Infective endocarditis guidelines

Dr. Dibbendhu KhanraSR1

What is Infective endocarditis?

• Challenge for internists• Headache for cardiologists• Hobby for microbiologists

What is new in the guideline?

• More tables, more dilemma• More organism• More antibiotics• Multimodal diagnosis• Infectious disease Specialist

Still it is important

• Changing epidemiology• Immuno-compromised Hosts• More intervention more infection• More diagnostic Tools• Expanding horizon of Surgery

Case 1

RHD/ MS/MR/ NSRLt HemiplegiaFever/ arthritis/ perpura

Case 2

• DM/ Isch CMP• ICD• Fever/ failure

Case 3

• Severe AS/ post AVR• Fever• CHB

Case 4

• Abdominal mass• Bleeding PR• Fever• Severe back pain

Case 5• IDU • (Brown Heroine/ Lemon Juice)• Fever• Difficulty in vision

Far from DUKE

Echo criteria eliminated

• The expansion of minor criteria to include elevated erythrocyte sedimentation rate or C-reactive protein, the presence of newly diagnosed clubbing, splenomegaly, and microscopic hematuria has been proposed

Diagnosis is so difficult

Role of Cardiologists

Role of Microbiologists

Rational emperics

Case 1RHD/ MS/MR/ NSRLt HemiplegiaFever/ arthritis/ perpura

Mitral valve vegVGS

Case 2

• DM/ Isch CMP• ICD• Fever/ failure

Pacemaker lead tip culture:Staph aureusTTE/TEE – NO veg

Case 3

• Severe AS/ post AVR• Fever• CHB

Aortic valve vegCulture Negative

Case 4

• Abdominal mass• Bleeding PR• Fever• Severe back pain

Ca rectumStr bovis

Case 5• IDU • (Brown Heroine/ Lemon Juice)• Fever• Difficulty in vision

Tricuspid veg 35mmCandida

NVE PVE

Str VGS/ Str. gallolyticus

Pen 4wOR Cx 4wOR Cx + Genta 2w

OR Vanco 4w(Pen/ BL Res)

Pen 6wOR Cx 6wOR Cx + Genta 2w/ 6w (MIC<0.12/>0.12)OR Vanco 6w

Str. Pneu/ Str. pyogens

Pen 4wOR Cx 4wOR Vanco +Rifam 4w(Pen/ BL Res)

Pen 6wOR Cx 6wOR Vanco +Rifam 6w(Pen/ BL Res)

Str. Gr B, C, G Cx 4w +Genta 2w Cx 6w +Genta 2w

Staph Oxacillin S Nafcillin 6wOR Cefazolin 6w

Nafcillin >6w+ Genta 2w+ Rifam >6w

Oxacillin R Vanco 6wOR Dapto 6w

Vanco >6w+ Genta 2w+ Rifam >6wSeptran if Vanco R

Enterococcus Pen S + Genta SPen S + Genta RPen R + Genta SPen R + Genta R

Ampi+Genta 4-6w OR Ampi+Cx 6wAmpi+Strep 4-6 w OR Ampi+Cx 6w

Vanco +Genta 6wLNZ/ Dapto >6w

GNB HACEK Cx OR Ampi OR Cipro 4w

Non HACEK Cx +Genta 6w + Surgery

Fungal IE, MDR GNB, Vancomycin Resistant enterococcie

Need for early surgery

Surgery for Infective endocarditis

Case 1RHD/ MS/MR/ NSRLt HemiplegiaFever/ arthritis/ perpura

Mitral valve vegVGSCx+Genta – veg +Failure +

Surgery? Anticoag?

Embolic CVA

Case 2

• DM/ Isch CMP• ICD• Fever/ failure

Pacemaker lead tip culture:Staph aureusTTE/TEE – NO veg

FDG/PET s/o veg 30mmABPlan: Reimplantation

Surgery /AB??TPI?

CDRIE vs Local device infection

CDRIE – nightmare to treat

Case 3

• Severe AS/ post AVR• Fever• CHB

Aortic valve vegCulture NegativeCoxiell IgG+

Surgery/ AB?

Culture NegativeInfective Endocarditis

Case 4

• Abdominal mass• Bleeding PR• Fever• Headache

Ca rectumVeg lt sideStr bovisMycotic anurysm

Mycotic aneuyrismIntracranial

Extracranial

Splenic abscess

Musculoskeletal

Renal

Case 5• IDU • (Brown Heroine/ Lemon Juice)• Fever• Difficulty in vision

Tricuspid veg 35mmCandida

Surgery/ anntifungal?

Fungal infective endocarditis• IVDU/IC/CDRIE• Duke not maintained• Early PVE, but also delayed• Younger• Aspergillus often culture negative• High mortality• Endophthalmitis: systemic + intraocular antifungal• Early surgey• AMB+/-flucytosine – 6wks• Long term azole supression

Prophylaxis is a myth

Peri-operative antibiotics

Prognosis

Follow Up

Endocarditis Team - new card in the game

What is new?• Duke not to be fulfilled always• TEE in selective cases• 3D Echo, FDG/PET – new modalities• PCR/ serology – major• Daptomycin: new killer of staph• Early surgery is the trend, if not contraindicated• Repair is better option than valve replacement• Culture negative: r/o atypical org/ ca/ APLS• Mycotic aneurysm screening for Lt side IE• Prophylaxis: very selective cases• Prohylactic antibiotic before cardiac device: not required• Stent related IE due to RGM to be remembered

Thank you