Update on
Endocarditis
Dr Catherine Berry
May 2012
Endocarditis
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Pathological characteristics of an episode of
GBS AV endocarditis
Group B streptococcus in endocarditis
What we know about endocarditis in 21st
century?
Review of endocarditis at JHH, 2011
Recent guidelines
Case
Valve…
From : www.clevelandclinicmeded.com
History
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1554 - First described pathologically by Jean François
Fernel
1646 – Riverius noted thrill with valvular “outgrowths” at
autopsy
1816 – 1st stethoscope
1835 – Bouillaud named disease endocarditis
1884 – Gram stain reported
1885 – Osler’s Gulstonian lectures – attempted
classification and clinical features
1890’s – 1st routine blood cultures
1930 – 1st clinical cures with penicillin
1966 – “Infective Endocarditis in the antibiotic era”
NEJM
Miller B, EID 2004 Jun
Osler’s simple vs malignant
endocarditis

“.. the simple being those with few or slight
symptoms, and which run a favourable course;
the malignant, the cases with severe
constitutional disturbance and extensive valvelesions, whether ulcerative or vegetative, the
term being more clinical than anatomical.”
J R Soc Med. 1985 December; 78(12): 1039–1046.
What do we know about endocarditis
in the 2000’s?
ICE –PCS 2000-5 (Arch
Int Med 2009)
 N=2781 - Nth/Sth
America, Europe,
Australasia
 Median age 56.5;
Incidence 3-10/100,000
 Acute disease

77% in 1st month; Osler’s
nodes 3% (prev 11-23%)
Risk factor
Rate
Pre-existing
valve dx..
70%
RHD
3.3%
Prosthetic
valve
22.2%
IVDU
9.8%
Chronic
venous access
device
~10%
Health care
assoc.
25%

2
Archives of Internal Medicine. 169(5):463&hyhen;473, March 9, 2009.
DOI: 10.1001/archinternmed.2008.603
What do we know about endocarditis
in the 2000’s?
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Outcomes
17.7% in hospital mortality
 48.2% required surgery
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Risk factors for death
SA or CoNS
 Pulmonary oedema
 Prosthetic valve
 Paravalvular dx.
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NB. Surgery assoc with OR for death of 0.6
Group B streptococcus
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S. agalactiae
1st recognised in cows
20-35% colonisation
Previously- peripartum, neonatal dx.
Now – elderly, health-care assoc. , DM
Mostly Skin/Soft tissue infections,
spontaneous bacteraemia
GBS endocarditis
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Epidemiology
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Clinical features
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complicates 2-9% of invasive GBS
1.7  2.8% of all endocarditis in recent series
Rapid onset 6-9 days
Presentation with heart failure 70%
Embolisation 37%
Surgical management 40%
Death 41 - 47%
?Gentamicin
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Retrospective analysis of additive gent  increased rates HF
(n=54)
No improvement in mortality.
Endocarditis @ JHH, 2011
20 cases
Ini
DA
MM
CB
TM
TJ
JH
BL
JY
NH
PK
JC
RG
RW
JT
NC
DB
SC
HM
PS
JG
SexAge
F
42
M
56
M
43
F
26
M
65
M
59
M
77
M
35
M
78
F
79
M
60
F
75
M
43
M
66
F
72
M
44
M
42
F
53
M
59
M
47
Valve
TV/MV
AV
MV
MV
AV
nil
MV
MV
AV
MV
nil
AV
nil
MV
AV
AV
MV
TV
AV
AV
Presentation
Fever, developed embolic events
Sepsis
Fever
Fever, heart failure
CVA, raised CRP
CVA, fever
Sepsis
Persistent pos. blood cultures
Fever, ICH in hospital
Delerium, decreased level of func.
CVA, multi-territory
"Acopia"
Vertebral OM
Fever, ICH, abdominal aneurysms
T7-10 OM
Sepsis, heart failure
Remote CVA, screening echo
Fever, back pain
CVA
Sepsis, pneumonia
Risk 1
Risk 2
Org
Duke's
self injecting - Munchausen Org x 10
definite
Tissue AVR
MSSA
definite
MS
IVDU
Kocuria kristinae
definite
IVDU
rotten tooth Strep spp.
definite
Tissue AVR
Granucatella adiacens
definite
phx. RHDx. - no valve.
S.mitis
poss
?
MSSA
definite
IVDU
poor dentitionAchromobacter denitrificans definite
AR
S. salivaris
definite
MV prolapse
Abiotrophia defectiva
definite
Prostate bx.
