Infective Endocarditis: Epidemiology, Diagnosis and Management Holger P. Salazar, MD, FACC Stern Cardiovascular Foundation No financial relation to disclose

Infective Endocarditis: Infective Endocarditis: Epidemiology, Diagnosis and Epidemiology, Diagnosis and

ManagementManagement

Holger P. Salazar, MD, FACCHolger P. Salazar, MD, FACCStern Cardiovascular FoundationStern Cardiovascular Foundation

No financial relation to discloseNo financial relation to disclose

Epidemiology of Infective EndocarditisEpidemiology of Infective Endocarditis

Epidemiology of Infective Epidemiology of Infective EndocarditisEndocarditis

Annual incidence in USA 10,000-20,000 new Annual incidence in USA 10,000-20,000 new cases, stable over past 30 yearscases, stable over past 30 years

Prosthetic valve endocarditis accounts for Prosthetic valve endocarditis accounts for 15% of cases15% of cases

Mortality is about 20%, due to CHF, valvular Mortality is about 20%, due to CHF, valvular dysfunction, or uncontrolled infectiondysfunction, or uncontrolled infection

50% over the age of 5050% over the age of 50

Valvular Involvement in Infective Valvular Involvement in Infective EndocarditisEndocarditis

ValveValve Percent of Cases Percent of Cases

MitralMitral 28-45% 28-45%

AorticAortic 5-36% 5-36%

Aortic + MitralAortic + Mitral 0-35% 0-35%

TricuspidTricuspid 5% 5%

Combined right and leftCombined right and left 0-4% 0-4%

Most Common Underlying Cardiac Most Common Underlying Cardiac Lesions In Infective Endocarditis Lesions In Infective Endocarditis

Mitral valve prolapseMitral valve prolapse

Degenerative valvular lesionsDegenerative valvular lesions Calcified mitral annulusCalcified mitral annulus

Valve nodulesValve nodules

Bicuspid Aortic ValveBicuspid Aortic Valve

Prosthetic ValveProsthetic Valve

Risk of Infective Endocarditis for Risk of Infective Endocarditis for Selected GroupsSelected Groups

Risk FactorRisk Factor Incidence* Incidence*

Injection Drug UseInjection Drug Use 150-2000150-2000

Rheumatic heart diseaseRheumatic heart disease 440 440

BioprosthesisBioprosthesis 383 383

Prior endocarditisPrior endocarditis 340-740 340-740

Mechanical prosthesisMechanical prosthesis 308 308

VSD (Medical therapy)VSD (Medical therapy) 220 220

*Cases per 105 patient-years

Classification of Infective EndocarditisClassification of Infective Endocarditis

Infective Endocarditis: Classification Infective Endocarditis: Classification

Native Valve (75-90% of cases)Native Valve (75-90% of cases)

Acute -- ˃ 1 to 2 weeksAcute -- ˃ 1 to 2 weeks

Subacute-- >2 weekSubacute-- >2 week

Prosthetic Valve (10-25% of cases)Prosthetic Valve (10-25% of cases)

Early Onset--Early Onset-- ˃ 12 months˃ 12 months

Late Onset-- > 12 monthsLate Onset-- > 12 months

Two Flavors of Infective Endocarditis: Two Flavors of Infective Endocarditis: Native and Prosthetic ValvesNative and Prosthetic Valves

Clinical Manifestations of EndocarditisClinical Manifestations of Endocarditis

Infective Endocarditis: Infective Endocarditis: Symptoms (%)Symptoms (%)

FeverFever 8080

ChillsChills 4040

WeaknessWeakness 4040

DyspneaDyspnea 4040

SweatsSweats 2525

Weight lossWeight loss 2525

MalaiseMalaise 2525

StrokeStroke 2020

Skin lesionsSkin lesions 2020

HeadacheHeadache 2020

AchinessAchiness 2020

Chest painChest pain 1515

Altered mentalAltered mental

statusstatus 10-1510-15

Back painBack pain 1010

Native Valve Endocarditis: Native Valve Endocarditis: Signs (%)Signs (%)

