ul><li>Myocardial abscess </li></ul><ul><li>Conduction abnormalities </li></ul>
  13. 15. S. Aureus mitral valve vegetation, anterior leaflet
  14. 17. Pathologic Changes <ul><li>Kidney </li></ul><ul><ul><li>Immune complex glomerulonephritis </li></ul></ul><ul><ul><li>Emboli with infarction, abscess </li></ul></ul><ul><li>Aortic mycotic aneurysms </li></ul><ul><li>Cerebral embolism </li></ul><ul><ul><li>Infarction, abscess, mycotic aneurysms </li></ul></ul><ul><ul><li>Purulent meningitis is rare </li></ul></ul>
  15. 19. Pathologic Changes <ul><li>Splenic enlargement, infarction </li></ul><ul><li>Septic or bland pulmonary embolism </li></ul><ul><li>Skin </li></ul><ul><ul><li>Petechiae </li></ul></ul><ul><ul><li>Osler nodes: diffuse infiltrate of neutrophils, and monocytes in the dermal vessels with immune complex deposition. Tender and erythematous </li></ul></ul><ul><ul><li>Janeway lesions: septic emboli with bacteria, neutrophils and SQ hemorrhage and necrosis. Blanching and non-tender. Palms and soles </li></ul></ul>
  16. 24. Case Definition <ul><li>1977 Pelletier and Petersdorf criteria </li></ul><ul><li>1981 von Reyn criteria </li></ul><ul><li>1994 Duke criteria </li></ul><ul><li>2000 Modified Duke criteria </li></ul>
  17. 25. Modified Duke Criteria <ul><li>Major Criteria </li></ul><ul><ul><li>Positive blood cultures with typical organisms </li></ul></ul><ul><ul><li>Persistently positive blood cultures </li></ul></ul><ul><ul><li>Evidence of Endocardial involvement </li></ul></ul><ul><ul><ul><li>Positive Echocardiogram </li></ul></ul></ul><ul><ul><ul><ul><li>Oscillating intracardiac mass </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Abscess </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Dehiscence of prosthetic valve </li></ul></ul></ul></ul><ul><ul><ul><li>New Valvular regurgitation </li></ul></ul></ul>
  18. 26. Modified Duke Criteria <ul><li>Minor Criteria </li></ul><ul><ul><li>Predisposition (valvular disease or IDU) </li></ul></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Vascular phenomena (Arterial emboli, septic pulmonary infarcts, intracranial hemorrhage, Osler, Janeway) </li></ul></ul><ul><ul><li>Immunologic phenomena (GN, Osler, Roth spots, Rheumatoid Factor) </li></ul></ul>
  19. 27. Modified Duke Criteria <ul><li>Definite IE </li></ul><ul><ul><li>Pathologic criteria </li></ul></ul><ul><ul><li>Clinical criteria </li></ul></ul><ul><ul><ul><li>2 Major Criteria OR </li></ul></ul></ul><ul><ul><ul><li>1 Major and 3 minor Criteria OR </li></ul></ul></ul><ul><ul><ul><li>5 Minor Criteria </li></ul></ul></ul><ul><li>Possible IE </li></ul><ul><ul><ul><li>1 Major and 1 Minor OR </li></ul></ul></ul><ul><ul><ul><li>3 Minor </li></ul></ul></ul><ul><li>Rejected IE </li></ul>
  20. 28. Blood Cultures <ul><li>MULTIPLE BLOOD CULTURES BEFORE EMPIRIC THERAPY </li></ul><ul><li>If not critically ill </li></ul><ul><ul><li>3 blood cultures over 12-24 hour period </li></ul></ul><ul><ul><li>? Delay therapy until diagnosis confirmed </li></ul></ul><ul><li>If critically ill </li></ul><ul><ul><li>3 blood cultures over one hour </li></ul></ul><ul><li>No more than 2 from same venipuncture </li></ul><ul><li>Relatively constant bacteremia </li></ul>
  21. 29. “Culture Negative” IE <ul><li>Less common with improved blood culture methods </li></ul><ul><li>Special media required </li></ul><ul><ul><li>Brucella, Mycoplasma, Chlamydia, Histoplasma, Legionella, Bartonella </li></ul></ul><ul><li>Longer incubation may be required </li></ul><ul><ul><li>HACEK </li></ul></ul><ul><li>Coxiella burnetii (Q Fever), Trophyrema whipplei will not grow in cell-free media </li></ul>
  22. 30. HACEK <ul><li>H aemophilus aphrophilus, H. paraphrophilus, parainfluenzae </li></ul><ul><li>A ctinobacillus actinomycetemcomitans </li></ul><ul><li>C ardiobacterium hominis </li></ul><ul><li>E ikenella corrodens </li></ul><ul><li>K ingella kingae </li></ul>
