This document defines infective endocarditis and discusses its pathogenesis, clinical features, diagnosis, treatment and complications. Some key points: - Infective endocarditis is defined as an infection of the endocardial surface of the heart, including heart valves. It most commonly affects the atrial side of the AV valves and ventricular side of semilunar valves. - Staphylococcus aureus is now the most common causative organism, whereas streptococci were previously more common. Risk factors include underlying heart conditions, intravenous drug use, and invasive procedures. - Clinical features include fever, heart murmur, embolic events, and immunological findings like Roth spots and Osler nodes

1. INFECTIVE ENDOCARDITIS
M. VINOD KUMAR

2. DEFINITION
• INVASION AND MULTIPLICATION OF MICROORGANISMS ON
THE ENDOCARDIAL SURFACE,
- WITHIN THE ENDOCARDIUM ,
- WITHIN THE MYOCARDIUM,
- OR ON PROSTHETIC MATERIALS WITHIN AND AROUND
CARDIAC STRUCTURES.

3. DEFINITION
• CONDITIONS IN WHICH STRUCTURES OF THE HEART
( FREQUENTLY VALVES) HARBOR AN INFECTIVE PROCESS;
- THAT LEADS TO VALVAR DYSFUNCTION,
- LOCALISED OR GENERALISED SEPSIS,
- OR SITES FOR EMBOLISM

4. THE TERM COVERS ,,,,
a) A/C TO DURATION
- ACUTE,
- SUBACUTE,
- CHRONIC
b) A/C TO INFECTING AGENT
- BACTERIAL,
- VIRAL,
- RICKETTSIAL
- FUNGAL
c) A/C TO SITE OF INFECTION
- NATIVE VALVE,
- PROSTHETIC VALVE

5. HISTORICAL NOTE
• 1841 - BOUILLAUD - THE TERM ENDOCARDITIS
• 1885 - OSLER - CLASSICAL FEATURES
• 1950 - PRINCIPLES OF AB THERAPY ESTABLISHED
• 1961 - KAY & COLLEAGUES - FIRST SURGICAL Rx
• 1970s - STINSON , RICHARDSON & COLLEAGUES
MODERN CONCEPTS OF SURGICAL Rx

6. PATHOGENESIS
• MOST COMMON SITE IS :
- ATRIAL SIDE OF AV VALVES
- VENTRICULAR SIDE OF SEMILUNAR VALVES
• INJURY MAY RESULT FROM :
- PRE-EXISTING LESIONS ( RHEUMATIC VALVULITIS,VALVAR CALCIFICATION )
- CATHETER TRAUMA
- HEMODYNAMIC FACTORS ( JET EFFECT OF BLOOD FLOW THRU :
PDA,
RESTRICTIVE VSD,
MVP,
BAV)

7. VALVE
ENDOTHELIUM
ENDOTHELIAL
DAMAGE
(BIOFILM)
NBTE
ADHERENCE
MUCOUS
MEMBRANE
BACTEREMIA
MATURE
INFECTED
VEGETATION
VALVE RING
ABSCESS
VALVE
INCOMPETENCE
VALVE
PERFORATION
TRAUMA
TURBULENCE
TRAUMA
IV DRUG USE
PATHOGENESIS

8. RODBARD HYPOTHESIS
ORIFICE LOW PRESSURE SINK
HIGH
PRESSURE
SOURCE
VENA CONTRACTA
Rodbard S. Blood velocity and endocarditis. Circulation 1963,27:18.

9. LOCI OF INFECTIVE ENDOCARDITIS LESIONS
CONDITION HIGH – PRESSURE
SOURCE
ORIFICE LOW – PRESSURE
SINK
LOCATION OF
LESIONS
AR AORTA CLOSED AORTIC
CUSPS
LV VENTRICULAR
SURFACE OF AOV
MR LV CLOSED MITRAL
LEAFLETS
LA ATRIAL SURFACE
OF MV
TR RV CLOSED
TRICUSPID
LEAFLETS
RA ATRIAL SURFACE,
TRICUSPID
LEAFLETS
VSD LV DEFECT RV RV SURFACE OF
DEFECT
PDA AORTA DUCTUS PULMONARY
ARTERY
PULMONARY
ARTERY