Enterococcus faecalis
poss
AVR
Enterococcus faecalis
definite
IVDU
MRSA
poss
MV prolapse dental work Rothia dentocariosa
definite
AVR
S. sanguinis
definite
IVDU
S. agalactiae
definite
IVDU
poor dentitionS. sanguinis
definite
IVDU
MRSA
definite
metal valve
PSSA
definite
recent pred use
E. coli
definite
?Sx. Outcome
survived
AVR survived - mild
MVR died
MVR survived
AVR died
survived - mod
died
MVR survived - mod
died
died.
died.
died
survived - mild
survived - mild
survived
died
survived
unknown
survived - mild
survived - sever
Mortality 2011 – 40%
Ini
DA
MM
CB
TM
TJ
JH
BL
JY
NH
PK
JC
RG
RW
JT
NC
DB
SC
HM
PS
JG
SexAge
F
42
M
56
M
43
F
26
M
65
M
59
M
77
M
35
M
78
F
79
M
60
F
75
M
43
M
66
F
72
M
44
M
42
F
53
M
59
M
47
Valve
TV/MV
AV
MV
MV
AV
nil
MV
MV
AV
MV
nil
AV
nil
MV
AV
AV
MV
TV
AV
AV
Presentation
Fever, developed embolic events
Sepsis
Fever
Fever, heart failure
CVA, raised CRP
CVA, fever
Sepsis
Persistent pos. blood cultures
Fever, ICH in hospital
Delerium, decreased level of func.
CVA, multi-territory
"Acopia"
Vertebral OM
Fever, ICH, abdominal aneurysms
T7-10 OM
Sepsis, heart failure
Remote CVA, screening echo
Fever, back pain
CVA
Sepsis, pneumonia
Risk 1
Risk 2
Org
Duke's
self injecting - Munchausen Org x 10
definite
Tissue AVR
MSSA
definite
MS
IVDU
Kocuria kristinae
definite
IVDU
rotten tooth Strep spp.
definite
Tissue AVR
Granucatella adiacens
definite
phx. RHDx. - no valve.
S.mitis
poss
?
MSSA
definite
IVDU
poor dentitionAchromobacter denitrificans
definite
AR
S. salivaris
definite
MV prolapse
Abiotrophia defectiva
definite
Prostate bx.
Enterococcus faecalis
poss
AVR
Enterococcus faecalis
definite
IVDU
MRSA
poss
MV prolapse dental work Rothia dentocariosa
definite
AVR
S. sanguinis
definite
IVDU
S. agalactiae
definite
IVDU
poor dentitionS. sanguinis
definite
IVDU
MRSA
definite
metal valve
PSSA
definite
recent pred use
E. coli
definite
?Sx. Outcome
survived
AVR survived - mild
MVR died
MVR survived
AVR died
survived - mod
died
MVR survived - mod
died
died.
died.
died
survived - mild
survived - mild
survived
died
survived
unknown
survived - mild
survived - sever
Morbidity or Mortality – 55%
Ini
DA
MM
CB
TM
TJ
JH
BL
JY
NH
PK
JC
RG
RW
JT
NC
DB
SC
HM
PS
JG
SexAge
F
42
M
56
M
43
F
26
M
65
M
59
M
77
M
35
M
78
F
79
M
60
F
75
M
43
M
66
F
72
M
44
M
42
F
53
M
59
M
47
Valve
TV/MV
AV
MV
MV
AV
nil
MV
MV
AV
MV
nil
AV
nil
MV
AV
AV
MV
TV
AV
AV
Presentation
Fever, developed embolic events
Sepsis
Fever
Fever, heart failure
CVA, raised CRP
CVA, fever
Sepsis
Persistent pos. blood cultures
Fever, ICH in hospital
Delerium, decreased level of func.
CVA, multi-territory
"Acopia"
Vertebral OM
Fever, ICH, abdominal aneurysms
T7-10 OM
Sepsis, heart failure
Remote CVA, screening echo
Fever, back pain
CVA
Sepsis, pneumonia
Risk 1
Risk 2
Org
Duke's
self injecting - Munchausen Org x 10
definite
Tissue AVR
MSSA
definite
MS
IVDU
Kocuria kristinae
definite
IVDU
rotten tooth Strep spp.
definite
Tissue AVR
Granucatella adiacens
definite
phx. RHDx. - no valve.
S.mitis
poss
?
MSSA
definite
IVDU
poor dentitionAchromobacter denitrificans definite
AR
S. salivaris
definite
MV prolapse
Abiotrophia defectiva
definite
Prostate bx.
