Updated: 4/18/2021

Endocarditis

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Snapshot
  • A 25-year-old woman presents to the emergency room for a fever. She has a history of intravenous drug use and had previously been treated for osteomyelitis. On physical exam, she is febrile, and heart auscultation reveals a new systolic murmur at the lower left sternal border. An echocardiogram reveals tricuspid valve vegetations.
Summary
  • An acute cardiac condition charaterized by Inflammation of the heart valve, typically secondary to bacterial infection.
  • Diagnosis is made by echocardiography.
  • Treatment is antibiotics or surgical valve replacement depending on the severity and chronicity of the disease.
Etiology
  • Epidemiology
    • location
      • mitral valve > tricuspid valve
      • tricuspid valve disease is associated with intravenous (IV) drug use
        • Staphylococcus aureus, Pseudomonas, and Candida
    • risk factors
      • rheumatic heart disease
      • IV drug use
      • immunosuppression
      • prosthetic heart valve
      • congenital heart disease
  • Etiology
    • acute endocarditis
      • Streptococcus pneumoniae
      • Streptococcus pyogenes
      • Staphylococcus aureus
        • IV drug users
        • large vegetations seen on the valves
      • Neisseria gonorrhea
    • subacute bacterial endocarditis is characterized by slower onset and less severe symptoms
      • Streptococcus galloyticus
        • in the setting of colon cancer
        • must perform colonoscopy 
      • enterococcus 
        • in the setting of gastrointestinal/genitourinary procedures
      • Streptococcus viridans 
        • often a complication of dental procedures 
        • can also occur with upper respiratory infections
        • makes dextrans, which binds to fibrin-platelet aggregates on the heart valves
      • Staphylococcus epidermidis
        • often in the setting of prosthetic valves
      • Candida albicans
        • IV drug users
    • non-infectious endocarditis
      • Libman-Sacks endocarditis
        • from systemic lupus erythematosus
        • mitral or aortic valve involvement
      • non-bacterial thrombotic (marantic) endocarditis 
        • from inflammatory states
        • very poor prognosis
        • thrombi made of platelets with fibrin without organisms or neutrophils
  • Pathogenesis
    • endothelial damage on the surface of the cardiac valve can cause a thrombus to form
      • factors include turbulent blood flow that can damage endothelium or deposition of fibrin-platelet aggregate on damaged endothelium
    • bacteria can then adhere to thrombus
    • vegetations are caused by further depositions of fibrin and platelets
  • Prognosis
    • often presents as fever of unknown origin
    • endocarditis prophylaxis may be required before dental procedures 
      • 2017 American Heart Association guidlines indicate antibiotic prophlaxis to prevent endocarditis only in patients with:
        • history of prosthetic valve (or with valve components)
        • history of unrepaired congential heart disease 
        • history of repaired congential heart disease with residual shunt
        • post-cardiac transplant with valve regurgitation 
        • history of prior infectious endocarditis
Presentation
  • Symptoms
    • persistent fevers (the most common symptom)
    • shortness of breath
    • systemic symptoms
      • weakness
      • fever
      • malaise
  • Physical exam
    • new murmur on auscultation
      • tricuspid valve in IV drug users 
        • a systolic murmur along the left lower sternal border in tricuspid regurgitation
    • from emboli
      • Roth spots
        • retinal hemorrhages on funduscopy
      • Janeway lesions
        • erythematous and nontender macules on palms or soles
      • nail bed splinter hemorrhages
    • from immune complex deposition
      • Osler nodes
        • tender nodules on fingers or toes
      • glomerulonephritis 
Imaging
  • Echocardiography   
    • indication
      • for all patients
    • findings
      • vegetations on valves
Studies
  •  Serum Labs
    • blood cultures
      • critical first step and needed to diagnose with Duke system.
  • Making the diagnosis
    • based on clinical presentation and Duke criteria
      • pathologic criteria
        • blood culture of the organism (best initial step)   
          • drawn at least 12 hours apart OR
          • multiple positive cultures (at least 3 of 4) with the first and last drawn at least 1 hour apart
        • histologic evidence of endocarditis from vegetation or intracardiac abscess
      • clinical criteria: one of the following
        • 2 major criteria
        • 1 major and 3 minor criteria
        • 5 minor criteria
    • if blood cultures are negative but echocardiography shows endocarditis, consider one of the causes of culture-negative endocarditis (CNE)
      • Coxiella burnetii
      • Bartonella spp
      • HACEK organisms
        • Haemophilus
        • Aggregatibacter
        • Cardiobacterium
        • Eikenella
        • Kingella
 
