Infective Endocarditis -- Printable Tables

TITLE:	INFECTIVE ENDOCARDITIS
AUTHOR:	THOMAS F. KEYS, MD -- Department of Infectious Disease
PUBLISHED:	JUNE 19, 2003
REVIEWED:	JULY 14, 2004

Table 1:
Underlying Heart Disease in 60 Patients with Native Valve Endocarditis
Lesion	Patients	Incidence (%)
Mitral Valve prolapse	14	23
Aortic sclerosis	12	20
Bicuspid aortic valve	6	10
Miscellaneous	6	10
Rheumatic	5	8
Unknown	17	28
Adapted from reference 2

Table 2:
Frequency of Sources Responsible for Endocarditis Due to Staphylococcus Aureus
Presumed	Hospital Cases	Community Cases
Intravenous catheter	12	11
Hemodialysis fistula	2	5
Surgical wound	12	2
Other	1	1
None	0	13
Adaped from reference 3

Table 3:
Native Valve Endocarditis Microbiology
Organism	Cases (%)
Streptococcus viridans	30-40
Enterococcus species	5-10
Other streptococci	10-25
Staphylococcus aureus	10-27
Coagulase-negative staphylococci	1-3
Gram-negative bacilli	2-13
Fungi	2-4
Other	5
"Culture negative"	5-24
Adapted from reference 4

Table 4:
Early-Onset Prosthetic Valve Endocarditis*
Organism	Cases (%) N=137
Staphylococcus epidermidis	31
Staphylococcus aureus	23
Streptococcal species	2
Enterococci	9
Diphtheroids	7
Gram-negative bacilli	14
Fungi	9
Other	3
Culture negative	3
* Within 60 days of surgery Table modified from reference 5

Table 5:
Clinical Findings in 90 Patients with Infective Endocarditis
Symptom	NVE (%) (N=60)	PVE (%) (N=30)
Fever	75	87
Weight loss	52	20
Skin lesions	51	47
New murmur	33	33
Splenomegaly	20	20
NVE=native valve endocarditis; PVE=prosthetic valve endocarditis Adapted from reference 2

Table 6:

Von Reyn Criteria for the Diagnosis
of Infective Endocarditis

Positive valve culture or histology or
Persistant bacteremia with new regurgitant heart murmur or valvular heart disease and vasculitis or
Negative or intermittent bacteremia and fever; plus new regurgitant heart murmur and vasculitis

Adapted from reference 10

Table 7:

Duke Criteria for the Diagnosis of Infective Endocarditis

Positive valve culture or histology or
Two major criteria: typical organism, persistant bacteremia, positive ECHO for vegetations, abscess or valve dehiscence or
Five of six minor criteria: valvular heart disease or IVDA,
fever greater than 38°C, vasculitis, skin lesions, suggestive ECHO (but not definite), positive blood culture or
One major and three minor criteria

Adapted from reference 11

Table 8:
Therapy of Native Valve Endocarditis: Penicillin-Sensitive Streptococci
Antibiotic	Regimen	Duration (wk)
Penicillin G	12-18 MU IV every 24 h	4
Ceftriaxone	2 g IV every 24 h	4
Ceftriaxone + Gentamicin	2 g IV every 24 h 1 mg/kg IV every 8 h	2
Vancomycin	1 g IV every 12 h	4
MU=million units; IV=intravenous Does assume normal renal function. Adapted from reference 12

Table 9:
Therapy of Native Valve Endocarditis for Penicillin-Insensitive Streptococci^a or Enterococci^b
Antibiotic	Regimen	Duration (wk)
Penicillin G + gentamicin	3 MU IV every 4 h 1 mg/kg IV/IM every 8 h	4-6^c 2-6^c
Vancomycin + gentamicin^d	1 g IV every 12 h 1 mg/kg IV/IM every 8 h	4-6^c 4-6
MU=million units; IV=intravenous; IM=intramuscular Does assume normal renal function. ^aMinimum inhibitory concentration=0.1-0.5 µg/mL. ^bMinimum inhibitory concentration >0.5 µg/mL. May want to clarify combo for entire course. ^cProlonged therapy for enterococci. ^dGentamicin with vancomycin only for enterococci. Adapted from reference 12

Table 10:
Therapy of Prosthetic Valve Staphylococcal Endocarditis
Isolate	Antibiotic	Regimen	Duration (wk)
MSSA or MSSE	Oxacillin + gentamicin + rifampin	2 g IV every 4 h 1 mg/kg IV/IM every 8 h 300 mg PO every 8 h	>6 First 2 >6
MRSA or MRSE	Vancomycin + gentamicin + rifampin	1 g IV every 12 h 1 mg/kg IV/IM every 8 h 300 mg PO every 8 h	>6 First 2 >6
MRSA=methicillin-resistant Staphylococcus aureus; MRSE=methicillin-resistant Staphylococcus epidermidis; MSSA=methicillin-sensitive Staphylococcus aureus; MSSE=methicillin-sensitive Staphylococcus epidermidis; IV=intravenous; IM=intramuscular; PO=orally. Doses assume normal renal function. Adapted from reference 12

