Endocarditis


Epidemiology

Risk Factors for Infective Endocarditis


Etiology

Non-Infective Endocarditis

Infective Endocarditis

Most Commonly Associated Organisms

Other Organisms


Physiology


Diagnosis

Electrocardiogram (EKG) (see Electrocardiogram, [[Electrocardiogram]])

Blood Culture (see Blood Culture, [[Blood Culture]])

Transthoracic Echocardiogram (TTE) (see Echocardiogram, [[Echocardiogram]])

Transesophageal Echocardiogram (TEE) (see Echocardiogram, [[Echocardiogram]])


Duke Diagnostic Criteria

Major Criteria

Minor Criteria


Clinical Manifestations

Cardiovascular Manifestations

Atrioventricular Heart Blocks

Congestive Heart Failure (CHF) (see Congestive Heart Failure, [[Congestive Heart Failure]])

Heart Murmur (see Heart Murmurs, [[Heart Murmurs]])

Sinus of Valsalva Aneurysm with/without Rupture (see Sinus of Valsalva Aneurysm, [[Sinus of Valsalva Aneurysm]])

Tamponade (see Tamponade, [[Tamponade]])

Dermatologic Manifestations

Neurologic Manifestations

General Comments

Neurologic Presentations

Systemic Embolic Manifestations

Ophthalmologic Manifestations

Other Manifestations

Sepsis (see Sepsis, [[Sepsis]])


Treatment

Antibiotic Therapy

Native valve:
1) PCN-susceptible Strep viridans/Strep bovis/other Strep:
a) PCN or ceftriaxone x 4 wks
b) PCN or cetriaxone + low-dose gent x 2 wks
c) Vanco x 4 wks
2) Relatively PCN-resistant Strep viridans/Strep bovis/other Strep:
a) PCN or ceftriaxone x 4 wks + low-dose gent x 2 wks
b) Vanco x 4 wks
3) Susceptible enterococcus/resistant Strep:
a) PCN or amp or vanco + low-dose gent x 4 wks (x 6 wks, if symptoms present for >3 mo)
4) Methicillin-sensitive Staph:
a) Naf or ox or cefazolin or vanco x 4-6 wks + low-dose gent x 3-5 days
5) Methicillin-resistant Staph:
a) Vanco x 4-6 wks + low-dose gent x 3-5 days
6) HACEK:
a) Ceftriaxone x 4 wks or amp + low-dose gent x 4 wks
7) Culture-negative:
a) Vanco +low-dose gent x 4 wks +/- ceftriaxone

Prosthetic valve: early prosthetic valve endocarditis (within 2 mo of surgery) usually requires replacement, while late endocarditis may be treated medically
1) PCN-susceptible Strep viridans/Strep bovis/other Strep:
a) PCN x 6 wks + low-dose gent x 2 wks
2) Relatively PCN-resistant Strep viridans/Strep bovis/other Strep:
a) PCN x 6 wks + low-dose gent x 2-4 wks
3) Susceptible enterococcus/resistant Strep:
a) PCN or amp or vanco + low-dose gent x 6 wks
4) Methicillin-sensitive Staph:
a) Naf or ox or cefazolin or vanco + PO rifampin (add after a few days to prevent selecting for resistance) x 6 wks + low-dose gent x 2 wks
5) Methicillin-resistant Staph:
a) Vanco x 6 wks + PO rifampin (add after few days) + low-dose gent x 2 wks
6) HACEK:
a) Ceftriaxone x 6 wks or amp + low-dose gent x 6 wks
7) Culture-negative:
a) Vanco +low-dose gent x 6 wks +/- ceftriaxone

Surgery

Clinical Factors in Considering Surgery

Indications for Surgery in Infective Endocarditis [MEDLINE]

Clinical Efficacy

Special Considerations


Infective Endocarditis Prophylaxis

Prophylaxis: controversial, as risk of endocarditis related to dental procedures (other than tooth extraction) is low (Strom, 1998)
1) Dental/oral/resp/esoph procedure: amox 2 g PO 1 hr pre (or clinda 600 mg PO or cephalexin 2 g PO or azithro/clarithro 500 mg PO) or amp 2 g IV 30 min pre (or clinda 600 mg IV or cefazolin 1 g IV)
2) GU/other GI procedure:
a) High-risk: amp 2 IV + gent 1.5 mg/kg IV (<120 mg) 30 min pre and amp 1 g IV (or amox 1 PO) 6 hrs post
-Alt: vanco 1 g IV over 1-2 hrs + gent 1.5 mg/kg IV to finish 30 min pre
b) Mod-risk: amox 2 g PO 1 hr pre (or amp 2 g IV 30 min pre)
-Alt: vanco 1 g IV over 1-2 hrs to finish 30 min pre


Prognosis


References