  23. 31. Other microbiologic methods <ul><li>PCR </li></ul><ul><ul><li>Coxiella burnetii </li></ul></ul><ul><ul><li>Tropheryma whipplei </li></ul></ul><ul><ul><li>Bartonella henselae </li></ul></ul><ul><li>Serology </li></ul><ul><ul><li>Coxiella burnetii </li></ul></ul><ul><ul><li>Bartonella </li></ul></ul><ul><ul><li>Brucella </li></ul></ul><ul><ul><li>Legionella </li></ul></ul><ul><ul><li>Chlamydophila psittaci </li></ul></ul>
  24. 32. Echocardiography <ul><li>Transthoracic </li></ul><ul><ul><li>Relatively low sensitivity </li></ul></ul><ul><ul><li>Good specificity </li></ul></ul><ul><li>Transesophageal </li></ul><ul><ul><li>Detection of valve ring abscess (87% vs. 28% sensitivity for TTE) </li></ul></ul><ul><ul><li>Detection of prosthetic valve IE </li></ul></ul>
  25. 33. When to go to TEE first? <ul><li>Limited thoracic windows = TTE low sensitivity </li></ul><ul><li>Prosthetic valves </li></ul><ul><li>Prior valvular abnormality </li></ul><ul><li>S. aureus bacteremia and suspected IE </li></ul><ul><li>Bacteremia with organisms likely to cause IE </li></ul><ul><li>= high prior probability of IE </li></ul>
  26. 34. Other tests <ul><li>Electrocardiogram </li></ul><ul><ul><li>Conduction delays </li></ul></ul><ul><ul><li>Ischemia or infarction </li></ul></ul><ul><li>Chest X-ray </li></ul><ul><ul><li>Septic emboli in right-sided IE </li></ul></ul><ul><ul><li>Valve calcification </li></ul></ul><ul><ul><li>CHF </li></ul></ul>
  27. 35. Treatment of IE <ul><li>Native vs. Prosthetic Valve </li></ul><ul><li>Bactericidal therapy is necessary </li></ul><ul><li>Eradication of bacteria in the vegetation </li></ul><ul><ul><li>May be metabolically inactive (stationary phase) </li></ul></ul><ul><ul><li>May need higher concentrations of antimicrobial agents </li></ul></ul>
  28. 36. Antimicrobial Therapy <ul><li>Most patients are afebrile in 3-5 days </li></ul><ul><li>Long duration of therapy (4-6 weeks or more) </li></ul><ul><li>Combination therapy most important for </li></ul><ul><ul><li>Shorter course regimens </li></ul></ul><ul><ul><li>Enterococcal endocarditis </li></ul></ul><ul><ul><li>Prosthetic valve infections </li></ul></ul>
  29. 37. Native Valve IE <ul><li>Viridans Streptococci and S. bovis </li></ul><ul><ul><li>Aqueous Penicillin G 12-20 million units/day continuously or divided q4 or q6 for 4 weeks </li></ul></ul><ul><ul><li>If intermediate susceptibility to penicillin, aqueous penicillin G 24 million units or ceftriaxone 2 g q24 PLUS aminoglycoside for the first 2 weeks </li></ul></ul>
  30. 38. Native Valve IE <ul><li>Aminoglycosides for synergy </li></ul><ul><ul><li>Low concentrations are adequate (1-3 mcg/ml) </li></ul></ul><ul><ul><li>Gentamicin 3 mg/kg divided q12 or q8 </li></ul></ul><ul><ul><li>Little data for q24 dosing </li></ul></ul>
  31. 39. Native Valve IE <ul><li>Enterococci, ampicillin sensitive </li></ul><ul><ul><li>High rates of failure </li></ul></ul><ul><ul><li>β-lactams are bacteriostatic, must combine with aminoglycoside for optimal therapy </li></ul></ul><ul><ul><li>High-level gentamicin resistance occurs in 35% </li></ul></ul><ul><ul><ul><li>High-dose ampicillin for 8-12 weeks </li></ul></ul></ul><ul><li>Enterococci, ampicillin resistant </li></ul><ul><ul><li>Vancomycin plus gentamicin </li></ul></ul><ul><li>Enterococci, vancomycin resistant </li></ul><ul><ul><li>Linezolid or daptomycin </li></ul></ul><ul><ul><li>Penicillin + vancomycin + gentamicin ? </li></ul></ul>
