Endocarditis

Typical bugs

Diagnosis 

  • Definite IE
    • Pathologic criteria - vegetation or intracardiac abscess confirmed on histology to show active endocarditis
    • OR Microorganisms in a vegetation or intracardiac abscess demonstrated on culture or histology
    • OR 2 major criteria
    • OR 1 major + 3 minor
    • OR 5 minor
  • Possible IE
    • 1 major + 1 minor
    • OR 3 minor
  • Reject diagnosis of IE if
    • Firm alternate diagnosis is made
    • Clinical manifestations resolve after ≤ 4 days of abx
    • No pathologic evidence of active endocarditis found at surgery after ≤ 4 days of abx
    • Not met clinical criteria for definite/possible IE

Modified Duke criteria for infective endocarditis

Major criteria Minor criteria

(+) blood culture

  • Typical IE organisms on 2 separate BCx; persistenly positive BCx
  • or Coxiella + or anti-phase 1 IgG antibody titer ≥ 1:800 on 1 BCx 

Vascular phenomena

  • Major arterial emboli, septic pulmonary infarcts
  • Mycotic aneurysm
  • Intracranial hemorrhage, conjunctival hemorrhage
  • Janeway lesions (non-tender macular/nodular lesions on palms/soles) = microabscess from septic emboli

Endocardial involvement

  • TEE/TTE positive for IE, abscess, new valvular regurg, new partial dehiscence of prosthetic valve
  • Worsening/change of pre-existing murmur not sufficient

Immunologic phenomena

  • Osler nodes (painful raised lesions on hands/feet) = immune complex deposition
  • Roth spots (retinal hemorrhage with pale center) = immune complex vasculitis
  • Glomerulonephritis
  Fever > 38 C
 

Predisposing factors

  • Predisposing heart disease
  • IV drug use
  (+) blood culture not meeting major criteria

Echocardiogram

  • TTE should be done in all suspected cases of IE
  • TEE in certain situations if high risk, or high suspicion of IE based on clinical criteria
    • e.g. prosthetic valve, previous endocarditis, congenital heart disease, heart failure, new murmur

Use of Echo in endocarditis

 

Abx

Surgical management

  • Suggested by: 
    • Persistent or growing vegetation despite abx x 7d
    • Multiple embolic events during first 2 wks of abx
    • Mobile > 10 mm vegetation on mitral/aortic valve (high risk of embolization)
    • Valvular dysfunction w/ signs of heart failure
    • Valve perforation/rupture, perivalvular abscess
author: admin | last edited: March 11, 2018, 10:43 p.m. | pk: 102 | unpublished

  1. http://circ.ahajournals.org/content/132/15/1435