Infective Endocarditis

High risk patients:

• Prosthetic valves
• High flow heart diseases -> any stenotic valvular lesions, MVP + regurg, PDA (septal defects are not high flow)
• AV fistula
• Indwelling Rt heart cath
• Marfan syndrome

 

Organisms:

• Native valves (in CHD): viridans
• Prosthetic valves: epidermidis, S. viridans, S. aureus
• IV drug users: aureus, S. epidermidis
• Rarely; enterococci or gram neg (HACEK)

 

Types:

 

Duke’s criteria:

2 major   OR   1 major + 3 minor   OR   5 minor

 

Management:

• If septic: fluids + pressors (nor-\epinephrine, dopamine)
• Take cultures before initiating abx
• Best first step in dx? Echo
• Do surveillance blood cultures to monitor therapy

 

Empiric antibiotics:

(combination therapy + IV + usually 6 wks)

• S. viridans:
  • Penicillin\amoxicillin\ceftriaxone + gentamicin
  • If allergic -> vancomycin + gentamicin
• S. aureus:
  • Oxacillin\flucloxacillin\nafcillin + gentamicin
  • If allergic -> vancomycin + gentamicin
  • If prosthetic valve -> add Rifampin to the above regimen

 

Endocarditis prophylaxis: 

• Who?
  • Prosthetic valve
  • Previous IE
  • Unrepaired cyanotic CHD

• When?
  • Only before dental procedures involving manipulation of the gingiva or perforation of the oral mucosa
  • Tonsillectomy \ adenoidectomy
  • Not recommended for GI, resp, skin procedures!

• How? (30-60 min before procedure)
  • Amoxicillin (2gm)
  • If allergic -> clindamycin (600mg)

 

Indications for surgery: 

• Refractory CHF
• Persistent sepsis
• Recurrent peripheral emboli
• Perivalvular complication (dehiscence, obstruction, leak)

 

 

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Download the PDF version: here

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References:

• Dr. Alghamdi’s lecture
• Kaplan step 2 lecture notes
• Paul Bolin’s video