  32. 40. Native Valve IE <ul><li>S. aureus </li></ul><ul><ul><li>Penicillinase-resistant semi-synthetic penicillin (oxacillin or nafcillin) 1.5-2 g IV q4 or cephalosporin (cefazolin 1-2 g IV q8) for 4-6 weeks </li></ul></ul><ul><ul><li>Aminoglycoside synergistic but does not affect survival, not recommended </li></ul></ul><ul><ul><li>Short course in right-sided IE </li></ul></ul><ul><ul><ul><li>2 weeks of semi-synthetic penicillin and aminoglycoside </li></ul></ul></ul>
  33. 41. Native Valve IE <ul><li>Methicillin-resistant S. aureus </li></ul><ul><ul><li>Vancomycin is bacteriostatic </li></ul></ul><ul><ul><li>Vancomycin plus aminoglycoside or rifampin </li></ul></ul><ul><ul><li>Daptomycin </li></ul></ul><ul><ul><li>Linezolid </li></ul></ul>
  34. 42. Native Valve IE <ul><li>HACEK </li></ul><ul><ul><li>Ceftriaxone 2 g IV q 24 x 4-6 weeks </li></ul></ul><ul><li>Fungal </li></ul><ul><ul><li>Amphotericin </li></ul></ul><ul><ul><li>Fluconazole </li></ul></ul><ul><ul><li>Caspofungin, little data </li></ul></ul><ul><ul><li>Surgery usually necessary 1-2 weeks into treatment </li></ul></ul>
  35. 43. Native Valve IE <ul><li>Indications for surgery </li></ul><ul><ul><li>Refractory CHF </li></ul></ul><ul><ul><li>More than one systemic embolic event </li></ul></ul><ul><ul><li>Uncontrolled infection </li></ul></ul><ul><ul><li>Physiologically significant valvular dysfunction </li></ul></ul><ul><ul><li>Ineffective antimicrobial therapy (e.g. fungal) </li></ul></ul><ul><ul><li>Local suppurative complications </li></ul></ul><ul><ul><li>Mycotic aneurysm </li></ul></ul>
  36. 44. Prosthetic Valve IE <ul><li>Staphylococci most common </li></ul><ul><ul><li>Coagulase negative staphylococci </li></ul></ul><ul><li>Enterococcus </li></ul><ul><li>Nutritonally variant streptococci </li></ul><ul><li>Fungi </li></ul>
  37. 45. Prosthetic Valve IE <ul><li>Risk is greatest in the first 3 months and first year (early PV IE) </li></ul><ul><ul><li>Coagulase-negative staphylococci in early endocarditis, S. aureus </li></ul></ul><ul><ul><li>Late-onset more similar to native valve disease in microbiology but more coagulase-negative staphylococci. Valve is endothelialized </li></ul></ul>
  38. 46. Prosthetic Valve IE <ul><li>TEE should be used first </li></ul><ul><li>Staphylococci </li></ul><ul><ul><li>Vancomycin or oxacillin plus rifampin for at least six weeks, gentamicin for the first two weeks (3 mg/kg q24) </li></ul></ul><ul><ul><li>Rifampin started at least 2 days after 2 other agents to avoid resistance </li></ul></ul>
  39. 49. Prophylaxis of IE <ul><li>Uncertainty and controversy </li></ul><ul><li>No randomized trials </li></ul><ul><li>Indirect evidence (uncontrolled clinical series, case-control studies) </li></ul><ul><li>Decision analysis </li></ul>
  40. 54. Clinical Case <ul><li>43 yo man ESRD, Cadaveric Renal Transplant 2004 </li></ul><ul><li>Recurrent UTIs, placement of nephrostomy tube </li></ul><ul><li>Fevers, chills, altered mental status, sepsis syndrome </li></ul><ul><li>Bradycardia to 35 and increased PR </li></ul>
  41. 55. Clinical Case <ul><li>Urine with MRSA, 4/4 blood cultures with MRSA </li></ul><ul><li>Initial TTE: EF 35-45%, thickened AV with moderate AS, thickened or calcified MV mild MR </li></ul><ul><ul><li>“ Compared with last previous echo, 3/3/00, there is no significant change. In the presence of valvular thickening, cannot rule out endocarditis. </li></ul></ul><ul><li>Next day TEE </li></ul><ul><ul><li>thickened AV, mild to moderate AS, no AR. 2 vegetations ~1 cm on ventricular side </li></ul></ul><ul><ul><li>Markedly thickened MV, large mobile vegetation >4cm on atrial side anterior leaflet, possible second vegetation on posterior leaflet, mild MR </li></ul></ul>
  42. 56. Clinical case <ul><li>Renal allograft removed the following day with abscess </li></ul><ul><li>Replacement of AV and MV and resection of left ventricular abscess cavity two days later </li></ul>

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