Update on Endocarditis Dr Catherine Berry May 2012 Endocarditis 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 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? Outcomes 17.7% in hospital mortality 48.2% required surgery Risk factors for death SA or CoNS Pulmonary oedema Prosthetic valve Paravalvular dx. NB. Surgery assoc with OR for death of 0.6 Group B streptococcus 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 Epidemiology Clinical features 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 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 male - 70% Median age - 54.5 >65 yrs (5 died) - 35% inter-hospital transfers - 40% surgical mmt. - 25% IVDU - 40% prosthetic valves - 25% Guidelines ACC/AHA 2006 (Circulation)* ECS 2009 (European Heart Journal) BSAC 2012 (Journal of Antimicrobial chemo) Whats new and ongoing controversies 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 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 Mortality 5-7% if delayed in non-perivalvular disease. AHA/European guidelines 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 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 Anxiety “Prev.” IVDU Chronic back pain – on jurnista Hypotensive requiring inotropic support Plt 16; INR 1.4; WCC 11.1; Cr 136; CRP 179 Mr DB Definite endocarditis (mod. Duke’s) Blood cultures x 3 positive for Group B streptococcus Echo – moderate to severe AR. 14/11 - T/f’d JHH ?need for Sx. ECG Mr DB Management plan IV penicillin HDU for inotropes APS/D+A for pain management Cardio BPT r/v TOE Mr DB 15/11 Off inotropes; plt recovered CCU BP 90/60; HR 110 16/11 S/B Cardiologist – Await TOE, for medical mmt. TOE Mr DB 17/11- 8pm Rapid response for RR 40; HR 140 “APO” Responded to morphine; olanzapine; frusemide Attempted contact with cardiologist – no response Mr DB Mr DB 18/11- 22/11 Transferred to ward CRP/obs stable. Escalating HF rx. Digoxin Frusemide ACEi Ongoing pain mmt Mr DB 23/11 - pm increased tachypnoea, desaturating off O2 ID AMO non-contactable Handed over to after hours medical staff 24/11 1.20am Found dead and unable to be revived 14 days presentation to death Final diagnosis: Aortic valve vegetative endocarditis. Left heart failure. Splenomegaly. Splenic infarction, splenic septic emboli. Mr DB Comments.. RCA recommendations – Endocarditis protocol 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 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)