10. REPRESENTATION OF IE AT A PDA
VEGETATIONS ARE DEPOSITED
ON PA WALL OPPOSITE A HIGH-
VELOCITY JET THRU AN OPEN
DUCTUS

11. MORPHOLOGY
• VEGETATIONS, EROSIVE CAVITIES – VENTRICULAR ASPECT OF AOV, ATRIAL
ASPECT OF MV
• OFTEN RESULT IN DISCONTINUITY AT
THE VA OR AV JUNCTION
• DISCRETE PERFORATIONS OF AOV
• DROP LESIONS ON AML
• PERIANNULAR PSEUODANEURYSMS
/ ABSCESS [ AOV > MV ]

12. CLINICAL FEATURES
• FEVER - 95 – 100%
• HEART MURMUR (CHANGING) - 85%-95%
• ANEMIA, HEMATURIA
• MYALGIAS
• ARTHRITIS/ARTHRALGIAS
• EMBOLIZATION ( CENTRAL / PERIPHERAL )
• CLASSIC PERIPHERAL SIGNS OF ENDOCARDITIS
• JANEWAY LESIONS – ALMOST ALWAYS BY STAPHYLOCOCCUS
• IN PRACTICE, DIAGNOSIS BASED ON TWO SETS :
1. POSITIVE BLOOD CULTURES
2. CARDIAC LESION CSTD BY NEW STENOSIS/REGURG OR VEGETATION

13. CLINICAL FEATURES
• EMBOLIC EVENTS = 24-67%
• BRAIN = MOST COMMON SITE OF EMBOLI
• NEUROLOGIC MANIFESTATIONS ARE PROTEAN ;
• INCLUDES - STROKE ( ISCHEMIC / HAEMORRHAGIC )
- TIA
- TOXIC ENCEPHALOPATHY
- MENINGITIS
- BRAIN ABSCESS
- SEIZURES

14. MODIFIED DUKE CRITERIA
MAJOR CRITERIA
BLOOD CULTURES POSITIVE FOR IE
1. TYPICAL MICROORGANISMS
2. PERSISTENT MICROORGANISMS
3. SINGLE POSITIVE BLOOD CULTURE FOR C . burnetti
EVIDENCE OF ENDOCARDIAL INVOLVEMENT
1. ECHO POSITIVE FOR IE
( VEGETATION, ABSCESS,
NEW PARTIAL DEHISCENCE OF PROSTHETIC VALVE )
2. NEW VALVULAR REGURGITATION
MINOR CRITERIA
1. PREDISPOSITION
2. FEVER
3. IMMUNOLOGIC PHENOMENA
4. VASCULAR PHENOMENA
5. MICROBIOLOGIC EVIDENCE
DEFINITE IE
2 MAJOR
1 MAJOR + 3 MINOR
5 MINOR
POSSIBLE IE
1 MAJOR + 1 MINOR
3 MINOR

15. VASCULAR PHENOMENA
JANEWAY LESIONS CONJUCTIVAL HEMORRHAGES
MYCOTIC ANEURYSMS

16. IMMUNOLOGIC PHENOMENA
OSLER NODES ROTH SPOTS

17. DIFFERENCES B/N BACTERIAL AND FUNGAL INFECTIVE
ENDOCARDITIS
PARAMETERS BACTERIAL FUNGAL
ONSET ACUTE INSIDOUS
CLINICAL COURSE FULMINANT PROTRACTED
TISSUE DESTRUCTION MASSIVE MINIMAL
VEGETATION SIZE USUALLY SMALL LARGE
PERIANNULAR ABSCESS PRESENT ABSENT
VASCULAR EMBOLI USUALLY INVOLVES
SMALLER VESSELS
USUALLY INVOLVES MAJOR
VESSELS
HEMATURIA COMMON NOT COMMON
SKIN LESIONS COMMON NOT COMMON
BLOOD CULTURES ARE USUALLY POSITIVE NEGATIVE
BLOOD SAMPLES VENOUS SAMPLE CAN BE
TAKEN
ARTERIAL SAMPLE FOR
LEFT SIDE LESION IS
NECESSARY FOR CULTURE

