Infective Endocarditis 경희대학교 의과대학 감염내과 박기호

Modified Duke Criteria Definite IE Possible IE 2 major criteria (blood cultures + echo) 1 major criteria + 3 minor criteria 5 minor criteria 1 major + 1 minor 3 minors Rejection criteria Resolution of endocarditis syndrome with antibiotic therapy for 4 days

Modified Duke Criteria Major Criteria  1. Positive blood culture   A) Typical microorganism for infective endocarditis from two separate blood cultures      Viridans streptococci, Streptococcus gallolyticus, HACEK group, Staphylococcus aureus, or       Community-acquired enterococci in the absence of a primary focus, or Persistently positive blood culture, defined as recovery of a microorganism consistent with infective endocarditis from: 가) Blood cultures drawn >12 h apart; or 나) All of 3 or a majority of 4 separate blood cultures, with first and last drawn at least 1 h apart C)  Single positive blood culture for Coxiella burnetii or phase I IgG antibody titer of >1:800 2. Evidence of endocardial involvement   A) Positive echocardiogramb Oscillating intracardiac mass on valve or supporting structures or in the path of regurgitant jets or in implanted material, in the absence of an alternative anatomic explanation, or      Abscess, or      New partial dehiscence of prosthetic valve, or   B) New valvular regurgitation (increase or change in preexisting murmur not sufficient)

Modified Duke Criteria Minor Criteria  1. Predisposition: predisposing heart condition or injection drug use 2. Fever 38.0°C (100.4°F) 3. Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, Janeway lesions 4. Immunologic phenomena: glomerulonephritis, Osler's nodes, Roth's spots, rheumatoid factor 5. Microbiologic evidence: positive blood culture but not meeting major criterion as noted previously or serologic evidence of active infection with organism consistent with infective endocarditis

Etiology of Native Valve Endocarditis AMC from 2000 through 2009 (Duke definite IE:328 cases) Unpublished

Musculoskeletal symptom Musculoskeletal manifestation: 84 (44%) of 192 cases of bacterial endocarditis Churchill MA, Jr., et al. Ann Intern Med 1977; 87: 754-9

Splenic septic emboli in endocarditis - 108 patients with left sided endocarditis Splenic infarcts and abscess: 19% (20/108) Incidental finding of splenic infarct: 38% (11/29) Splenectomy in 50% (10/20) Persistent sepsis in 60% (n = 6), large (>2cm) in 30%, splenic rupture in 10% (n=1) perioperative mortality: 33% (3/10) Ting W, et al. Circulation 1990; 82: IV105-9

Baddour LM, et al. Circulation 2005; 111: e394-434

Aminoglycoside toxicity Figure 1. % of auditory toxicity, represented as a function of age Gatell JM, et al. Antimicrob Agents Chemother 1987; 31: 1383-7

Gavalda. et al. Ann Intern Med 2007; 146: 574-9

Habib G, et al. Eur Heart J 2009; 30: 2369-41 c(i) linezolid 2 600 mg/day i.v. or orally for 8 weeks (IIa, C), (ii) quinupristin–dafopristin 3 7.5 mg/kg/day for 8 weeks (IIa, C), (iii) b-lactam combinations including imipenem plus ampicillin or ceftriaxone plus ampicillin for 8 weeks (IIb, C). Habib G, et al. Eur Heart J 2009; 30: 2369-41

Ampicillin and ceftriaxone 159 patients with Enterococcal faecalis IE Ampicillin-ceftriaxone (AC) and Ampicillin-aminoglycoside (AA) Three-month mortality (8% vs 7%, P = 0.72). Renal failure (23% vs. 0%, P<0.001). Fernandez-Hidalgo N, et al. Clin Infect Dis 2013; 56: 1261-8

Summary Musculosketal Sx: common (immunologic or embolic) Enterococcal endocarditis: PCN/AMP + AG AG: nephrotoxicity + ototoxicity Audiometry monitoring: AG combination New treatment for enterococcal infection - Double beta-lactam (Ampicillin + Ceftriaxone)