Ver el código de «Endocarditis»

==Background==
*Defined as an infection of the endocardial surface of the heart, affecting native (or prosthetic) heart valves as well as in-dwelling cardiac devices
*Consider in patients with known risk factors and unexplained fever
*Mitral valve most commonly affected overall; tricuspid valve most common in IVDA
*Noninfectious vegetations can arise in patients with malignancy/[[SLE]]/Hypercoagulable state ("Marantic" endocarditis)
*[[S. aureus]] is single most common cause (accounts for 1/3 of all cases)<ref>Selton-Suty C, Célard M, Le Moing V, et al. Preeminence of Staphylococcus aureus in infective endocarditis: a 1-year population-based survey. Clin Infect Dis. 2012;54(9):1230-1239. doi:10.1093/cid/cis199</ref>
*[[Strep viridans]] is the most common cause of native valve endocarditis, excluding risk factors below
*[[Blood cultures]] are falsely negative ~5% (think HACEK organisms)
*Only 20% have an increase in a known murmur and only 48% have a new murmur<ref name="Hoen">Hoen, B. et al. Infective Endocarditis. NEJM. 2013. 368;15. 1425-1433 [http://www.cardioaragon.es/web/pdf/InfectiveEndocarditisNEJM2013.pdf PDF]</ref>

===Prophylaxis===
{{Endocarditis prophylaxis}}

===Risk Factors===
*[[IVDA]]
**Tricuspid valve most commonly affected
*Prosthetic heart valve
**Coagulase negative [[staph]]ylcocci are substantial etiologies in this patient population<ref>Lalani T et al. Prosthetic valve endocarditis due to coagulase-negative staphylococci: findings from the International Collaboration on Endocarditis Merged Database. Eur J Clin Microbiol Infect Dis. 2006 Jun;25(6):365-8.</ref>
*Structural heart disease
**Rheumatic heart disease (biggest risk factor in low-income countries)
**Mitral valve prolapse
**Bicuspid aortic valve
*[[Hemodialysis]]
*[[HIV]] infection
*[[Fungal infections|Fungal]] endocarditis risk factors, with [[Candida]] most common
**Prolonged antibiotics
**TPN through central line

==Clinical Features==
[[File:Splinter hemorrhage.jpg|thumb|Splinter hemorrhage]]
[[File:Osler Nodules Hand.jpg|thumb|Osler's nodes.]]
[[File:PMC5072319 12879 2016 1912 Fig2 HTML.png|thumb|Janeway lesions]]
[[File:PMC5059132 kjtcv-49-408f1.png|thumb|Roth spots on fundoscopy (A); 2 weeks after treatment (B); 6 weeks after treatment.]]
*[[Fever]]
**Present in 80% of cases
*Heart [[murmur]]
**Preexisting murmur found in 85% of cases; new murmur found in 48%
*[[CHF]]
**Acute or progressive (70%)
*Derm
**Osler nodes
***Tender red/purple nodules on distal finger and toes
**Splinter hemorrhages
***Nail bed hemorrhages not extending the length of the nail
**Janeway lesions
***Non-tender, small erythematous or hemorrhagic macular, papular or nodular lesions on the palms or soles only a few millimeters in diameter
*CNS
**65% of emboli involve the CNS<ref>Mylonakis. E, Calderwood S. Infective endocardidits in adults. NEJM. 2001;345(18):138-1330</ref>
**[[Central retinal artery occlusion]]
*Pulmonary
**[[Pneumonia]]
**[[Empyema]]
**[[Pulmonary emboli]]
*Cardiac
**[[MI]]
**[[Myocarditis]]
*Abdominal 
**Bowel, renal, splenic infarcts
*Ophtho
**Roth spots
***White centered retinal hemorrhage 
***Associated with multiple systemic illnesses, most commonly bacterial endocarditis