18. CULTURE NEGATIVE INFECTIVE ENDOCARDITIS
• ACCOUNTS FOR 5% OF ALL IE
• CAUSES :
1. PRIOR ANTIBIOTIC THERAPY
2. FASTIDIOUS ORGANISMS
( GRAM NEGATIVE BACILLI, HACEK sps , BRUCELLA, FUNGI )
3. INTRACELLULAR BACTERIA
( C. burnetti, Bartonella, Chlamydia, T. whipplei )
• DIAGNOSIS :
– SEROLOGICAL TESTING
– CELL CULTURE
– GENE AMPLIFICATION

19. NATURAL HISTORY
• EPIDEMIOLOGY :
THEN NOW
YOUNGER POPULATION AFFECTS OLDER AGE GROUP
OFTEN IN PREXISTING VALVAR
DISEASE ( RHD )
EVEN IN NORMAL VALVES
STREPTOCOCCI WAS THE
LEADING CAUSE
STAPHYLOCOCCI IS THE
LEADING CAUSATIVE
ORGANISM
POOR DENTITION WAS ONE OF
THE MAJOR CAUSE
INVASIVE PROCEDURES (
HEMODIALYSIS , CATHETERS )

20. NATURAL HISTORY - EPIDEMIOLOGY
• PHV – STRONG RISK FACTOR
• RISK FACTORS FOR PVE
• CAUSATIVE FACTORS FOR PVE
• PEDIATRIC POPULATION
• ( PRE AND POST OP RISK FACTORS )

21. NATURAL HISTORY
50%
30%
10%
5%
5%
CAUSATIVE ORGANISMS
Staphylococcus aureus
Streptococcus
Enterococcus
Gram negative bacilli
others ( fungi, viral,
rickettsial )

22. NATURAL HISTORY
ACUTE BACTERIAL ENDOCARDITIS SUBACUTE BACTERIAL ENDOCARDITIS
OFTEN BY S. aureus OFTEN BY S. viridans
FULMINATING CLINICAL COURSE PROTRACTED CLINICAL COURSE
ANTIBIOTICS ALONE SELDOM CURES ANTIBIOTICS ALONE OFTEN CURES
JANEWAY LESION AND ROTH SPOTS ARE
SEEN ONLY IN ACUTE FORM
OSLER NODES, SPLINTER HEMORRHAGES,
NEW MURMUR IS COMMON TO BOTH
NO PREEXISTING VALVULAR DISEASE OFTEN ASSOC WITH PREEXISTING
VALVULAR DISEASE

23. NATURAL HISTORY - COMPLICATIONS
A) CARDIAC
1. HEART FAILURE
NVE – VALVAR REGURGITATION
PVE – PERIANNULAR LEAKAGE AND ABSCESS
2. MYOCARDIAL ABSCESS
3. CONDUCTION ABNORMALITIES
4. MYOCARDIAL PERFORATION
5. PERICARDITIS

24. B) RENAL COMPLICATIONS
1. PRERENAL FAILURE – LCOS
2. MICROABSCESS - SEPTIC EMBOLI
3. GLOMERULAR DYSFUNCTION – CIC’s
4. RENAL FAILURE - ANTIBIOTIC TOXICITY

25. C) EMBOLIC EVENTS
• INCIDENCE ( NVE > PVE )
• S. aureus, Candida, HACEK sps INCREASES THE RISK OF
EMBOLISM
• NEUROLOGIC MANIFESTATIONS ARE MOST COMMON
• MOST DEVASTATING NEUROLOGIC COMPLICATION IS ICH

26. SITE OF EMBOLISATION
Habib G. Management of infective endocarditis. Heart 2006;92:124-30.

27. RISK OF EMBOLIC EVENTS A/C TO VEGETATION SIZE
Vilacosta I, Graupner C, San Roman JA, Sarria C, Ronderos R, Fernandez C et al. Risk of
embolization after institution of antibiotic therapy for infective endocarditis. J Am Coll Cardiol
2002; 39:1489.

