Bacterial endocarditis

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Endocarditis is defined at "exudative and proliferative inflammatory alterations of the endocardium, characterized by the presence of vegetations on the surface of the endocardium or in the endocardium itself, and most commonly involving a heart valve, but sometimes affecting the inner lining of the cardiac chambers or the endocardium elsewhere. It may occur as a primary disorder or as a complication of or in association with another disease".[1]

Diagnosis

In general, a patient should fulfill the Duke Criteria[2] in order to establish the diagnosis of endocarditis.

Role of patient characteristics

As the Duke Criteria relies heavily on the results of echocardiography, research has addressed when to order an echocardiogram by using signs and symptoms to predict occult endocarditis among patients with intravenous drug abuse[3][4][5] and among non drug-abusing patients [6][7]. Unfortunately, this research is over 20 years old and it is possible that changes in the epidemiology of endocarditis and bacteria such as staphylococcus make the following estimates incorrectly low.

Among patients who do not use illicit drugs and have a fever in the emergency room, there is a less than 5% chance of occult endocarditis. Mellors [7] in 1987 found no cases of endocarditis nor of staphylococcal bacteremia among 135 febrile patients in the emergency room. The upper confidence interval for 0% of 135 is 5%, so for statistical reasons alone, there is up to a 5% chance of endocarditis among these patients. In contrast, Leibovici [6] found that among 113 non-selected adults admitted to the hospital because of fever there were two cases (1.8% with 95%CI: 0% to 7%) of endocarditis.

Among patients who do use illicit drugs and have a fever in the emergency room, there is about a 10% to 15% prevalence of endocarditis. This estimate is not substantially changed by whether the doctor believes the patient has a trivial explanation for their fever[5]. Weisse[3] found that 13% of 121 patients had endocarditis. Marantz [5] also found a prevalence of endocarditis of 13% among such patients in the emergency room with fever. Samet [4] found a 6% incidence among 283 such patients, but after excluding patients with initially apparent major illness to explain the fever (including 11 cases of manifest endocarditis), there was a 7% prevalence of endocarditis.

Clinical prediction rule. A clinical prediction rule, that has not been validated, suggests there is no chance of endocarditis in the absence of "vasculitic/embolic phenomena; the presence of central venous access; a recent history of injected drug use; presence of a prosthetic valve; and positive blood cultures".[8]

Among patients with staphylococcus aureus bacteremia (SAB), one study found a 29% prevalence of endocarditis in community-acquired SAB versus 5% in nosocomial SAB[9]. However, only 2% of strains were resistant to methicillin and so these numbers may be low in areas of higher resistance. The likelihood of endocarditis may be higher for MSSA than MRSA.[10]

A clinical prediction rule aids in identifying patients with bacteremia from staphylococcus aureus who might develop endocarditis.[11]

Physical examination

The classic signs on physical examination have a sensitivity of less than 10%.[12]

Echocardiography

The role of electrocardiography has been addressed in clinical practice guidelines from the American Heart Association, with endorsement by the Infectious Diseases Society of America, have been updated in 2015.[13]

Transesophageal echocardiography is more accurate than transthoracic echocardiography.[14][15]

Transthoracic echocardiography

The transthoracic echocardiogram has a sensitivity and specificity of approximately 65% and 95% if the echocardiographer believes there is 'probabable' or 'almost certain' evidence of endocarditis[16][17].

Transesophageal echocardiography

Patients at highest risk of endocarditis should have early transesophageal echocardiography.[18]

Computed tomographic cardiac angiography

Computed tomographic cardiac angiography can detect vegetations and abscesses/pseudoaneurysms, but not leaflet perforations, almost as well as transesophageal echocardiography.[19]

Treatment

About half of patients will require cardiac surgery.[12]

Prognosis

Complications include:[12]

Prevention

European Guidelines

Clinical practice guidelines for the United Kingdom have been created by the National Institute for Health and Clinical Excellence.[20]

United States Guidelines

2008 Guideline

In 2008, the American Heart Association revised their clinical practice guidelines resulting in fewer patients receiving prophylaxis.[21]

The following two lists are quoted from the guidelines:

  • The committee concluded that only an extremely small number of cases of infective endocarditis may be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100 percent effective.
  • Infective endocarditis prophylaxis for dental procedures is reasonable only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis.
  • For patients with these underlying cardiac conditions, prophylaxis is reasonable for all dental procedures that involve manipulation of either gingival tissue or the periapical region of teeth or perforation of oral mucosa.
  • Prophylaxis is not recommended solely on the basis of an increased lifetime risk of acquisition of infective endocarditis.