==Differential Diagnosis==
{{Acute Fever DDX}}
{{Septic Embolus DDX}}

==Evaluation==
[[File:PMC4497914 kjim-30-434-g003.png|thumb|Echocardiography showing typical vegetation on aortic valve (arrow).]]
[[File:PMC2649868 ymj-50-152-g001.png|thumb|Transthoracic echocardiography shows vegetations (arrows) on both mitral leaflets; (A) Diastole. (B) Systole. LA, left atrium; LV, left ventricle; Ao, aorta.]]
[[File:PMC5412748 JCE-27-33-g010.png|thumb|Vegetations in infective endocarditis (arrows). (a) Transthoracic echocardiogram parasternal long-axis view showing vegetation on native aortic valve; (b) transesophageal echocardiography long axis of endocarditis of native aortic valve; (c) transesophageal echocardiography visualization of vegetation on the atrial side of mechanical mitral valve; (d) transesophageal echocardiography showing endocarditis of bioprosthetic mitral valve. LA: Left atrium; LV: Left ventricle.]]
[[File:PMC5087261 JCHIMP-6-32827-g001.png|thumb|CT chest: Multiple cavitary (a) and pre-cavitary lesions (b) in both lung fields consistent septic emboli from pulmonary valve endocarditis.]]
===Work-Up===
*[[Blood culture]] (from 3 separate sites)<ref name="cultures">Lee A, Mirrett S, Reller LB, Weinstein MP. Detection of bloodstream infections in adults: how many blood cultures are needed? J Clin Microbiol 2007;45:
3546 – 3548</ref>
*CBC
**Staphylococcal endocarditis: [[Leukocytosis]] +/- [[thrombocytopenia]]
**Subacute endocarditis: WBC may be normal or elevated
*[[Urinalysis]]
**[[Hematuria]]
*ESR
**Elevated in >90% of cases
*[[ECG]]
**Ischemia, [[heart block]]
*[[CXR]]
**Pulmonary emboli, [[CHF]]
*[[Cardiac ultrasound|Ultrasound]]
**Obtain as soon as possible
**TEE may be required for:
***Prosthetic valves
***Difficulty obtaining clear TTE images (obesity, COPD)
***High clinical probability of endocarditis

===Diagnosis===
*Inpatient diagnosis is based on the Duke's Criteria although many of the criteria are not filled in the ED
**Heightened clinical suspicion is necessary even if diagnosis does not meet the official criteria.<ref>Durack D, Lukes A, Bright D "New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service". Am J Med. 1994. 96 (3): 200–9</ref>

====Modified Duke Criteria<ref>Li, JS et al. "Proposed Modifications to the Duke Criteria for the Diagnosis of Infective Endocarditis". Clinical Infectious Diseases. 2000. 30(4). 633.</ref>====
*2 major criteria '''OR'''
*1 major and 3 minor criteria '''OR'''
*5 minor criteria
====Major Criteria====
*Positive blood culture with typical IE microorganism, defined as one of the following:
**Typical microorganism consistent with IE from 2 separate blood cultures, as noted below:
***[[Streptococcus viridans|Viridans-group streptococci]], or
***''[[Streptococcus bovis]]'' including nutritional variant strains, or
***[[HACEK]] group, or
***''[[Staphylococcus aureus]]'', or
***Community-acquired ''[[Enterococci]]'', in the absence of a primary focus
**Microorganisms consistent with IE from persistently positive blood cultures defined as:
***Two positive cultures of blood samples drawn >12 hours apart, or
***All of 3 or a majority of 4 separate cultures of blood (with first and last sample drawn 1 hour apart)
***''[[Coxiella burnetii]]'' detected by one positive blood culture or IgG
***Staphylococus lugdunensis should raise concerns for endocarditis with a single positive blood culture<ref>Liu Po-Yen et al. Staphylococcus lugdunensis Infective Endocarditis: A Literature Review and Analysis of Risk Factors. Journal of Microbiology, Immunology and Infection
Volume 43, Issue 6, December 2010, Pages 478-484.</ref>
*Evidence of endocardial involvement with positive echocardiogram defined as:
**Valvular mass or supporting structures or
**Abscess, or
**New disruption of a prosthetic valve or new valvular regurgitation

====Minor Criteria====
*Predisposing factor: known cardiac lesion, recreational drug injection
*Fever >38°C
*Evidence of emboli: arterial emboli,pulmonary infarcts, [[Eponyms_(F-L)*Janeway_lesions|Janeway lesions]], conjunctival hemorrhage
*[[Glomerulonephritis]], [[Eponyms_(M-P)*Osler.27s_nodes|Osler's nodes]]
*Positive blood culture (that does not meet a major criterion) or serologic evidence of infection

