Endocarditis, Infective

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Basics

Infective endocarditis (IE) is an infection of the inner layer of the heart including the valves (native/prosthetic), interventricular septum, intracardiac devices, chordae tendineae, and mural endocardium. IE occurs worldwide and is generally fatal if left untreated.

Description

  • An infection of the valvular (primarily) and/or mural (rarely) endocardium
  • System(s) affected: cardiovascular, endocrine/metabolic, hematologic/lymphatic, immunologic, pulmonary, renal/urologic, skin/exocrine, neurologic
  • Synonym(s): bacterial endocarditis; subacute bacterial endocarditis (SBE); acute bacterial endocarditis (ABE)

Epidemiology

More common in males (range is 3:2 to 9:1). >50% of cases in the United States occur in individuals >60 years of age.

Incidence

  • Native valve endocarditis has variable rates of incidence due to changes in definition over the years.
  • 1.5–3% incidence 1 year after prosthetic valve replacement; 3–6% 5 years postreplacement
  • Increasing incidence of cardiovascular device–related infections due to higher frequency of implantable devices.
  • Can be community- or hospital-acquired
  • Most commonly affects the mitral valve and aortic valve (increased left-sided pressures and turbulent flow)

Etiology and Pathophysiology

IE is most commonly caused by a nonbacterial thrombus that adheres to an endocardial surface, coupled with a bacterial source sufficient to seed the thrombus. This can occur from direct bacterial invasion or valvular trauma:

  • Native valve endocarditis
    • Acute: Staphylococcus aureus; Streptococcus groups A, B, C, G; Streptococcus pneumoniae; Staphylococcus lugdunensis; Enterococcus spp.; Haemophilus influenzae or parainfluenzae; Neisseria gonorrhoeae
    • Subacute: α-hemolytic streptococci, Streptococcus bovis, Enterococcus spp., S. aureus, Staphylococcus epidermidis; HACEK organisms
  • Intravenous drug abuse endocarditis (IVDA) (most commonly tricuspid valve): S. aureus, Enterococcus spp.; Pseudomonas aeruginosa, Burkholderia cepacia, other bacilli (gram-negative); Candida spp.
  • Prosthetic valve endocarditis
    • Early (≥12 months after valve implantation): S. aureus, S. epidermidis; gram-negative bacilli; Candida spp., Aspergillus spp.
    • Late (>12 months after valve implantation): α-hemolytic streptococci, S. aureus, Enterococcus spp., S. epidermidis, Candida spp., Aspergillus spp.
  • Culture-negative endocarditis: 10% of cases; Bartonella quintana (homeless); Brucella spp., fungi, Coxiella burnetii (Q fever), Chlamydia trachomatis, Chlamydophila psittaci, HACEK organisms
  • Device-related endocarditis: coagulase-negative staphylococci or S. aureus

Risk Factors

  • Injection drug use, IV catheterization, certain malignancies (colon cancer), poor dentition/infection, chronic hemodialysis, age >60 years, male sex
  • High risk with:
    • Structural heart disease, prosthetic cardiac valves, valvular disease, implantable devices, total parenteral nutrition
    • Previous IE
    • Congenital heart disease (CHD): unrepaired cyanotic CHD, including palliative shunts and conduits; repaired CHD with prosthetic device during the first 6 months; repaired CHD with residual defects at or near prosthetic site; cardiac transplant with valvulopathy (1)[B]

General Prevention

  • Good oral hygiene
  • Antibiotic prophylaxis is only recommended in patients with a high risk of adverse outcomes if IE were to occur (1)[B]—(see “Risk Factors”). Administer 30 to 60 minutes prior to the procedure (exception vancomycin which should be administered 120 minutes prior to the procedure).
  • Procedures requiring prophylaxis
    • Oral/upper respiratory tract procedures/biopsies: Amoxicillin 2 g PO 30 to 60 minutes before procedure or ampicillin 2 g IV/IM are first-line prophylactic choices. Clindamycin no longer recommended for dental prophylaxis because it is associated with more frequent and severe adverse effects (i.e., Clostridium difficile infection)
    • GI/GU: Only consider coverage for Enterococcus (with penicillin, ampicillin, piperacillin, or vancomycin) for patients with an established infection undergoing procedures (1)[B].
    • Cardiac valvular surgery or placement of prosthetic intracardiac/intravascular materials: perioperative cefazolin 1 to 2 g IV 30 minutes preoperative or vancomycin 15 mg/kg (maximum 1 g) (penicillin-allergic patients) 60 minutes preoperative (1)[B]
    • Skin/soft tissue: incision and drainage of infected tissue; use agents active against skin pathogens (e.g., cefazolin 1 to 2 g IV q8h or vancomycin 15 mg/kg q12h; max 1 g) if penicillin-allergic or if methicillin-resistant S. aureus (MRSA) suspected.

Commonly Associated Conditions

Most patients with IE have preexisting conditions (see high-risk above).

