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Amen Corner: Endocarditis Prophylaxis

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Amen Corner: Endocarditis Prophylaxis Jimmy Klemis, MD Cardiology Conference April 18 2002 Case Presentation 60 M admitted for 5 wk history of not feeling well ... – PowerPoint PPT presentation

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Title: Amen Corner: Endocarditis Prophylaxis


1
Amen CornerEndocarditis Prophylaxis
  • Jimmy Klemis, MD
  • Cardiology Conference
  • April 18 2002

2
Amen Corner -- where the 11th green, 12th hole
and 13th tee meet at the southeast corner of
Augusta National -- got its name when the great
golf writer Herbert Warren Wind observed more
than 40 years ago that a golfer who successfully
negotiates it should say "Amen."
Amen Corner II where the patient with
structural heart disease, a bacteremic-inducing
procedure, and a bad outcome meet got its name
when the lowly cardiology fellow Jimmy Klemis
observed more than 4 weeks ago that a physician
who misses the opportunity to prevent it doesnt
get to say Amen
3
Case Presentation
  • 60 M admitted for 5 wk history of not feeling
    well c/o, fatigue, DOE, and nocturnal angina.
    Patient states was doing well until 1-2d after
    recent colonoscopy/bx for hx heme stools. Found
    to have colon polyp, discharged to f/u with PCP.
  • PMHx CAD/LAD stent 12wk ago, HLP, hx mild AI/AS
  • Denies drug/etoh

4
Case Presentation
  • PE T 99.8 HR 95 BP 102/62
  • HNT poor dentition, no jvd, nl carotid
    pulsation
  • CV nl S1/2, S3, no S4, 2/6 diastolic decr m
    LSB, 2/6 sys m RUSB
  • RESP basilar rales
  • ABD nt/nd
  • EXT no edema

5
Case Presentation
  • Admitted for eval new CP, suspected endocarditis
    empiric Abx started, Bld Cx 4/4 for S.
    viridans
  • TEE 4AI, vegetation NCC AV, EF 60
  • Abx continued, CT surg consulted. Pt initially
    hemodynamically stable and defervesced. 10d into
    hosp course pt decompensated tachy/hypotension/E
    MD
  • Unsuccessful resucitation, pt died

6
Endocarditis
  • Bacteremia (daily activites, procedures,
    infections)
  • adherence/colonization on platelet fibrin
    aggregates which have formed on valve endothelium
    due to congenital or acquired dz
  • if host defenses overwhelmed ? ENDOCARDITIS

7
Endocarditis Prophylaxis
  • No randomized or controlled clinical trials
    proving that antimicrobial prophylaxis prevents
    IE in structurally abnl hearts after procedures
  • Overall incidence of procedure-related
    endocarditis is low
  • However, significant literature establishing
    certain hi-risk conditions more likely
    predisposed to endocarditis and certain
    procedures which may have higher incidence of
    bacteremia with aggressive pathogens known to
    cause endocarditis

8
Determining Risk
  • Cardiac conditions
  • Type of Procedure

9
Cardiac conditions which predispose pt for IE
  • Based on risk of progression to severe
    endocarditis with substantial morbidity and
    mortality (not simply risk of developing IE)
  • Classified into
  • HIGH risk - prophylaxis
  • MODERATE risk - prophylaxis
  • NEGLIGIBLE risk - no prophylaxis

10
Cardiac Conditions High Risk1
  • Prosthetic Valves (400x risk2)
  • Previous endocarditis
  • Congenital
  • Complex cyanotic dz (Tetralogy, Transposition,
    Single Vent)
  • Patent Ductus Arteriosus
  • VSD
  • Coarctation
  • Valvular
  • Aortic Stenosis/ Aortic Regurg
  • Mitral Regurgitation
  • Mitral Stenosis with Regurg
  • Surgically constructed systemic pulmonary shunts
    or conduits

