Endocarditis

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Alison Leung, Patrick Charles, and I attended the conference held at Mt Sinai tonight and the over arching theme was cardiac echo.  Of particular note were cases of a 30ish yoM presenting w/ 4 days of chest pain and found to have a malignant pericardial effusion and a man from Pakistan with TB and lung consolidation/pneumonias on echo.  Many images were obtained with TEE. For the sake of brevity, this pearl is going to focus on ENDOCARDITIS as several great examples were shown.  My examples will be from the internet with references.

Figure 1. Mitral valve vegetation shown by echocardiogram. The vegetation is the mass seen in the dark space between the left atrium (LA) and left ventricle (LV). RA indicates right atrium; RV, right ventricle.

How do we diagnose it?  DUKE CRITERIA!

For diagnosis the requirement is:

•2 major and 1 minor criteria or

•1 major and 3 minor criteria or

•5 minor criteria

MAJOR CRITERIA

•Positive blood cultures for infective endocarditis

•Typical microorganism for infective endocarditis from 2 separate blood cultures (per EMRA SOP is 3 cultures 2 minutes apart and taken prior to antibiotic administration provided the patient is stable

▪ Viridans streptococci, Streptococcus bovis, and HACEK group or

▪Community-acquired Staphylococcus aureus or enterococci in the absence of a primary focus or

▪Persistently positive blood cultures, defined as recovery of a microorganism consistent with infective endocarditis from:

▪2 blood cultures drawn 12 hours apart or all of 3 or most of 4 or more separate blood cultures, with first and last drawn at least 1 hour apart

•Evidence of endocardial involvement

▪Positive echocardiogram for infective endocarditis

▪oscillating intracardiac mass on valve or supporting structures or in the path of regurgitant jets or on implanted material in the absence of an alternative anatomical explanation or

▪abscess or

▪new partial dehiscence of prosthetic valve or new valvular regurgitation

MINOR CRITERIA

•Predisposing heart condition or intravenous drug use

•Fever: 38°C

•Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions

•Immunologic phenomena:

▪Glomerulonephritis

▪Osler nodes

▪Roth spots

▪Rheumatoid factor

•Microbiologic evidence: positive blood culture but not meeting major criterion as noted previously or serologic evidence of active infection with organism consistent with infective endocarditis

•Echocardiography findings consistent with infective endocarditis but not meeting major criterion as noted previously

Some great videos since I am unable to paste them into the email:  https://www.ultrasoundoftheweek.com/uotw-60/

Pearls from EMRA:

1Consider a loading dose of vancomycin 25-30mg/kg for seriously ill patients

2TEE may be necessary to assess for vegetation and degree of heart failure

3Implanted devices should not have the pocket sampled; definitive treatment requires exploration

Native Valve:

Common Organisms:  Viridans group streptococci, Staph aureus, Streptococcus species, Enterococcus species

Treatment Option 1:  Oxacillin/nafcillin 2g IV q4h AND gentamicin 1mg/kg IV TID  AND ampicillin 2g IV q4h.  Aminoglycosides with a Beta Lactam=synergy!.  No aminoglycosides alone, please!

Treatment Option 2:  Vancomycin 15-20mg/kg IV BID and gentamicin 1mg/kg IV TID

Treatment Option 3:  Daptomycin 6mg/kg IV daily

Prosthetic Valve:

Common Organisms:

<2mos Post-Op:  Coagulase-Negative staphylococci, S. aureus

>2 mos Post-Op: Coagulase-Negative staphylococci, viridian’s group streptococci, S. aureus,  Enterococcus species

Treatment:  Vancomycin 15-20mg/kg IV BID AND Rifampin 30mg po or IV TID AND gentamicin 1mg/kg IV TID

 

IV Drug Users:

Common Organisms:  Staph Aureus

Treatment Option 1:  Vancomycin 15-20mg/kg IV BID

Treatment Option 2:  Daptomycin 6mg/kg IV daily

 

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