FeverFever 9090

MurmurMurmur 85 85 New New 3-5 3-5

Changing 5-10Changing 5-10

EmboliEmboli 50+50+

Splenomegaly 20-57Splenomegaly 20-57

MetastaticMetastatic 20 20 infectioninfection

Retinal lesionsRetinal lesions 20 20

Skin manifestationsSkin manifestations 18-50 18-50

PetechiaePetechiae 20-40 20-40

SplintersSplinters 15 15

Osler’s nodesOsler’s nodes 10-23 10-23

Janeway lesionsJaneway lesions <10 <10

Cutaneous Findings of EndocarditisCutaneous Findings of Endocarditis

Osler’s nodes are small raised, swollen, painful erythematous lesions the size of a pea,on pads of fingers or toes

Janeway lesions are nontendermacular lesions most commonly involving the palms and soles and are caused by septic emboli

Splinter hemorrhages

Roth’s Spots and EndocarditisRoth’s Spots and Endocarditis

Round or oval retinalhemorrhages with white spots seen in the retina early in the course of IE,caused by complexmediated vasculitis

Microbiology of EndocarditisMicrobiology of Endocarditis

Microbiology of Native Valve Microbiology of Native Valve EndocarditisEndocarditis

OrganismOrganism Percent of Percent of CasesCases

Viridans streptococciViridans streptococci 30-40%30-40%

Other streptococciOther streptococci 15-25%15-25%

Staphylococcus aureusStaphylococcus aureus 10-27%10-27%

Enterococcus speciesEnterococcus species 5-18% 5-18%

Gram negative bacilliGram negative bacilli 2-13%2-13%

Microbiology of Prosthetic-Valve Microbiology of Prosthetic-Valve EndocarditisEndocarditis

OrganismOrganism Percentage of Cases Percentage of Cases

Early Onset Late Onset (> 12 Early Onset Late Onset (> 12 m)m)

Coagulase negative staphCoagulase negative staph 30-35%30-35% 15%15%

Staphylococcus aureusStaphylococcus aureus 17-23%17-23% 20%20%

Gram negative bacilliGram negative bacilli 10%10% 5%5%

StreptococciStreptococci 5-10% 5-10% 33%33%

FungiFungi 10% 10% 2% 2%

Causes of Culture-Negative Causes of Culture-Negative EndocarditisEndocarditis

Coxiella burnetti (Q fever)Coxiella burnetti (Q fever)

Bartonella species (cat scratch Bartonella species (cat scratch disease)disease)

HACEK organisms*HACEK organisms*

LegionellaLegionella species species

AspergillusAspergillus species species

LactobacillusLactobacillus species species

* Haemophilus species; Actinobacillus actinomycetemcomitans; Cardiobacteriumhominis; Eikenella corrodens; and Kingella kingae

Echocardiography and Diagnosis of Echocardiography and Diagnosis of EndocarditisEndocarditis

Transthoracic Echocardiography Transthoracic Echocardiography and Endocarditisand Endocarditis

No technological advance has had as much impact on No technological advance has had as much impact on approach to patients with IEapproach to patients with IE

Rapid, non-invasive and specific for vegetations (98%)Rapid, non-invasive and specific for vegetations (98%)

May be inadequate in 20% of patients because of May be inadequate in 20% of patients because of obesity, COPD, or chest-wall deformitiesobesity, COPD, or chest-wall deformities

TTE should be used in the evaluation of those with TTE should be used in the evaluation of those with suspected native valve IE who are good candidates for suspected native valve IE who are good candidates for imagingimaging

Transesophageal Echocardiography Transesophageal Echocardiography and Endocarditisand Endocarditis

More costly and invasive but increases the More costly and invasive but increases the sensitivty (from 75% to 95%) while maintaining sensitivty (from 75% to 95%) while maintaining specificity (85-98%)specificity (85-98%)

More sensitive for defining perivalvular More sensitive for defining perivalvular extension, perforation of valves, and myocardial extension, perforation of valves, and myocardial abscessabscess

A negative TEE has a negative predictive value A negative TEE has a negative predictive value for IE of > 92%for IE of > 92%

TTE or TEE or Both?TTE or TEE or Both?