Duke Criteria
Major Minor
  • Positive blood cultures from 2 separate blood cultures drawn > 12 hours apart, 3 out of 4 blood cultures that are positive, with first and last samples drawn 1 hour apart, single positive blood culture for Coxiella burnetti, or antiphase I IgG antibody titer > 1:800
  • Abnormal echocardiogram with vegetation or abscess or partial dehiscence of prosthetic valve
  • Fever
  • Presence of risk factors, including intravenous drug use, structural heart disease, prosthetic heart valve, dentla procedures, or history of endocarditis
  • Vascular phenomena, including Janeway lesions, emboli, mycotic aneurysm, and conjunctival hemorrhage
  • Immunologic phenomena, including glomerulonephritis, Osler nodes, and Roth spots
  • Positive blood cultures not meeting major criterion
  • Echocardiographic findings consistent with endocarditis but not meeting major criterion
 
Differential
  • Osteomyelitis
    • distinguishing factor
      • although this can present as fever of unknown origin, it typically lacks other findings of endocarditis and will not have vegetations on echocardiography
Treatment
  • Management approach
    • choice of antibiotics ultimately depend on causative agent and susceptibility as well as presence of prosthetic material in the heart
    • all anitbiotics should given intravenously
  • Medical
    • vancomycin   
      • indications
        • empiric antibiotic therapy for patients with no prosthetic valve
        • often for 4-6 weeks
    penicillin or ceftriaxone 
    • indications
      • antibiotic therapy for patients with Streptococcus viridans and no prosthetic valve
      • often for 4-6 weeks
    • vancomycin plus gentamicin and rifampin
      • indications
        • empiric antibiotic therapy for patients with prosthetic valve
        • often for 4-6 weeks
    • vancomycin plus cefepime/piperacillin-tazobactam 
      • for critically ill/unstable patients
      • coverage for Pseudomonas aeruginosa as more common in IV drug users
  • Operative
    • surgical valve replacement 
      • indications
        • heart failure
        • patients who are refractory to medical therapy
        • abscess formation
Complications
  • Cardiac complications
    • perivalvular abscess
    • arrhythmias
    • heart failure
  • Splenic abscesses
  • Renal infarction due to septic emboli
  • Neurologic complications
    • stroke from septic emboli 

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(M2.CV.17.4691) A 43-year-old man with a history of hepatitis C and current intravenous drug use presents with 5 days of fever, chills, headache, and severe back pain. On physical exam, temperature is 100.6 deg F (38.1 deg C), blood pressure is 109/56 mmHg, pulse is 94/min, and respirations are 18/min. He is thin and diaphoretic with pinpoint pupils, poor dentition, and track marks on his arms and legs. A high-pitched systolic murmur is heard, loudest in the left sternal border and with inspiration. He is admitted to the hospital and started on broad-spectrum antibiotics. One of the blood cultures drawn 12 hours ago returns positive for Staphylococcus aureus. Which of the following is the most appropriate next step to confirm the diagnosis?

QID: 107643
1

Repeat blood cultures now

0%

(0/3)

2

Repeat blood cultures 24 hours after initial cultures were drawn

67%

(2/3)

3

Repeat blood cultures 36 hours after initial cultures were drawn

0%

(0/3)

4

Repeat blood cultures 48 hours after initial cultures were drawn

0%

(0/3)

5

Do not repeat blood cultures

33%

(1/3)

M 6 B

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(M2.CV.15.50) A 63-year-old gentleman with a history of mitral valve prolapse presents to his internist with a 2-week history of fever, night sweats, and general malaise. Three weeks ago, he underwent periodontal surgery for gingival hyperplasia, for which he did not receive antibiotic prophylaxis. He denies a history of drug abuse. His physical exam is notable for a temperature of 39 deg C and a faint pansystolic murmur loudest at the cardiac apex. His nails are shown in Figure A, and painful lesions on his fingers are shown in Figure B. What is the most likely causative organism in this case?

QID: 104935
FIGURES:
1

Staphylococcus aureus

7%

(2/28)

2

Staphylococcus epidermidis

4%

(1/28)

3

Streptococcus viridans

82%

(23/28)

4

Streptococcus pneumoniae

0%

(0/28)

5

Enterococcus faecalis

0%

(0/28)

M 6 B

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(M2.CV.15.18) A 37-year-old man with a history of IV drug use presents to the ED with complaints of fevers, chills, and malaise for one week. He admits to recently using IV and intramuscular heroin. Vital signs are as follows: T 40.0 C, HR 120 bpm, BP 110/68 mmHg, RR 14, O2Sat 98%. Examination reveals a new systolic murmur that is loudest at the lower left sternal border. Initial management includes administration of which of the following regimens?

QID: 104903
1

IV Vancomycin

30%

(23/77)

2

IV Vancomycin, IV levofloxacin

1%

(1/77)

3

IV Vancomycin, IV ceftriaxone

42%

(32/77)

4

IV Vancomycin, IV gentamycin, PO rifampin

8%

(6/77)

5

IV Vancomycin, IV ceftriaxone, IV fluconazole

18%

(14/77)

M 7 B

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