28. RECOMMENDED PLAN
NVE
PRIMARY
ANTIBIOTIC
THERAPY
SURGERY ONLY
FOR
COMPLICATIONS
EARLY PVE ANTIBIOTIC
THERAPY AND
SURGICAL
TREATMENT IS
ESSENTIAL
LATE PVE ANTIBIOTIC
THERAPY
SURGICAL
TREATMENT IF
REQUIRED

29. THERAPY - ANTIBIOTICS
• BLOOD CULTURES SHOULD BE OBTAINED BEFORE INITIATING
AB THERAPY
• PROLONGED PARENTERAL AB ADMN IS ADVISABLE
• AFTER INITIATING AB THERAPY – BLOOD CULTURES SHOULD
BE DRAWN EVERY 1-2 DAYS UNTIL THEY BECOME NEGATIVE
• AMINOGLYCOSIDES + CELL WALL ACTIVE AGENT = SYNERGY

30. ANTIBIOTIC Rx FOR STREPTOCOCCI ( MIC < 0.125 mg/L )
ANTIBIOTIC DOSAGE AND ROUTE DURATION
( WEEKS)
LEVEL OF
EVIDENCE
STANDARD TREATMENT
PENICILLIN G
Or
CEFTRIAXONE
12-18 MU/day i.v
2 g/day i.v or i.m 24 h
4
4
I B
I B
TWO – WEEK TREATMENT
PENICILLIN G
OR
CEFTRIAXONE
With
GENTAMICIN
12-18 MU/day i.v in 6 doses
2 g/day i.v or i.m in 1 dose
3 mg/kg/day i.v or i.m in 1 dose
2
2
2
I B
I B
I B
IN BETA-LACTAM ALLERGIC PATIENTS
VANCOMYCIN 15 mg/kg i.v q 12 h 4 I C

31. ANTIBIOTIC Rx FOR STREPTOCOCCI (MIC < 0.125 – 2 mg/L )
ANTIBIOTIC DOSAGE AND ROUTE DURATION
(WEEKS)
LEVEL OF
EVIDENCE
STANDARD TREATMENT
PENICILLIN G
WITH
GENTAMICIN
24 MU i.v per 24 h
3 mg/kg i.v / i.m q 24 h
4
2
I B
I B
IN BETA-LACTAM ALLERGIC PATIENTS
VANCOMYCIN
WITH
GENTAMICIN
15 mg/kg i.v 12 h
3 mg/kg/day i.v or i.m q 24 h
4
2
I C

32. ANTIBIOTIC Rx FOR STAPHYLOCOCCUS
ANTIBIOTIC DOSAGE AND ROUTE DURATION
( WEEKS )
LEVEL OF
EVIDENCE
A) NATIVE VALVES
METHICILLIN SUSCEPTIBLE
OXACILLIN
WITH
GENTAMICIN
2 g i.v in 4 h
1 mg/kg i.v or i.m 8 h
6
3-5 days
I B
METHICILLIN RESISTANT
VANCOMYCIN 15 mg/kg i.v in 12 h 6 I B

33. ANTIBIOTIC Rx FOR ENTEROCOCCUS
ANTIBIOTIC DOSAGE AND ROUTE DURATION
(WEEKS)
LEVEL OF
EVIDENCE
A ) IF SUSCEPTIBLE TO PENICILLIN
AMPICILLIN
PLUS
GENTAMICIN (OR)
2 g IV q 4 h
1 mg/kg IV/IM q 8 h
4-6
4-6
I B
PENICILLIN G
PLUS
GENTAMICIN
18-30 MU IV 24 h
PLUS
1 mg/kg IV/IM q 8 h
4-6
B) IF RESISTANT TO PENICILLIN
VANCOMYCIN
PLUS
GENTAMICIN
15 mg/kg IV Q 12 h
1 mg/kg IV / IM q 8 h
6 I B

34. ANTIBIOTIC Rx FOR STAPHYLOCOCCUS
ANTIBIOTIC DOSAGE AND ROUTE DURATION
( WEEKS )
LEVEL OF
EVIDENCE
A) PROSTHETIC VALVES
OXACILLIN - SUSCEPTIBLE
OXACILLIN
WITH
RIFAMPIN
AND
GENTAMICIN
2 g i.v I q 4 h
300 mg i.v or orally q 8 h
1 mg/kg i.v or i.m q 8 h
> 6
6
2
I B
OXACILLIN - RESISTANT
VANCOMYCIN
WITH
RIFAMPIN
AND
GENTAMICIN
15 mg/kg i.v q 12 h
300 mg i.v or orally q 8 h
1 mg/kg i.v or i.m q 8 h
> 6
> 6
2
I B