Enterococcus faecalis
poss
AVR
Enterococcus faecalis
definite
IVDU
MRSA
poss
MV prolapse dental work Rothia dentocariosa
definite
AVR
S. sanguinis
definite
IVDU
S. agalactiae
definite
IVDU
poor dentitionS. sanguinis
definite
IVDU
MRSA
definite
metal valve
PSSA
definite
recent pred use
E. coli
definite
?Sx. Outcome
survived
AVR survived - mild
MVR died
MVR survived
AVR died
survived - mod
died
MVR survived - mod
died
died.
died.
died
survived - mild
survived - mild
survived
died
survived
unknown
survived - mild
survived - sever
Endocarditis 2011
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male - 70%
Median age - 54.5
>65 yrs (5 died) - 35%
inter-hospital transfers - 40%
surgical mmt. - 25%
IVDU - 40%
prosthetic valves - 25%
Guidelines
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ACC/AHA 2006 (Circulation)*
ECS 2009 (European Heart Journal)
BSAC 2012 (Journal of Antimicrobial chemo)
Whats new and ongoing controversies
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Most recommendations remain on “C” level evidence
16S PCR on valve tissue
Significance of Bartonella & Q-fever in culture neg IE
Optimal surgical timing
Combination therapy in staphylococcal IE
MRSA abx selection
Indications for cardiac surgery in the management of infective endocarditis (IE) adapted from
the European Society for Cardiology guidelines49 and the American Heart Association.50.
Gould F K et al. J. Antimicrob. Chemother. 2012;67:269-289
The dilemma
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Recurrent embolisation is 4.8/1000 pt days (1st
week)  1.7/1000 days
Surgical mortality 15% mortality 1st week (n=95)
12% recurrence
 7% valvular dysfunction
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Mortality 5-7% if delayed in non-perivalvular
disease.
AHA/European guidelines
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No delay if TIA or clinically silent embolisation
Immediate indications should not be delayed in
ischaemic CVA episodes unless
coma
 ICH
 Severe neurological dx.
 Severe co-morbidities
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Overall 70% survivors complete recovery
Peri-operative neurological risk (3-6%)
Case - Mr DB
P/w back pain and “run out of medication” to
Manning Base.
 Bkd
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Anxiety
 “Prev.” IVDU
 Chronic back pain – on jurnista
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Hypotensive requiring inotropic support
 Plt 16; INR 1.4; WCC 11.1; Cr 136; CRP 179
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Mr DB
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Definite endocarditis (mod. Duke’s)
Blood cultures x 3 positive for Group B
streptococcus
 Echo – moderate to severe AR.
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14/11 - T/f’d JHH ?need for Sx.
ECG
Mr DB
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Management plan
IV penicillin
 HDU for inotropes
 APS/D+A for pain management
 Cardio BPT r/v  TOE
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Mr DB
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15/11
Off inotropes; plt recovered  CCU
 BP 90/60; HR 110
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16/11
S/B Cardiologist – Await TOE, for medical mmt.
 TOE
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Mr DB
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17/11- 8pm
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Rapid response for RR 40; HR 140
“APO”
 Responded to morphine; olanzapine; frusemide
 Attempted contact with cardiologist – no response
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Mr DB
Mr DB
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18/11- 22/11
Transferred to ward
 CRP/obs stable.
 Escalating HF rx.
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Digoxin
 Frusemide
 ACEi
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Ongoing pain mmt
Mr DB
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23/11 - pm
increased tachypnoea, desaturating off O2
 ID AMO non-contactable
 Handed over to after hours medical staff
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24/11 1.20am
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Found dead and unable to be revived
14 days presentation to death
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Final diagnosis:
Aortic valve vegetative endocarditis.
Left heart failure.
Splenomegaly.
Splenic infarction, splenic septic emboli.
Mr DB
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Comments..
RCA recommendations –
Endocarditis protocol
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An agreement on AMO1
Consults should have outcome with intended follow-up
time-frame and frequency documented ?consult form
How results of TOE’s should be conveyed
CTS should be aware of all IE patients in the hospital.
Documentation requirements by all members of
treating teams
Process and person responsible to re-engage Cardiology
and CTS if the pt is not improving.
Conclusions
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Endocarditis has the same morbidity and
mortality it did 30 years ago!
Aetiology and presentation is evolving
GBS endocarditis has an acute and fulminant
natural hx.
A co-ordinated, multi-disciplinary approach is
required to optimise outcomes
"Medicine is a science of uncertainty and an
art of probability.”
- William Osler (1849–1919)