Recent guidelines suggest that among patients Recent guidelines suggest that among patients with suspected endocarditis appropriate use of with suspected endocarditis appropriate use of echocardiography depends on prior probability echocardiography depends on prior probability of IEof IE

If this probability is < 4% , a negative TTE is cost If this probability is < 4% , a negative TTE is cost effective and satisfactory in ruling out IEeffective and satisfactory in ruling out IE

If this probability is 4 to 60%, initial use of TEE If this probability is 4 to 60%, initial use of TEE is more cost effective and efficient than initial is more cost effective and efficient than initial TTE followed by TEE (if former negative)TTE followed by TEE (if former negative)

Mylonakis & Calderwood NEJM 2001;345:1318

Limitations of Echocardiography in Limitations of Echocardiography in the Diagnosis of Endocarditisthe Diagnosis of Endocarditis

Falsely negative early in diseaseFalsely negative early in disease

False positive diagnosis with thickened valve False positive diagnosis with thickened valve leaflets, valve nodules or tumorsleaflets, valve nodules or tumors

Inability to distinguish healed from active Inability to distinguish healed from active vegetationsvegetations

Lower sensitivity in those with mechanical Lower sensitivity in those with mechanical prostheses prostheses

Blood cultures remain the test of choice for Blood cultures remain the test of choice for patients with suspected endocarditispatients with suspected endocarditis

Duke Criteria for Diagnosis of Duke Criteria for Diagnosis of EndocarditisEndocarditis

Duke Criteria for Diagnosis of Infective Duke Criteria for Diagnosis of Infective Endocarditis: Major CriteriaEndocarditis: Major Criteria

Positive blood culture for typical organism (from 2 separate Positive blood culture for typical organism (from 2 separate culturescultures or Staphylococcus aureus or Staphylococcus aureus or enterococcal or enterococcal bacteremia without a primary focus) bacteremia without a primary focus) oror

Persistent bacteremia for any organism > 12 hrs apart Persistent bacteremia for any organism > 12 hrs apart oror

All of 3 or majority of 4 BC positive drawn > 1 hr apartAll of 3 or majority of 4 BC positive drawn > 1 hr apart

Echocardiographic criteriaEchocardiographic criteria

- Oscillating mass, abscess or new dehiscence of - Oscillating mass, abscess or new dehiscence of prosthesisprosthesis

- New valvular regurgitation- New valvular regurgitation

Duke Criteria for Diagnosis of Infective Duke Criteria for Diagnosis of Infective Endocarditis: Minor CriteriaEndocarditis: Minor Criteria

Predisposing heart condition or injection drug usePredisposing heart condition or injection drug use

Fever greater than or equal to 38Fever greater than or equal to 38oo C C

Immunologic phenomena: GN, Osler’s nodes, Roth Spots, RFImmunologic phenomena: GN, Osler’s nodes, Roth Spots, RF

Echo consistent, but not meeting major criteriaEcho consistent, but not meeting major criteria

Vascular phenomena: arterial embolism, septic PE, mycotic Vascular phenomena: arterial embolism, septic PE, mycotic aneurysm, intracranial hemorrhage, Janeway lesionsaneurysm, intracranial hemorrhage, Janeway lesions

Microbiologic evidence: positive BC not meeting major Microbiologic evidence: positive BC not meeting major criteria criteria oror serology indicating active infection with consistent serology indicating active infection with consistent organismorganism

Duke Criteria for Diagnosis of Duke Criteria for Diagnosis of Infective EndocarditisInfective Endocarditis

Definite endocarditis: Pathologic criteriaDefinite endocarditis: Pathologic criteria

Organisms by culture Organisms by culture oror histology in vegetation, histology in vegetation, embolus, or cardiac abscess embolus, or cardiac abscess oror

Pathologic lesion such as vegetation or cardiac Pathologic lesion such as vegetation or cardiac abscessabscess

Clinical criteriaClinical criteria

2 major, or 1 major plus 3 minor, 2 major, or 1 major plus 3 minor, oror 5 minor 5 minor criteria criteria

Right Sided Endocarditis in Injection Right Sided Endocarditis in Injection Drug UsersDrug Users

Right-sided Endocarditis in Injection Right-sided Endocarditis in Injection Drug UsersDrug Users

46 y/o man injection drug user (heroin)with fevers, sweats and right sided pleuriticchest pain. Blood cultures grew penicillin-susceptible S. aureus and echocardiogram showed 1 mm Tricuspid valve vegetation.HIV negative and in hospital for 7 days with oxacillin and gentamicin followed by21 days of outpatient ceftriaxone (2 gms/day).

