inf endo dibu
TRANSCRIPT
Infective endocarditis guidelines
Dr. Dibbendhu KhanraSR1
What is Infective endocarditis?
• Challenge for internists• Headache for cardiologists• Hobby for microbiologists
What is new in the guideline?
• More tables, more dilemma• More organism• More antibiotics• Multimodal diagnosis• Infectious disease Specialist
Still it is important
• Changing epidemiology• Immuno-compromised Hosts• More intervention more infection• More diagnostic Tools• Expanding horizon of Surgery
Case 1
RHD/ MS/MR/ NSRLt HemiplegiaFever/ arthritis/ perpura
Case 2
• DM/ Isch CMP• ICD• Fever/ failure
Case 3
• Severe AS/ post AVR• Fever• CHB
Case 4
• Abdominal mass• Bleeding PR• Fever• Severe back pain
Case 5• IDU • (Brown Heroine/ Lemon Juice)• Fever• Difficulty in vision
Far from DUKE
Echo criteria eliminated
• The expansion of minor criteria to include elevated erythrocyte sedimentation rate or C-reactive protein, the presence of newly diagnosed clubbing, splenomegaly, and microscopic hematuria has been proposed
Diagnosis is so difficult
Role of Cardiologists
Role of Microbiologists
Rational emperics
Case 1RHD/ MS/MR/ NSRLt HemiplegiaFever/ arthritis/ perpura
Mitral valve vegVGS
Case 2
• DM/ Isch CMP• ICD• Fever/ failure
Pacemaker lead tip culture:Staph aureusTTE/TEE – NO veg
Case 3
• Severe AS/ post AVR• Fever• CHB
Aortic valve vegCulture Negative
Case 4
• Abdominal mass• Bleeding PR• Fever• Severe back pain
Ca rectumStr bovis
Case 5• IDU • (Brown Heroine/ Lemon Juice)• Fever• Difficulty in vision
Tricuspid veg 35mmCandida
NVE PVE
Str VGS/ Str. gallolyticus
Pen 4wOR Cx 4wOR Cx + Genta 2w
OR Vanco 4w(Pen/ BL Res)
Pen 6wOR Cx 6wOR Cx + Genta 2w/ 6w (MIC<0.12/>0.12)OR Vanco 6w
Str. Pneu/ Str. pyogens
Pen 4wOR Cx 4wOR Vanco +Rifam 4w(Pen/ BL Res)
Pen 6wOR Cx 6wOR Vanco +Rifam 6w(Pen/ BL Res)
Str. Gr B, C, G Cx 4w +Genta 2w Cx 6w +Genta 2w
Staph Oxacillin S Nafcillin 6wOR Cefazolin 6w
Nafcillin >6w+ Genta 2w+ Rifam >6w
Oxacillin R Vanco 6wOR Dapto 6w
Vanco >6w+ Genta 2w+ Rifam >6wSeptran if Vanco R
Enterococcus Pen S + Genta SPen S + Genta RPen R + Genta SPen R + Genta R
Ampi+Genta 4-6w OR Ampi+Cx 6wAmpi+Strep 4-6 w OR Ampi+Cx 6w
Vanco +Genta 6wLNZ/ Dapto >6w
GNB HACEK Cx OR Ampi OR Cipro 4w
Non HACEK Cx +Genta 6w + Surgery
Fungal IE, MDR GNB, Vancomycin Resistant enterococcie
Need for early surgery
Surgery for Infective endocarditis
Case 1RHD/ MS/MR/ NSRLt HemiplegiaFever/ arthritis/ perpura
Mitral valve vegVGSCx+Genta – veg +Failure +
Surgery? Anticoag?
Embolic CVA
Case 2
• DM/ Isch CMP• ICD• Fever/ failure
Pacemaker lead tip culture:Staph aureusTTE/TEE – NO veg
FDG/PET s/o veg 30mmABPlan: Reimplantation
Surgery /AB??TPI?
CDRIE vs Local device infection
CDRIE – nightmare to treat
Case 3
• Severe AS/ post AVR• Fever• CHB
Aortic valve vegCulture NegativeCoxiell IgG+
Surgery/ AB?
Culture NegativeInfective Endocarditis
Case 4
• Abdominal mass• Bleeding PR• Fever• Headache
Ca rectumVeg lt sideStr bovisMycotic anurysm
Mycotic aneuyrismIntracranial
Extracranial
Splenic abscess
Musculoskeletal
Renal
Case 5• IDU • (Brown Heroine/ Lemon Juice)• Fever• Difficulty in vision
Tricuspid veg 35mmCandida
Surgery/ anntifungal?
Fungal infective endocarditis• IVDU/IC/CDRIE• Duke not maintained• Early PVE, but also delayed• Younger• Aspergillus often culture negative• High mortality• Endophthalmitis: systemic + intraocular antifungal• Early surgey• AMB+/-flucytosine – 6wks• Long term azole supression
Prophylaxis is a myth
Peri-operative antibiotics
Prognosis
Follow Up
Endocarditis Team - new card in the game
What is new?• Duke not to be fulfilled always• TEE in selective cases• 3D Echo, FDG/PET – new modalities• PCR/ serology – major• Daptomycin: new killer of staph• Early surgery is the trend, if not contraindicated• Repair is better option than valve replacement• Culture negative: r/o atypical org/ ca/ APLS• Mycotic aneurysm screening for Lt side IE• Prophylaxis: very selective cases• Prohylactic antibiotic before cardiac device: not required• Stent related IE due to RGM to be remembered
Thank you