35. ANTIBIOTIC Rx FOR CULTURE NEGATIVE IE
PATHOGENS PROPOSED THERAPY TREATMENT OUTCOME
Brucella sps DOXYCYCLINE + COTRIMOXAZOLE +
RIFAMPIN > 3 MONTHS ORALLY
SUCCESS DEFINED AS
ANTIBODY TITRE < 1:60
Coxiella burnetti
(agent of Q fever)
DOXYCYCLINE + OFLOXACIN
( > 18 MONTHS TREATMENT )
SUCCESS DEFINED AS
ANTIBODY TITRE < 1:200
Bartonella spp DOXYCYCLINE ( 6 WEEKS ) SUCCESS EXPECTED IN > 90%
Legionella spp RIFAMPIN OR CIPROFLOXACIN
(6 WEEKS)
OPTIMAL Rx UNKNOWN
Mycoplasma spp NEWER FLUOROQUINOLONES OPTIMAL Rx UNKNOWN
Tropheryma Whipplei DOXYCYCLINE + HYDROXYCHLOROQUINE ( >
18 MONTHS )
LONG TERM TREATMENT

36. ECHOCARDIOGRAPHIC AND CLINICAL FEATURES S/O NEED FOR
SURGICAL INTERVENTION
VEGETATION
• PERSISTENT
• > 10 mm
• > 1 EMBOLIC EVENT
DURING FIRST 2 WKS
OF AB THERAPY
• INCREASE IN SIZE
AFTER 4 WKS OF AB
THERAPY
VALVAR
DYSFUNCTION
• ACUTE AR/MR WITH
SIGNS OF
VENTRICULAR
DILATATION
• HEART FAILURE
UNRESPONSIVE TO
MEDICAL THERAPY
• VALVE PERFORATION
/RUPTURE
PERIVALVAR
EXTENSION
• VALVAR DEHISCENCE,
RUPTURE, OR FISTULA
• NEW HEART BLOCK
• LARGE ABSCESS OR
EXTENSION OF
ABSCESS DESPITE AB
THERAPY

37. INDICATIONS FOR SURGERY
1. CHF
2. PERIANULAR EXTENSION
3. PERSISTENT SEPSIS
4. DIFFICULT ORGANISMS
5. PVE
1. SEVERE AR/MR
2. ELEVATED LVEDP / PAH
3. PROSTHETIC DEHISCENCE /
OBSTRUCTION
1. SYSTEMIC EMBOLISM
( RECURRENT EMBOLI ;
LARGE VEG > 10 mm;
LARGE VEG WITH COMPL.COURSE;
VERY LARGE VEG > 15 mm )
2. CEREBROVASCULAR
COMPLICATIONS
( TIA / ISCHEMIC STROKE )
1.FEVER OR POSITIVE BLOOD
CULTURE > 7 DAYS DESPITE
AB REGIMEN
2. RELAPSING IE ( NON
STREPTO ORGANISMS AND
IN PTS PHV )
S. aureus
MRSA, VRSA
PSEUDOMONAS
FUNGAL
Q FEVER
1. EARLY PVE
2. PVE CAUSED BY S. aureus
3. LATE PVE WITH CHF,
PERIANULAR EXTENSION,
PERSISTENT BACTEREMIA

38. SURGERY
• GOALS :
1. REMOVE INFECTED TISSUE AND DRAIN ABSCESSES
2. RESTORE OR RECONSTRUCT AV OR VA CONTINUITY
3. REVERSE THE HEMODYNAMIC ABNORMALITY

39. SURGICAL TREATMENT
ACTIVE INFECTIVE
ENDOCARDITIS
ONLY CUSPS
INVOLVED
VALVE REPAIR/
REPLACEMENT
CUSPS + ANNULUS
INVOLVED
RADICAL RESECTION
+ RECONSTRUCTION
SMALL DEFECT
(1-2 CM)
FRESH
AUTOLOGOUS
PERICARDIUM
LARGE DEFECTS
GLUTARALDHELYDE
FIXED BOVINE
PERICARDIUM
VALVE REPAIR/
REPLACEMENT

