Bacterial Endocarditis Allergan research grant Genentech - PDF document

2/ 1/ 2017 Disclosures Bacterial Endocarditis • Allergan – research grant • Genentech – research grant Henry F. Chambers, MD Infective endocarditis: Outline • Native valve endocarditis • Prosthetic valve endocarditis • Cardiac implantable device infections • Unusual causes of endocarditis • Prophylaxis (time permitting) Circulation. 132:1435-86, 2015 1

2/ 1/ 2017 Which of the following is the most common bacterial etiology of infective endocarditis worldwide? 1. Streptococcus mutans Native Valve Endocarditis 2. Streptococcus sanguis 3. Group A β -hemolytic streptococcus 4. Enterococcus faecalis 5. Staphylococcus aureus When bacteremia is documented, which of the Which of the following is NOT a following is LEAST likely to be associated with HACEK Organism? endocarditis? 1. Haemophilus species 1.Streptococcus mutans 2. Acinetobacter species 2.Streptococcus gallolyticus 3. Cardiobacterium hominis 3.Streptococcus mitis 4. Eikenella corrodens 4.Enterococcus faecalis 5. Kingella species 5.Group A β -hemolytic streptococcus 6. Who gives a flying #%&$ anyway? 2

2/ 1/ 2017 Etiology of Native Valve Endocarditis Etiology of Native Valve Endocarditis in Injection Drug Users Organism Percent of cases Organism Right-sided Left-sided S. aureus 27-35 S. aureus 77% 23% Streptococci 33-35 Streptococci 5% 15% Enterococci 8-10 Enterococci 2% 24% Coagulase-negative staphylococci 4-9 Gram-negative bacilli 5% 12% HACEK/Gram-negative bacilli 3/4 Candida <1% 12% Polymicrobial 2 Culture-negative 3% 3% Candida 1 Culture-negative 6 Which of the following is NOT a major Definition of IE criterion in the Modified Duke Criteria for the Diagnosis of IE? • Definite IE 1. Typical organism consistent with IE from 2 separate blood culture in absence of a – Pathological criteria: positive culture or histology primary focus of vegetation, embolus, intracardiac focus – Clinical criteria: 2 major OR 1 major + 3 minor OR 2. Anti-phase 1 IgG antibody titer for Coxiella 5 minor burnetii > 1:800 • Possible IE: 1 major + 1 minor or 3 minor 3. Oscillating intracardiac mass on a valve or • Rejected: alternative diagnosis, does not supporting structure on TTE meet criteria for possible 4. Worsening or changing pre-existing regurgitation murmur 3

2/ 1/ 2017 Modified Duke Criteria for the Diagnosis of IE Major Criteria for Diagnosis of IE 1. Typical organism consistent with IE from 2 • Blood cultures separate blood culture in absence of a – At least 3 sets from different sites with first primary focus and last at least 1h apart 2. Anti-phase 1 IgG antibody titer for Coxiella • Echocardiography burnetii > 1:800 3. Oscillating intracardiac mass on a valve or – Should be performed expeditiously in supporting structure on TTE, abscess, PVE patients suspected of IE dehiscence 4. New valvular regurgitation Typical Organisms in Blood Cultures Minor Criteria Consistent with IE • Organisms* • Predisposing heart condition, IDU – Staphylococcus aureus • Temperature > 38 o C – Viridans group streptococci • Vascular/immunologic phenomena: GN, – Strep. gallolyticus (aka bovis) Osler node, Janeway lesion, Roth spot, +RF, – Enterococcus (community-acquired) septic pulmonary emboli, systemic emboli, – HACEK mycotic aneurysm • In absence of primary focus • Positive blood culture not meeting major • Or persistently positive blood cultures criterion, positive serologic test – 2 cultures drawn > 12h apart positive – All 3 or majority of > 4 separate cultures with first and • ECHO minor criteria eliminated last drawn > 1h apart * Coag-negative staph in patients with prosthetic valve 4

2/ 1/ 2017 What is High Risk? IE SUSPECTED • High risk patients (examples) High risk patient or moderate Low risk patient to high clinical suspicion, – Prosthetic valve & low clinical suspicion Initial TTE difficult imaging candidate – Congenital heart disease – Previous endocarditis TEE after TTE asap Neg Pos – New murmur, heart failure, heart block, stigmata of IE Rx • High risk TTE (examples) Neg Pos Low High risk suspicion – Large or mobile vegetations, anterior MV leaflet veg suspicion features on TTE Look for Rx – Valvular insufficiency, perivalular extension, valve Yes suspicion other No perforation source TEE No – Ventricular dysfunction Look for other TEE TEE source “Acute” Community-acquired Native Osle r no de Jane way le sio ns Valve Endocarditis • A 63 y.o. man with no significant past medical history presents with a week of fever, rigors, and progressive dyspnea on exertion. • Exam – T 39.5, BP 160/40, P110 – Skin and conjunctiva (next slide) – JVD (+), rales ½ way up bilaterally. – Loud diastolic decrescendo murmur at the lower left sternal border. Co njunc tival he mo rrhage Ro th spo ts 5