==Management==
;Initial management should focus on early blood cultures and antibiotics
===[[CHF]]/[[Cardiogenic Shock]]===
*Often due to valve failure, rupture, or a new defect.
===[[Pulmonary edema]]===
*Often due to mitral or aortic valve rupture causing severe regurgitation
*Focus on after-load reduction
===[[Respiratory failure]] (emboli)===
*Often requires [[intubation]] with failure either due to [[CHF]] or [[Pneumonia]]
*Multi-lobar [[pneumonia]] suggests a tricuspid or pulmonary valve lesion with emboli to lungs

==[[Antibiotics]]==
''Start after 3 sets of blood cultures are obtained (if possible)<ref name="cultures"></ref>''

Therapy should be based on:
*Whether the patient has received prior antibiotic therapy
*Prosthetic valves
*Local antibiotic resistance patterns or knowledge of prior endocarditis cultures
*Prior hospitalizations and risk of MRSA

{{Endocarditis_Empiric_Antibiotics}}

==Disposition==
Admit all suspected cases and consult Cardiothoracic surgery for endocarditis complicated by:<ref name="Hoen"></ref>
*New Heart failure suspected due to severe regurgitation
*Cardiogenic Shock
*Echocardiography demonstrating a new fistula
*Surgery indicated for<ref>Kosowsky JM, Takhar SS: Infective Endocarditis and Valvular Heart Disease in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2013, (Ch) 84: pp 1113-1123.</ref>:
**Acute heart failure
**Periannular extension
**Recurrent emboli
**Large mobile vegetations
**Persistent bacteremia
**Fungal endocarditis (penetration of antifungals into vegetation walls poor)<ref>British Society for Antimicrobial Chemotherapy. Guidelines for the antibiotic treatment of endocarditis in adults: report of the Working Party of the British Society for Antimicrobial Chemotherapy. J. Antimicrob. Chemother. (December 2004) 54 (6): 971-981.</ref>
***IV [[amphotericin B]]
***Lifelong PO antifungal


==Miscellaneous==
*No therapeutic anticoagulation necessary
**Anticoagulation carries higher risk of bleeding without delivering mortality benefit or reducing embolic complication<ref>Elkaryoni A et al. ANTICOAGULATION IN INFECTIVE ENDOCARDITIS: INSIGHTS FROM NATIONWIDE INPATIENT SAMPLE. Journal of the American College of Cardiology. Volume 73, Issue 9 Supplement 1, March 2019.</ref>
*[[Septic pulmonary embolism]]
**Most common culture growths are MSSA, MRSA, and candida<ref>Li Zhao RY et al. Clinical characteristics of septic pulmonary embolism in adults: A systematic review. Respiratory Medicine. Volume 108, Issue 1, January 2014, Pages 1-8.</ref>
**Furthermore, therapeutic anticoagulation not indicated for [[septic pulmonary embolism]]

==Complications==
===Cardiac===
*[[Congestive Heart Failure (CHF)|Heart Failure]]
**Most common cause of death due to IE
*Perivalvular Abscess
===Embolic===
*[[CVA]]
*[[Vision loss|Blindness]]
*Painful, ischemic extremities
*Unusual pain syndromes (due to splenic or renal infarction)
*[[Mycotic aneurysm]]
*[[Hypoxia]]
*[[MI]]

===Neurologic===
*[[CVA|Embolic stroke]]
*Acute [[encephalopathy]]
*[[Meningitis|Meningoencephalitis]]
*Purulent or aseptic [[meningitis]]
*[[ICH|Cerebral hemorrhage]]
*[[Seizure]]
*[[Epidural abscess|Spinal abscess]]
===Renal===
*[[Renal infarction]]
*[[Glomerulonephritis]]
===Musculoskeletal===
*[[Vertebral osteomyelitis]]

==See Also==
*[[Fever]]
*[[In-training exam review]]

==External Links==
*[http://www.mdcalc.com/duke-criteria-for-infective-endocarditis/ MDCalc - Duke Criteria]
*[https://emcrit.org/ibcc/endo/ EMCrit - Endocarditis]

==References==
<references/>

[[Category:ID]] [[Category:Cardiology]]