40. SURGICAL TREATMENT
MYOCARDIAL
PROTECTION
AVOIDANCE OF
CONTAMINATION

41. SURGICAL TREATMENT
VALVE REPAIR
VALVE
REPLACEMENT
AORTIC ROOT
ABSCESS
ONLY AORTIC
VALVE IS
INVOLVED
HOMOGRAFT
IS IDEAL
BIO /
MECHANICAL
PROSTHESIS

42. REPAIR OF AML PERFORATION ( DROP LESION)
SMOOTH SURFACE SHOULD FACE THE ATRIUM

43. REPAIR OF PML VEGETATION
P2 SEGMENT IS MOST COMMONLY INVOLVED

44. REPAIR OF TV INFECTIVE ENDOCARDITIS
NOTE : IN IV DRUG ABUSERS IF TRICUSPID
VALVE REPAIR IS NOT POSSIBLE, THEN
TRICUSPID VALVE RESECTION WITHOUT
REPLACEMENT IS ALSO AN OPTION.

45. SURGICAL TREATMENT
MECHANICAL
PROSTHESIS
BIO PROSTHESIS

46. POST OP CARE
• TISSUE GRAM STAIN AND CULTURE ANALYSIS IS MANDATORY
• USE OF PHENLYEPHRINE, VASOPRESSIN TO INC PERIPHERAL
RESISTANCE IN SEPTIC PATIENTS
• IV ANTIBIOTIC Rx FOR 4-6 WEEKS
• CANDIDA :ORAL KETOCONAZOLE / FLUCONAZOLE FOR 3-6 MONTHS
• ASPERGILLUS : ORAL VORICONAZOLE ( EVEN FOR LIFE LONG )
• MONITORING A) ANTIBIOTIC LEVELS
B) RENAL FUNCTION
C) CELL COUNTS

47. RESULTS
• EARLY DEATH
• TIME-RELATED SURVIVAL
• INCREMENTAL RISK FACTORS
• IN-HOSPITAL MORBIDITY
• RECURRENT INFECTION

48. 1. NVE – EARLY DEATH
• FACTORS AFFECTING THE OUTCOME
- STAGE OF ENDOCARDITIS ( ACTIVE / HEALED)
- URGENCY OF THE SURGICAL INDICATION
- MODALITY OF THE TREATMENT ( OPERATIVE V/S NON-
OPERATIVE)
- COMPLEXITY OF THE PROCEDURE ( DURATION OF THE
ILLNESS AND INFECTING MICROORGANISM)

49. 1. EARLY DEATH - PVE
• PVE – INCREMENTAL RISK FACTOR FOR OPERATIVE
MORTALITY IN THE DOMAIN OF ALL IE.
• FACTORS RESPONSIBLE FOR INCREASED MORTALITY
- REOPERATION
- PREVALENCE OF ABSCESS
- ANNULAR EROSION
- PERIANULAR ANEURYSM
- FASTIDIOUS/FUNGAL ORGANISM

50. 2. TIME-RELATED SURVIVAL
Haydock D, Barratt-Boyes B, Macedo T, Kirklin JW Blackstone E. Aortic valve replacement for
active infectious endocarditis in 108 patients. Heart 2010;96:696-700.

51. 3. INCREMENTAL RISK FACTORS
Moon MR, Miller DC, Moore KA,Oyer PE, Mitchell RS, Robbins RC, et al. Treatment of endocarditis
with valve replacement : the question of tissue versus mechanical prosthesis. Ann Thorac Surg
2001;71:1164.

52. 4. IN-HOSPITAL MORBIDITY
• CONTINUING EPISODES OF SEPSIS AFTER SURGERY
• NEW CONDUCTION ABNORMALITIES
• POST OP BLEEDING
• NEW / DEEPENING NEUROLOGIC DEFICIT

53. 5. RECURRENT INFECTION
• INCIDENCE INCREASES WITH :
- NONSTREPTOCOCCAL ORGANISMS
- ANNULAR DESTRUCTION
- AORTIC VALVE IS INVOLVED
- IV DRUG ABUSERS
• AORTIC NVE / PVE / MITRAL NVE/ MITRAL PVE :
( ALLOGRAFTS > MECHANICAL = BIOPROSTHESIS )

54. 5. RECURRENT INFECTION
Haydock D, Baratt-Boyes B, Macedo T, Kirklin JW, Blackstone E. Aortic valve replacement for
active infectious endocarditis in 108 patients. J Thorac Cardiovasc Surg 1992;103:130.