Table 11:
Therapy of Endocarditis Due to HACEK Microorganisms
Antibiotic	Regimen	Duration (wk)
Ceftriaxone	2 g IV every 24 h	4
Ampicillin + gentamicin	2 g IV every 4 h 1 mg/kg IV/IM every 8 h	4 4
HACEK=Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, and Kingella species of bacteria; IV=intravenous; IM=intramuscular Does assume normal renal function Adapted from reference 12

Table 12:
Persistent Fevers During Treatment of Infective Endocarditis
Reason	Patients	%
Annular abscesses	11	26
Pulmonary or systemic emboli	7	17
Drug hypersensitivity	7	17
Myocarditis	3	7
Intravenous site infection	2	5
Other	6	14
Unknown	6	14
Adapted from reference 20

Table 13:
Neurologic Complications In Native (NVE) and Prosthetic Valve Endocarditis (PVE)
Complication	NVE (%)	PVE (%)
Stroke	15	21
Encephalopathy	9	8
Retinal emboli	3	3
Headache	4	3
Mycotic aneurysm	3	--
Abscess	1	2
Meningitis	1	2
Seizures	1	--
Total	37	39
Adapted from reference 21

Table 14:
Dental and Cardiac Risk Factors for Infective Endocarditis
Risk Factor	Cases (N=273)	Controls (N=273)
Dental prophylaxis	24	23
Extractions	6	0
Gingival surgery	1	0
History of endocarditis	17	1
Cardiac valvular surgery	37	2
Mitral valve prolapse	52	6
Adapted from reference 23

Table 15:
Prevention of Bacterial Endocarditis: Diseases at Risk for Infective Endocarditis
High Risk	Moderate Risk	Negligible Risk
Prosthetic heart valves	Acquired valvular dysfunction	Isolated atrial septal defect
Previous bacterial endocarditis	Hypertrophic cardiomyopathy	Surgical repair of atrial septal defect, ventricular septal defect, or patient ductus arteriosus
Complex cyanotic congenital heart disease	Mitral valve prolapse with regurgitation	Previous coronary artery bypass grafting
Surgically constructed pulmonary shunts		Mitral valve prolapse without regurgitation
		Cardiac pacemakers
Adapted from reference 25

Table 16:
Examples of American Heart Association Recommendations for Prophylaxis During Endocarditis
Yes	No
Dental extractions	Dental restoration
Periodontal procedures	Adjustment of braces
Dental implants	Flexible bronchoscopy
Prophylactic cleaning	Gastrointestinal endoscopy
Tonsillectomy	Cesarean section deliveries
Esophageal dilatation	Cardiac catheterization
Sclerotherapy	Urethral catheterization^a
Cystoscopy
Urethral dilatation
^aWhen urine is sterile. Adapted from reference 25

Table 17:
Prophylactic Regimens for Dental, Oral, Respiratory, and Esophageal Procedures
Situation	Agent	Regimen
Standard	Amoxicillin	2 g PO 1 h before
Unable to take PO	Ampicillin	2 g IM/IV 30 min before
Penicillin allergy	Clindamycin Cephalexin Azithromycin	600 mg PO 1 h before 2 g PO 1 h before 500 mg PO 1 h before
IV=intravenous; IM=intramuscular; PO=orally Adapted from reference 25

Table 18:
Prophylactic Regimens for Genitouinary and Gastrointestinal Procedures
Category	Regimen
High risk	Ampicillin,^a 2 g IM/IV, 30 min before + gentamicin, 1.5 mg/kg, 30 min before and ampicillin 1 g IM/IV or amoxacillin 1 g PO 6 hours after
Moderate risk	Amoxicillin, 2 g PO, 1 h before or ampicillin, 2 g IM/IV, 3 min before
^aFor penicillin allergy, substitute vancomycin, 1 g IV; infuse over 1-2 h and gentamicin, 1.5 mg/kg and complete 30 min before IV=intravenous; IM=intramuscular; PO=orally. Adapted from reference 25

This information is provided for general medical education purposes only and is not meant to substitute for the independent medical judgment of a physician relative to diagnostic and treatment options of a specific patient's medical condition.

In no event will The Cleveland Clinic Foundation be liable for any decision made or action taken in reliance upon the information provided through this web site.