Multiple peripheral septic emboli with cavitation

Right-Sided Endocarditis in Right-Sided Endocarditis in Injection Drug UsersInjection Drug Users

Common complication with overall favorable Common complication with overall favorable prognosisprognosis

Vegetations > 2 cm associated with higher Vegetations > 2 cm associated with higher mortality (33% vs 1.3%)mortality (33% vs 1.3%)

S. aureus most common pathogen (>80%) than S. aureus most common pathogen (>80%) than Viridans streptococciViridans streptococci

>50% with septic emboli on chest radiographs>50% with septic emboli on chest radiographs

Hecht SR and Berger M Ann Int Med 1992;117:560

Right Sided Endocarditis in Right Sided Endocarditis in Injection Drug Users: TreatmentInjection Drug Users: Treatment

Two week regimen (nafcillin or oxacillin + Two week regimen (nafcillin or oxacillin + gentamicin) for susceptible isolatesgentamicin) for susceptible isolates

Oral therapies still controversialOral therapies still controversial

Exclusion to “short-course” protocol:Exclusion to “short-course” protocol:

Extracardiac complications of IEExtracardiac complications of IE

Fever for > 7 daysFever for > 7 days

HIV infectionHIV infection

Vegetation > 1-2 cmVegetation > 1-2 cm

Chambers HF Ann Intern Med 1988;109:619

AHA Guidelines for Treatment of AHA Guidelines for Treatment of EndocarditisEndocarditis

Aortic Versus Mitral Valve Aortic Versus Mitral Valve EndocarditisEndocarditis

AorticAortic ~55% ~55% ~75% ~75%

MitralMitral ~85%~85% ~40%~40%

PulmonaryPulmonary ~1%~1%

TricuspidTricuspid ~20%~20%

Acute aortic regurgitation is poorly tolerated because the LV is Acute aortic regurgitation is poorly tolerated because the LV is less compliant than the LA resulting higher LV wall stress! less compliant than the LA resulting higher LV wall stress! Watch out for abrupt deterioration!Watch out for abrupt deterioration!

Overall Overall incidenceincidence

Surgical Surgical PatientsPatients

AHA Guidelines for Antibiotic Therapy in AHA Guidelines for Antibiotic Therapy in Native Valve EndocarditisNative Valve Endocarditis

OrganismOrganism RegimenRegimen WeeksWeeks

PCN-sensitive PCN-sensitive PCN G 12-18 MI qd PCN G 12-18 MI qd oror 44 Ceftriaxone 2 Ceftriaxone 2 g qd g qd or or 44 Ceftriaxone 2 g qd + Ceftriaxone 2 g qd +

22 Gentamicin 3 Gentamicin 3 mg/kg qd mg/kg qd or or Vancomycin 1 g bidVancomycin 1 g bid 44

PCN-insensitivePCN-insensitive PCN G 18 MI qd + PCN G 18 MI qd + 44 Gentamicin 1 Gentamicin 1 mg/kg tid mg/kg tid 22 or or Vancomycin 1 g Vancomycin 1 g bidbid 44

Doses assume normal renal functionDoses assume normal renal function



MSSAMSSA Oxacillin or Nafcillin 2 g q4hOxacillin or Nafcillin 2 g q4h 4-6 4-6 or or Cefazolin 2 g tidCefazolin 2 g tid4-6 4-6

both +/- Gentamicin 1 mg/kg tid 3-5dboth +/- Gentamicin 1 mg/kg tid 3-5d

or or Vancomycin 1 g bid +/- GentVancomycin 1 g bid +/- Gent

MRSAMRSA Vancomycin 1 g bidVancomycin 1 g bid 4-6 4-6 +/- +/- Gentamicin 1 mg/kg tidGentamicin 1 mg/kg tid 4-64-6 Doses assume normal Doses assume normal

renal functionrenal function


OrganismOrganism Regimen Regimen WeeksWeeks

Enterococci (VSE)Enterococci (VSE) PCN + Gentamicin PCN + Gentamicin oror 6 6Vancomycin + GentamicinVancomycin + Gentamicin 6 6

as aboveas above

HACEKHACEK Ceftriaxone 2 g qd Ceftriaxone 2 g qd oror 4 4 Ampicillin 2 g q4h +Ampicillin 2 g q4h + 4 4