55. RECURRENT ENDOCARDITIS
McGiffin DC, et al. Aortic Valve infection. Risk factors for death and recurrent endocarditis
after aortic valve replacement. J Thorac Cardiovasc Surg 1992;104:511

56. TIMING OF SURGERY
EMERGENCY SURGERY ( WITHIN 24 HRS )
1. NVE / PVE WITH SEVERE CHF / CARDIOGENIC SHOCK
CAUSED BY
- ACUTE VALVAR REGURGITATION
- SEVERE PROSTHETIC DYSFUNCTION
- FISTULA INTO A CARDIAC CHAMBER / PERICARDIAL SPACE

57. TIMING OF SURGERY
URGENT SURGERY ( WITHIN DAYS )
1. NVE / PVE WITH PERSISTING CHF, SIGNS OF POOR HEMODYNAMIC
TOLERANCE OR ABSCESS
2. PVE BY STAPHYLOCOCCI OR GRAM – NEGATIVE ORGANISMS
3. LARGE VEGETATION ( 10 mm ) WITH AN EMBOLIC EVENT
4. LARGE VEGETATION WITH OTHER COMPLICATED COURSE
5. VERY LARGE VEGETATION (> 15 mm)
6. LARGE ABSCESS / PERIANNULAR INVOLVEMENT

58. TIMING OF SURGERY
ELECTIVE SURGERY ( DURING IN-HOSPITAL STAY )
1. SEVERE AR / MR WITH CHF – RESPONSIVE TO MEDICAL THERAPY
2. PVE WITH VALVAR DEHISCENCE / CHF – RESPONSIVE TO MEDICAL THERAPY
3. PRESENCE OF ABSCESS /PERIANULAR EXTENSION
4. FUNGAL / OTHER INFECTIONS RESISTANT TO MEDICAL CARE

59. ANTIBIOTIC PROPHYLAXIS RECOMMENDATIONS
S.NO : RECOMMENDATION : PROPHYLAXIS CLASS LEVEL
1. ONLY BE CONSIDERED FOR PATIENTS AT HIGH
RISK :
A) PATIENTS WITH A PROSTHETIC VALVE
B) PATIENTS WITH PREVIOUS IE
C) PATIENTS WITH CYANOTIC CONGENITAL
HEART DISEASE ( ONLY IN SOME CASES )
IIa C
2 NO LONGER RECOMMENDED IN OTHER FORMS
OF VALVULAR OR CONGENITAL HEART DISEASE
III C

60. PROCEDURAL ANTIBIOTIC PROPHYLAXIS
S.NO : RECOMMENDATIONS PROPHYLAXIS LEVEL CLASS
1. DENTAL PROCEDURES :
A) SHOULD ONLY BE CONSIDERED FOR
MANIPULATION OF THE GINGIVA
B) SHOULD NOT BE CONSIDERED FOR
LOCAL ANAESTHETIC INJ, REMOVAL OF SUTURES
IIa
III
C
C
2. RESPIRATORY TRACT PROCEDURES :
NOT RECOMMENDED
III C
3. GI OR UROGENITAL PROCEDURES :
NOT RECOMMENDED
III C
4. SKIN AND SOFT TISSUE :
NOT RECOMMENDED FOR ANY PROCEDURE
III C

61. RECOMMENDED PROPHYLAXIS FOR DENTAL PROCEDURES AT RISK
Single dose 30-60 min before procedure
SITUATION ANTIBIOTIC ADULTS CHILDREN
NO ALLERGY TO
PENICILLIN/
AMPICILLIN
AMOXYCILLIN/
AMPICILLIN
2 gm p.o/i.v 50 mg/kg p.o / i.v
ALLERGY TO
PENICILLIN /
AMPICILLIN
CLINDAMYCIN/
CEPHALEXIN
600 mg p.o / i.v
2 gm
20 mg /kg p.o / i.v
50 mg /kg