Highest risk cardiac conditions are:

  • Patients with prosthetic heart valves and patients with a history of infective endocarditis. (Level of Evidence: C)
  • Patients who have complex cyanotic congenital heart disease (e.g., single-ventricle states, transposition of the great arteries, tetralogy of Fallot). (Level of Evidence: C)
  • Patients with surgically constructed systemic pulmonary shunts or conduits. (Level of Evidence: C)
  • Patients with congenital cardiac valve malformations, particularly those with bicuspid aortic valves, and patients with acquired valvular dysfunction (e.g., rheumatic heart disease). (Level of Evidence: C)
  • Patients who have undergone valve repair. (Level of Evidence: C)
  • Patients who have hypertrophic cardiomyopathy when there is latent or resting obstruction. (Level of Evidence: C)
  • Patients with MVP and auscultatory evidence of valvular regurgitation and/or thickened leaflets on echocardiography.low asterisk (Level of Evidence: C)

2006 Guideline

According to the 2006 clinical practice guidelines from the American Heart Association, the following patients are "Highest Risk of Adverse Outcome From Endocarditis for Which Prophylaxis With Dental Procedures Is Reasonable" if they are undergoing "dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa":[22]

  • "Prosthetic cardiac valve or prosthetic material used for cardiac valve repair"
  • "Previous IE [infective endocarditis]"
  • "Congenital heart disease (CHD)*"
    • "Unrepaired cyanotic CHD, including palliative shunts and conduits"
    • "Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure"
    • "Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)"
  • Cardiac transplantation recipients who develop cardiac valvulopathy