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Basics

Infective endocarditis (IE) is an infection of the inner layer of the heart including the valves (native/prosthetic), interventricular septum, intracardiac devices, chordae tendineae, and mural endocardium. IE occurs worldwide and is generally fatal if left untreated.

Description

  • An infection of the valvular (primarily) and/or mural (rarely) endocardium
  • System(s) affected: cardiovascular, endocrine/metabolic, hematologic/lymphatic, immunologic, pulmonary, renal/urologic, skin/exocrine, neurologic
  • Synonym(s): bacterial endocarditis; subacute bacterial endocarditis (SBE); acute bacterial endocarditis (ABE)

Epidemiology

More common in males (range is 3:2 to 9:1). >50% of cases in the United States occur in individuals >60 years of age.

Incidence

  • Native valve endocarditis has variable rates of incidence due to changes in definition over the years.
  • 1.5–3% incidence 1 year after prosthetic valve replacement; 3–6% 5 years postreplacement
  • Increasing incidence of cardiovascular device–related infections due to higher frequency of implantable devices.
  • Can be community- or hospital-acquired
  • Most commonly affects the mitral valve and aortic valve (increased left-sided pressures and turbulent flow)

Etiology and Pathophysiology

IE is most commonly caused by a nonbacterial thrombus that adheres to an endocardial surface, coupled with a bacterial source sufficient to seed the thrombus. This can occur from direct bacterial invasion or valvular trauma:

  • Native valve endocarditis
    • Acute: Staphylococcus aureus; Streptococcus groups A, B, C, G; Streptococcus pneumoniae; Staphylococcus lugdunensis; Enterococcus spp.; Haemophilus influenzae or parainfluenzae; Neisseria gonorrhoeae
    • Subacute: α-hemolytic streptococci, Streptococcus bovis, Enterococcus spp., S. aureus, Staphylococcus epidermidis; HACEK organisms
  • Intravenous drug abuse endocarditis (IVDA) (most commonly tricuspid valve): S. aureus, Enterococcus spp.; Pseudomonas aeruginosa, Burkholderia cepacia, other bacilli (gram-negative); Candida spp.
  • Prosthetic valve endocarditis
    • Early (≥12 months after valve implantation): S. aureus, S. epidermidis; gram-negative bacilli; Candida spp., Aspergillus spp.
    • Late (>12 months after valve implantation): α-hemolytic streptococci, S. aureus, Enterococcus spp., S. epidermidis, Candida spp., Aspergillus spp.
  • Culture-negative endocarditis: 10% of cases; Bartonella quintana (homeless); Brucella spp., fungi, Coxiella burnetii (Q fever), Chlamydia trachomatis, Chlamydophila psittaci, HACEK organisms
  • Device-related endocarditis: coagulase-negative staphylococci or S. aureus

Risk Factors

  • Injection drug use, IV catheterization, certain malignancies (colon cancer), poor dentition/infection, chronic hemodialysis, age >60 years, male sex
  • High risk with:
    • Structural heart disease, prosthetic cardiac valves, valvular disease, implantable devices, total parenteral nutrition
    • Previous IE
    • Congenital heart disease (CHD): unrepaired cyanotic CHD, including palliative shunts and conduits; repaired CHD with prosthetic device during the first 6 months; repaired CHD with residual defects at or near prosthetic site; cardiac transplant with valvulopathy (1)[B]

General Prevention

  • Good oral hygiene
  • Antibiotic prophylaxis is only recommended in patients with a high risk of adverse outcomes if IE were to occur (1)[B]—(see “Risk Factors”). Administer 30 to 60 minutes prior to the procedure (exception vancomycin which should be administered 120 minutes prior to the procedure).
  • Procedures requiring prophylaxis
    • Oral/upper respiratory tract procedures/biopsies: Amoxicillin 2 g PO 30 to 60 minutes before procedure or ampicillin 2 g IV/IM are first-line prophylactic choices. Clindamycin no longer recommended for dental prophylaxis because it is associated with more frequent and severe adverse effects (i.e., Clostridium difficile infection)
    • GI/GU: Only consider coverage for Enterococcus (with penicillin, ampicillin, piperacillin, or vancomycin) for patients with an established infection undergoing procedures (1)[B].
    • Cardiac valvular surgery or placement of prosthetic intracardiac/intravascular materials: perioperative cefazolin 1 to 2 g IV 30 minutes preoperative or vancomycin 15 mg/kg (maximum 1 g) (penicillin-allergic patients) 60 minutes preoperative (1)[B]
    • Skin/soft tissue: incision and drainage of infected tissue; use agents active against skin pathogens (e.g., cefazolin 1 to 2 g IV q8h or vancomycin 15 mg/kg q12h; max 1 g) if penicillin-allergic or if methicillin-resistant S. aureus (MRSA) suspected.

Commonly Associated Conditions

Most patients with IE have preexisting conditions (see high-risk above).

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