Gentamicin 1 mg/kg tidGentamicin 1 mg/kg tid 4 4

Doses assume normal renal function

AHA Guidelines for Antibiotic Therapy in AHA Guidelines for Antibiotic Therapy in Prosthetic Valve EndocarditisProsthetic Valve Endocarditis


MSSA or MSSEMSSA or MSSE Oxacillin or Nafcillin 2 g q4hOxacillin or Nafcillin 2 g q4h 6+ 6+ + + Gentamicin 1 mg/kg tid Gentamicin 1 mg/kg tid 2 2

+ Rifampin 300 mg tid+ Rifampin 300 mg tid 6+6+

MRSA or MRSEMRSA or MRSE Vancomycin 1 g bidVancomycin 1 g bid 6+ 6+ + + Gentamicin 1 mg/kg tidGentamicin 1 mg/kg tid 2 2

+ Rifampin 300 mg tid+ Rifampin 300 mg tid 6+6+ Doses assume Doses assume

normal renal functionnormal renal function

Steel: Often the Best Antimicrobial Steel: Often the Best Antimicrobial Agent In Treating Infective EndocarditisAgent In Treating Infective Endocarditis

Medical versus Surgical therapyMedical versus Surgical therapy

Surgery is always in addition to medical Surgery is always in addition to medical therapytherapy

The vast majority of the operated patients The vast majority of the operated patients would die if not operatedwould die if not operated

Some medically treated patients are Some medically treated patients are “inoperable“inoperable” ”

Surgical Indications in EndocarditisSurgical Indications in Endocarditis

Refractory CHFRefractory CHF

> 1 serious embolic > 1 serious embolic eventevent

Uncontrolled infectionUncontrolled infection

Physiologically Physiologically significant valve significant valve dysfunction by echodysfunction by echo

Fungal endocarditisFungal endocarditis

Ineffective antimicrobial Ineffective antimicrobial therapytherapy

Mycotic aneurysmMycotic aneurysm

Most cases of PVE due to Most cases of PVE due to antibiotic resistant antibiotic resistant pathogenspathogens

Local cardiac suppurative Local cardiac suppurative complicationscomplications

Echocardiographic Features Predicting Echocardiographic Features Predicting Need for Surgery in EndocarditisNeed for Surgery in Endocarditis

Persistent vegetations Persistent vegetations after a major embolusafter a major embolus

Large (> 1 cm) mitral Large (> 1 cm) mitral valve vegetationvalve vegetation

Increasing vegetation Increasing vegetation size after 4 weeks of size after 4 weeks of antimicrobial therapyantimicrobial therapy

Acute mitral Acute mitral insufficiencyinsufficiency

Valve perforation or Valve perforation or rupturerupture

Periannular Periannular extension of infectionextension of infection

AHA Committee on EndocarditisAHA Committee on Endocarditis

Homograft or Prosthetic Valve Homograft or Prosthetic Valve Replacement for Aortic Valve IEReplacement for Aortic Valve IE

There are no and probably will be no randomized studies!There are no and probably will be no randomized studies!

Good results are possible to obtain with eitherGood results are possible to obtain with either

However, an increasing number of publications favor However, an increasing number of publications favor homograftshomografts

Technically easier and saferTechnically easier and safer

Lower risk of heart blockLower risk of heart block Lower infection and re-infection rateLower infection and re-infection rate Homograft does not require anticoagulationHomograft does not require anticoagulation

Limited supply of homograftsLimited supply of homografts

Limited durability of homograftLimited durability of homograft

Timing of Timing of SurgerySurgery

30% require surgery in the acute phase30% require surgery in the acute phase

another 20-40% will require surgery lateranother 20-40% will require surgery later Main principle: Don’t postpone an indicated operation, however:Main principle: Don’t postpone an indicated operation, however:

Pts with strokes: Postpone surgery, if possible 1-3 weeks, Pts with strokes: Postpone surgery, if possible 1-3 weeks, particularly if evidence of hemorrhageparticularly if evidence of hemorrhage

If valve repair is planned: 1 week of preop antibiotic If valve repair is planned: 1 week of preop antibiotic treatmenttreatment

Re-infection rate is lower after surgery for healed Re-infection rate is lower after surgery for healed endocarditisendocarditis

Early Surgery Versus Conventional Treatment for IEEarly Surgery Versus Conventional Treatment for IEKaplan–Meier Curves for Cumulative Probabilities of Death Kaplan–Meier Curves for Cumulative Probabilities of Death

and Composite End Point at 6 Monthsand Composite End Point at 6 Months

Kang DH, et al: NEJM 2012; 366:2466

Early Surgery Versus Conventional Treatment for IEEarly Surgery Versus Conventional Treatment for IEClinical End PointsClinical End Points

Kang D et al. N Engl J Med 2012;366:2466-2473.

Kang DH, et al: NEJM 2012; 366:2466

Early Surgery Versus Conventional Treatment for Infective Endocarditis

Special Surgical Considerations Special Surgical Considerations Related to LocationRelated to Location

Aortic valve IE: Be aggressive!Aortic valve IE: Be aggressive!

Acute aortic regurgitation is poorly toleratedAcute aortic regurgitation is poorly tolerated

Mitral valve IE: Repair whenever possible, Mitral valve IE: Repair whenever possible, consider risk of embolismconsider risk of embolism

Right-sided IE: Be conservative!Right-sided IE: Be conservative!

Repair, excision, (replacement)Repair, excision, (replacement)

Pulmonary valve IE is very uncommonPulmonary valve IE is very uncommon

Aortic Root Endocarditis With Aortic Root Endocarditis With Vegetation and Fistula to Right AtriumVegetation and Fistula to Right Atrium

The infection penetrates through to the floor of the The infection penetrates through to the floor of the Right atrium just about to destroy the A-V nodeRight atrium just about to destroy the A-V node

Ventricular Assist Device Associated Ventricular Assist Device Associated EndocarditisEndocarditis

LVAD and EndocarditisLVAD and Endocarditis

Endocarditis and Ventricular Endocarditis and Ventricular Assist DevicesAssist Devices

Patients with VADs are at high risk for nosocomial Patients with VADs are at high risk for nosocomial bloodstream infectionsbloodstream infections

Incidence of VAD associated IE may be as high as 13% Incidence of VAD associated IE may be as high as 13% (relapsing bacteremia/fungemia common)(relapsing bacteremia/fungemia common)

At least 24 cases in literature (33% Candida 20% At least 24 cases in literature (33% Candida 20% Enterococcus) with 50% associated mortalityEnterococcus) with 50% associated mortality

Difficult to visualize inflow and outflow conduits by Difficult to visualize inflow and outflow conduits by echocardiographyechocardiography

Treatment: tranplantation! Device exchange high rate of Treatment: tranplantation! Device exchange high rate of failure/deathfailure/death

Gordon and McCarthy in Advanced Therapy Cardiac Surgery 2002

Pacemaker Associated EndocarditisPacemaker Associated Endocarditis

Pacemaker-Associated EndocarditisPacemaker-Associated Endocarditis

>2 million people (including 1 million Americans) use >2 million people (including 1 million Americans) use pacemakers pacemakers

Infections uncommon but difficult to eradicate without Infections uncommon but difficult to eradicate without device removal (generator + leads via laser extraction device removal (generator + leads via laser extraction if possible)if possible)

Pacemaker endocarditis can be difficult diagnosis to Pacemaker endocarditis can be difficult diagnosis to make on clinical groundsmake on clinical grounds

TEE sensitive in finding suspicious lesions on TEE sensitive in finding suspicious lesions on pacemakerpacemaker

Chua J et al Ann Int Med 2000;133:644

Pacemaker-Associated EndocarditisPacemaker-Associated Endocarditis

Prophylaxis to Prevent EndocarditisProphylaxis to Prevent Endocarditis

Endocarditis ProphylaxisEndocarditis Prophylaxis

Class I: No class I indications.Class I: No class I indications.