References

  1. Anonymous (2015), Bacterial endocarditis (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. Durack D, Lukes A, Bright D (1994). "New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service.". Am J Med 96 (3): 200-9. PMID 8154507.
  3. 3.0 3.1 Weisse A, Heller D, Schimenti R, Montgomery R, Kapila R (1993). "The febrile parenteral drug user: a prospective study in 121 patients.". Am J Med 94 (3): 274-80. PMID 8452151.
  4. 4.0 4.1 Samet J, Shevitz A, Fowle J, Singer D (1990). "Hospitalization decision in febrile intravenous drug users.". Am J Med 89 (1): 53-7. PMID 2368794.
  5. 5.0 5.1 5.2 Marantz P, Linzer M, Feiner C, Feinstein S, Kozin A, Friedland G (1987). "Inability to predict diagnosis in febrile intravenous drug abusers.". Ann Intern Med 106 (6): 823-8. PMID 3579068.
  6. 6.0 6.1 Leibovici L, Cohen O, Wysenbeek A (1990). "Occult bacterial infection in adults with unexplained fever. Validation of a diagnostic index.". Arch Intern Med 150 (6): 1270-2. PMID 2353860.
  7. 7.0 7.1 Mellors J, Horwitz R, Harvey M, Horwitz S (1987). "A simple index to identify occult bacterial infection in adults with acute unexplained fever.". Arch Intern Med 147 (4): 666-71. PMID 3827454.
  8. Greaves K, Mou D, Patel A, Celermajer DS (March 2003). "Clinical criteria and the appropriate use of transthoracic echocardiography for the exclusion of infective endocarditis". Heart 89 (3): 273–5. PMID 12591829. PMC 1767572[e]
  9. Kaech C, Elzi L, Sendi P, Frei R, Laifer G, Bassetti S, Fluckiger U (2006). "Course and outcome of Staphylococcus aureus bacteraemia: a retrospective analysis of 308 episodes in a Swiss tertiary-care centre.". Clin Microbiol Infect 12 (4): 345-52. DOI:10.1111/j.1469-0691.2005.01359.x. PMID 16524411. Research Blogging.
  10. Abraham J, Mansour C, Veledar E, Khan B, Lerakis S (March 2004). "Staphylococcus aureus bacteremia and endocarditis: the Grady Memorial Hospital experience with methicillin-sensitive S aureus and methicillin-resistant S aureus bacteremia". Am. Heart J. 147 (3): 536–9. DOI:10.1016/j.ahj.2003.09.018. PMID 14999206. Research Blogging.
  11. Kaasch AJ, Fowler VG, Rieg S, Peyerl-Hoffmann G, Birkholz H, Hellmich M et al. (2011). "Use of a Simple Criteria Set for Guiding Echocardiography in Nosocomial Staphylococcus aureus Bacteremia.". Clin Infect Dis 53 (1): 1-9. DOI:10.1093/cid/cir320. PMID 21653295. Research Blogging.
  12. 12.0 12.1 12.2 Murdoch DR, Corey GR, Hoen B, et al (March 2009). "Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study". Arch. Intern. Med. 169 (5): 463–73. DOI:10.1001/archinternmed.2008.603. PMID 19273776. Research Blogging.
  13. Baddour LM, Wilson WR, Bayer AS, Fowler VG, Tleyjeh IM, Rybak MJ et al. (2015). "Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association.". Circulation 132 (15): 1435-86. DOI:10.1161/CIR.0000000000000296. PMID 26373316. Research Blogging.
  14. Erbel R, Rohmann S, Drexler M, Mohr-Kahaly S, Gerharz CD, Iversen S et al. (1988). "Improved diagnostic value of echocardiography in patients with infective endocarditis by transoesophageal approach. A prospective study.". Eur Heart J 9 (1): 43-53. PMID 3345769[e]
  15. Fowler VG, Li J, Corey GR, Boley J, Marr KA, Gopal AK et al. (1997). "Role of echocardiography in evaluation of patients with Staphylococcus aureus bacteremia: experience in 103 patients.". J Am Coll Cardiol 30 (4): 1072-8. PMID 9316542[e]
  16. Shively B, Gurule F, Roldan C, Leggett J, Schiller N (1991). "Diagnostic value of transesophageal compared with transthoracic echocardiography in infective endocarditis.". J Am Coll Cardiol 18 (2): 391-7. PMID 1856406.
  17. Erbel R, Rohmann S, Drexler M, Mohr-Kahaly S, Gerharz C, Iversen S, Oelert H, Meyer J (1988). "Improved diagnostic value of echocardiography in patients with infective endocarditis by transoesophageal approach. A prospective study.". Eur Heart J 9 (1): 43-53. PMID 3345769.
  18. Ryan EW, Bolger AF (November 2000). "Transesophageal echocardiography (TEE) in the evaluation of infective endocarditis". Cardiol Clin 18 (4): 773–87. PMID 11236165[e]
  19. Feuchtner GM, Stolzmann P, Dichtl W, et al (February 2009). "Multislice computed tomography in infective endocarditis: comparison with transesophageal echocardiography and intraoperative findings". J. Am. Coll. Cardiol. 53 (5): 436–44. DOI:10.1016/j.jacc.2008.01.077. PMID 19179202. Research Blogging.
  20. Stokes T, Richey R, Wray D, Wrayon D (July 2008). "Prophylaxis against infective endocarditis: summary of NICE guidance". Heart 94 (7): 930–1. DOI:10.1136/hrt.2008.147090. PMID 18552226. Research Blogging.
  21. Nishimura RA, Carabello BA, Faxon DP, et al (August 2008). "ACC/AHA 2008 Guideline update on valvular heart disease: focused update on infective endocarditis: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Journal of the American College of Cardiology 52 (8): 676–85. DOI:10.1016/j.jacc.2008.05.008. PMID 18702976. Research Blogging.
  22. Wilson W, Taubert KA, Gewitz M, et al (2007). "Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group". Circulation 116 (15): 1736–54. DOI:10.1161/CIRCULATIONAHA.106.183095. PMID 17446442. Research Blogging.