2/ 1/ 2017 Which of the following is the most appropriate empirical regimen for this patient? 1. Ampicillin + gentamicin 2. Cefazolin + gentamicin 3. Ceftriaxone + gentamicin 4. Nafcillin + vancomycin 5. Vancomycin + gentamicin Septic Pulmonary Emboli, Staph endocarditis Definitive Therapy – Native Valve Endocarditis Splinter Hemorrhage 6

2/ 1/ 2017 Treatment of Viridans Group Native Valve S. aureus IE Streptococci and Strep. gallolyticus IE Regimen Duration Comments • Pen MIC < 0.12 μ g/ml MSSA Nafcillin or 6 wk 2 wk uncomplicated R- – Penicillin, ceftriaxone, vancomycin x 4 weeks oxacillin sided IE (IDU) – Penicillin or ceftriaxone + gent x 2 weeks Cefazolin 6 wk Pen-allergic naf-intolerant • Pen MIC > 0.12 μ g/ml, < 0.5 μ g/ml patient (equivalent to naf) – Penicillin or ceftriaxone (4 wk) + gent (2 wk) MRSA – Ceftriaxone or vancomyin (4wk) Vancomycin 6 wk MSSA if beta-lactam • Pen MIC > 0.5 μ g/ml hypersensitivity – Penicillin or ceftriaxone + gent Daptomycin 6 wk > 8 mg/kg/day, vanco – Vancomycin alternative – Duration not defined (4 wk?) No gentamicin, no rifampin – both III/B Contraindications to Short Course Treatment of Therapy of Endocarditis due to Endocarditis Caused by Penicillin-Susceptible “Nutritionally Variant Streptococci” Viridans Streptococci/Strep gallolyticus • Isolate with MIC Pen > • Prosthetic valve • Abiotrophia and Granulicatella species 0.1µg/ml – (short course not effective – ↑ relapses) • High level resistance gent – Susceptibility tests unreliable • VIII nerve dysfunction • Native valve with cardiac – Often penicillin tolerant, tendancy to • Reduced renal function complications relapse – Cr Cl < 20 mL/min – Intra or extra cardiac • Therapy abscess/focal infection • Visual impairment • Native valve with CNS (severe) – Pen or amp 4 wks + gentamicin 2-4 wks complications • Non-viridans streptococci, (not β -lactam alone) • Yoyo Ma or Itzak Perlman Gemella, Abiotrophia, – Or vancomycin alone (?) Granulicatella species 7

2/ 1/ 2017 Enterococcal Endocarditis HACEK Organisms Regimen Duration Comments (Strength of Rec) Pen or amp + gent 4-6 wk Pen S, Gent 1 mg/kg q8h, 6 • Haemophilus species wk for PVE, symptoms>3 mo • Aggregatibacter species Amp + Ceftriaxone 6 wk Pen S, Aminoglycoside susceptible or resistant • Cardiobacterium hominis Pen or amp + strep 4-6 wk Gent resistant, Strep • Eikenella corrodens synergy, ClCr > 50 • Kingella species Vanco + gent 6 wk Pen resistant or beta-lactam intolerant (toxic!) Linezolid or dapto > 6 wk VRE: Dapto 10-12 mg/kg & combo with amp or ceftaroline Culture-Negative Endocarditis Regimens Recommended for Treatment of IE Due to a HACEK organism • Prior antibiotics • Fastidious organisms Regimen Comments – HACEK Ampicillin Avoid: assume amp or pen resistant – Abiotrophia defectiva, et al unless MIC test confirmed susceptible – Brucella sp. • “ Non-cultivatable ” organism Amp + gent NO GENT: nephrotoxic – Bartonella quintana Ceftriaxone Regimen of choice – Coxiella burnetii, Chlamydophila psittaci, Trophyrema whipplei, Legionella sp, Mycoplasma Ceftriaxone + gent NO GENT: nephrotoxic • Fungi (molds) Ciprofloxacin Levo or FQ as single agent OK as • Not endocarditis alternative regimen – Libman-Sacks, myxoma, APLS, marantic, tumor 8

2/ 1/ 2017 Surgical Management NVE/PVE • Optimal timing of surgery not known • Early surgery Prosthetic Valve Endocarditis – Heart failure due to valvular dysfuntion – IE from fungi or MDR organisms (i.e., VRE) – Presence of heart block, annular or aortic abscesses – Persistent bacteremia or fever > 5-7 days not attributable to another source – Emboli, large vegetations (> 10mm) Prosthetic Valve Endocarditis While awaiting TEE, which of the following antimicrobial regimens is most appropriate • A 70 y.o. male with fever, chills, and low back in this setting? pain for 6 days. • Bioprosthetic AVR 9 months previously for 1. Vancomycin critical aortic stenosis. 2. Daptomycin • Exam 3. Vancomycin + rifampin – T 38, BP 104/70, P 110 – Left conjunctival petechiae. 4. Vancomycin + gentamicin + rifampin – Rales 1/3 way up bilaterally. 5. Daptomycin + linezolid + gentamicin – Grade II/VI SEM • Blood cultures: 3/3 positive at 18 hours for Gram-positive cocci 9