Class IIa: Reasonable for pts at highest risk for adverse outcomes from Class IIa: Reasonable for pts at highest risk for adverse outcomes from IE having dental procedures that involve manipulation of either gingival IE having dental procedures that involve manipulation of either gingival tissue or the periapical region of the teeth or perforation of the oral tissue or the periapical region of the teeth or perforation of the oral mucosamucosa

- Pts with prosthetic cardiac valves or prosthetic - Pts with prosthetic cardiac valves or prosthetic

material used for valve repairmaterial used for valve repair

- Pts with previous IE- Pts with previous IE

- Pts with CHD: unrepaired cianotic CHD including - Pts with CHD: unrepaired cianotic CHD including

paliative shunts and conduits paliative shunts and conduits

ACC/AHA 2008 Guideline Update on Valvular Heart Disease: JACC 2008; 676


Class IIa (cont):Class IIa (cont):

- Complete repaired CHD fixed with prosthetic material- Complete repaired CHD fixed with prosthetic material

or device, whether placed surgically or by catheteror device, whether placed surgically or by catheter

intervention, during first 6 months after procedureintervention, during first 6 months after procedure

- Repaired CHD with residual defects at the site or - Repaired CHD with residual defects at the site or

adjacent to the site of a prosthetic patch or deviceadjacent to the site of a prosthetic patch or device

- Cardiac transplant pts with valve regurgitation due- Cardiac transplant pts with valve regurgitation due

to structurally abnormal valveto structurally abnormal valve

Class III: Prophylaxis not recommended against nondental Class III: Prophylaxis not recommended against nondental procedures: TEE, EGD or colonoscopyprocedures: TEE, EGD or colonoscopy



Prophylaxis accepted in high risk pts:Prophylaxis accepted in high risk pts:

- Incision of the respiratory tract mucosa, such- Incision of the respiratory tract mucosa, such

as tonsillectomy and adenoidectomyas tonsillectomy and adenoidectomy

- Infections of the GI or GU tract- Infections of the GI or GU tract

- Pts undergoing elective cistoscopy or other- Pts undergoing elective cistoscopy or other

urinary tract manipulation who have urinary tract manipulation who have

enterococcal UTIenterococcal UTI


Procedures Not Requiring Procedures Not Requiring Prophylaxis in At Risk PatientsProphylaxis in At Risk Patients

Dental restorationDental restoration

Adjustment of bracesAdjustment of braces

Flexible bronchoscopyFlexible bronchoscopy

GI endoscopyGI endoscopy

C-section deliveriesC-section deliveries

Cardiac catheterizationCardiac catheterization

Urethral catheterization (sterile urine)Urethral catheterization (sterile urine)

ACC/AHA Guidelines for Prevention of ACC/AHA Guidelines for Prevention of Bacterial EndocarditisBacterial Endocarditis

Oral: Amoxicillin 2g 30-60 min before oral procedureOral: Amoxicillin 2g 30-60 min before oral procedure

Unable to take PO: Ampicillin 2g IM or IV, or cefazolin or Unable to take PO: Ampicillin 2g IM or IV, or cefazolin or

ceftriaxome IV 1g IM or IV 30-60 min before procedureceftriaxome IV 1g IM or IV 30-60 min before procedure

Allergic to PCN – oral: clindamycin 600mg,Allergic to PCN – oral: clindamycin 600mg,

azithromycin or clarithromycin 500mg 30-60 min beforeazithromycin or clarithromycin 500mg 30-60 min before

procedureprocedure

Allergic to PCN and unable to take PO: clindamycin 600mg Allergic to PCN and unable to take PO: clindamycin 600mg IM or IV or cefazolin or ceftriaxone 1g IM or IV (do not use if IM or IV or cefazolin or ceftriaxone 1g IM or IV (do not use if anaphylaxis, angioedema, urticaria with PCNanaphylaxis, angioedema, urticaria with PCN


Documents

Infective Endocarditis: Epidemiology, Diagnosis and Management Holger P. Salazar, MD, FACC Stern Cardiovascular Foundation No financial relation to disclose