Shuktika Nandkeolyar, PGY2 5/29/2017 Acute Infective Bacterial Endocarditis Diagnosis and initial management Shuktika Nandkeolyar, PGY2 5/29/2017

Objectives Know the screening criteria (Duke’s criteria) for endocarditis Know the initial work up of endocarditis Common exam findings Imaging modalities Lab work

Vignette 26 y/o F PMHx IVDU (heroin) who presents with fevers, chills, nausea, vomiting and diarrhea for the past 3 weeks. She was febrile to 102.5F, HR 128, BP 91/62. CXR demonstrated multiple pulmonary lesions. On exam, 3/6 RLSB systolic murmur, remainder of the exam in unremarkable. What work up would you order to diagnose endocarditis?

Predisposing factors to bacterial infective endocarditis Dental manipulation and disease Instrumentation (urinary tract, GI tract, IV infusions) Cardiac surgery Injection drug use 2) instrumentation: think gram positive bugs which could be introduced / cause transient bacteremia.

(Modified) Duke’s Criteria Definitive IE (Clinical criteria) 2 major criteria OR 1 major and 3 minor criteria, OR 5 minor criteria Possible IE 1 major and 1 minor, or 3 minor criteria Pathological criteria: microorganisms demonstrated by culture or histological examination of a vegetation, embolized tissue specimen, or intracardiac abscess

Major Criteria Major Two Blood cultures positive with typical organisms: Single positive blood culture for coxiella burnetti Echocardiogram positive for IE Persistently positive blood cultures defined as: at least 2 positive cultures of blood samples > 12h apart, or all 3 or a majority of >4 separate cultures of blood ) with first and last samples drawn at least 1h apart. HACEK: Haemophilus, Arregregatibacter, cardiobacterium, eikenella, kingella Typical organisms: strep Viridans, strep bovis, HACEK, S. aureus, community-acquired enterococci (in the absence of primary focus), microorganisms consistent with IE from persistently positive cultures

Minor Criteria Predisposition / predisposing heart condition, or IVDU Fever, temperature >38C Vascular phenomena: Immunological phenomena: Microbiological evidence: + blood culture that doesn’t meet major criteria Our patient had fever, and septic pulmonary infarcts and was an IVDU. She met “probable endocarditis” even before doing any labs or imaging, based on Duke’s criteria major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage, Janeway lesions Immunologic criteria glomerulonephritis, Osler nodes, Roth spots, RF

Pretest Probability High risk patients (pretest probability > 4%): prosthetic valves congenital heart diseases previous endocarditis new murmur (new onset) heart failure Other stigmata of endocarditis (see next slide for physical exam). Low Risk: EVERYONE ELSE!

Physical Exam findings #1: Antibiotics, salicylates, steroids, severe CHF, uremia may mask temperature elevations. Can also consider hypoxemia in the setting of endocarditis causing valvular disease causing HF OR pulmonary emboli Osler’s nodes: painful, erythematous, nodular lesions Roth spot: oval retinal heorrhages with pale centers Janeway lesions: erythematous blanching macules, nonpainful

Labs 3 sets of blood cultures from different sites CBC w/ diff: looking for leukocytosis, bandemia, anemia BMP: evidence of kidney disease UA: if kidney disease, evaluate for hematuria/proteinuria EKG: look for conduction abnormalities

When to get an Echo If Either way, get TTE first! The urgency of the TEE depends on risk factors. High risk candidates are patients with prosthetic valves, congenital heart diseases, previous endocarditis, new murmur, heart failure, or other stigmata of endocarditis. Our patient in our clinical vignette is high risk so we would go down high risk pathway for her (this means probable endocarditis ) A TTE is first line, regardless of high or low risk! If your pretest probability is > 4%, or Patient has probable endocarditis based on Duke’s criteria, Consider TEE in addition to TTE.

Other Imaging If hypoxic, consider CXR or CT of chest If focal neurologic deficits, consider CT of head for hemorrhagic stroke. MRI if looking for ischemic septic emboli. CT head will change management if a surgery is in order – if hemorrhagic stroke, it can be a reason to delay valve surgery

Back to our vignette? 26 y/o F PMHx IVDU (heroin) who presents with fevers, chills, nausea, vomiting and diarrhea for the past 3 weeks. She was febrile to 102.5F, HR 128, BP 91/62. CXR demonstrated multiple pulmonary lesions. On exam, 3/6 RLSB systolic murmur, remainder of the exam in unremarkable. What work up would you order to diagnose endocardits?

Consider the following: Labs: Blood cultures x3 CBC BMP Utox EKG Imaging: CT chest TTE Initial management: IVF resuscitation Antibiotics ID and Cardiology consult CT chest given shortness of breath. Utox given IVDU history. EKG to ensure no conduction defects (unexpected in this young female).

Summary Duke’s criteria: High pretest probability (>4%) Major: Positive blood cultures or TTE/TEE findings Minor: fevers, IVDU, atypical cultures, vascular or immunologic phenomena High pretest probability (>4%) high risk behaviors Hx prior valvular disease or congenital heart disease probable endocarditis by Duke’s criteria Labs: CBC, CMP, 3 sets of blood cultures Imaging: TTE first! Consider other imaging based on symptoms or exam findings.

References Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications, L. M. Baddour et al., Circulation. 2015 Uptodate.com MKSAP17 Medcomic.com