Endocarditis

[Circulation 2015; 132:1435-86, European Heart J 2015;36:3075-128]

- 10-20% of patients who develop endocarditis have no pre-existing heart disease.

- Diagnosis includes:

• multiple positive blood cultures

• new murmur

• definite emboli

• vegetations on echocardiogram.

- For more specific diagnostic criteria, refer to Modified Duke Criteria www.circulationaha.org (Circulation 2015; 132:1435-86).

- Blood cultures:

• NB: in patients who are stable (no heart failure) with subacute presentation, wait for results of blood cultures before starting antibiotic therapy.

• draw maximum 2 sets/day

• adults – 8-10mL of blood/bottle

• consult microbiology laboratory if unusual/fastidious (Bartonella, Chlamydia/Chlamydophila, Coxiella, Brucella, Legionella, Tropheryma whippleii) organism suspected

• repeat blood cultures every 48h until clearance of bacteremia to guide duration of therapy. Duration of therapy should start from date of first negative blood culture.

- For positive cultures or blood culture negative endocarditis, see Recommended Therapy of Culture-Directed Infections; Treatment of Culture-proven Endocarditis and Blood Culture Negative Endocarditis (BCNE) respectively.

- Echocardiogram:

• transthoracic echocardiogram (TTE) - sensitivity: 70% native valve; 50% prosthetic valve

• transesophageal echocardiogram (TEE) - sensitivity: 96% native valve; 92% prosthetic valve

• TEE recommended if:

  • prosthetic valves (TTE < 50% sensitivity) or intracardiac device

  • congenital heart disease

  • previous endocarditis

  • TTE negative AND:

    • new murmur

    • heart failure

    • stigmata of endocarditis

    • persistent (> 5 days) bacteremia.

• if initial TTE and/or TEE is negative, repeat TTE/TEE 5 days later if clinical suspicion of endocarditis remains high, persistent fever and/or bacteremia; or sooner if persistent S. aureus bacteremia or clinical findings change.

• should be repeated following treatment for endocarditis to establish a new baseline.

- Ophthalmological exam recommended for patients with endocarditis due to fungi.

- For surgical indications (heart failure, uncontrolled infection, prevention of embolic events) and timing see Circulation 2015; 132:1435-86, or European Heart J 2015; 36:3075-128, Table 22.

Duration of antibiotic therapy post-valve replacement:

• negative valve cultures - duration as for native valve endocarditis, starting from date of first negative blood culture (not from day of surgery).

• positive valve cultures - full course of therapy starting from day of surgery.

Vancomycin

• Vancomycin is less rapidly bactericidal than ß-lactams so should only be used when β-lactams contraindicated (due to severe allergy, or resistance). Longer duration of therapy may be required.

• Desired vancomycin trough is 10-20mg/L. Monitor renal function closely. See Vancomycin Dosing & Monitoring Guidelines.