1Durack, et al. NEJM 1995
Mod Risk per 1997 AHA guidelines
2Steckleberg, et al. Inf Dis Clin N Amer 1993
11
Cardiac Conditions - Moderate Risk1
  • Valvular
  • MVP regurg and/or thickened leaflets
  • pure Mitral Stenosis
  • TR/TS
  • Pulmonic Stenosis
  • Bicuspid AV/ Aortic Sclerosis
  • degenerative valve dz in eldery
  • Asymmetric Septal Hypertrophy/HOCM
  • surgically repaired intracardiac lesions w/o
    hemodynamic abnormality, lt 6 mos after surg

1Durack, et al. NEJM 1995
12
Negligible Risk (no prophylaxis)
  • MVP no regurg
  • Physiologic/innocent murmur
  • Pacemaker/ICD
  • Isolated Secundum ASD
  • prev CABG
  • surgical repair ASD/VSD/PDA , no residua gt 6mos
    after surgery

13
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14
Procedures
  • 1930s studies linking significant bacteremia
    induced after extraction of teeth1
  • Serratia marcesens introduced as sentinal
    organism shown to be present in venous blood
    immediately after tooth extraction2
  • incidental bacteremia also seen in control
    groups, less often, less virulent

1Okell, et al. Lancet. 1935
2Burket, et al. J Dent Res 1937
15
Procedure related bacteremia1
  • Procedure related bacteremias are short lived
  • highest freq Bld Cx 30 secs after tooth
    extraction
  • episodes bacteremia from dental procedures
    generally last lt 10 min
  • most pt have sxs within 1-2 wks of procedure and
    can occur as early as 1-2 days if sxs occur
    later less likely procedurally related

1Durack, et al. NEJM 1995
16
Procedures
  • Highest risk oral/dental
  • Int risk GU/Pulm
  • Low risk GI

1Durack, et al. NEJM 1995
17
Dental/Oral Procedures
  • PROPHYLAXIS
  • Procedures with gingival/mucosal bleeding
  • extractions, periodontal, endodontal procedures
  • professional cleaning or scaling
  • orthodontic bands
  • NO PROPHYLAXIS
  • Minimal/no bleeding
  • simple fillings above gumline
  • Restorative dentistry
  • adjustment of orthodontic appliances
  • xray, injections, fluoride treatments

clinical judgement if potentially significant
bleeding
18
GI/GU Procedures
  • PROPHYLAXIS
  • Esoph dilatation
  • Sclerotherapy for esoph varices
  • ERCP with biliary obstruction
  • Biliary surgery
  • Surgery involving intestinal mucosa
  • Prostatic Surgery
  • Cystoscopy
  • Ureteral dilatation
  • NO PROPHYLAXIS
  • TEE
  • Endoscopy w/wo bx1
  • Ureteral catheterization
  • DC
  • Therapeutic Ab
  • Vaginal hysterectomy
  • Vaginal delivery (lt5 risk)
  • IUD insertion/removal

1lt10 cases of IE after dx GI/endoscopy Durack, et
al. NEJM 1995
Optional for High Risk pt
19
Other Procedures
  • PROPHYLAXIS
  • Tonsillectomy
  • Rigid Bronchoscopy
  • Surgery involving resp mucosa
  • NO PROPHYLAXIS
  • Endotracheal intubation
  • Flex Bronchoscopy w/wo biopsy
  • Cardiac cath/stent
  • Pacer/ICD implantation
  • Incision/Bx of surgically scrubbed skin

Optional for High risk pt
20
?Evidence linking IE to procedures
  • Largely circumstantial, unproven but based on
    organisms involved and temporal relation to
    procedures
  • Animal studies 1970s showed endocarditis
    preventable with prophylaxis in rabbits
  • Estimates show only 6 of endocarditis cases
    preventable with prophylaxis (240-480 cases
    annually in US) but extensive morbidity/mortality
    associated should sway toward appropriate
    identification and prophylaxis of at risk pt
    undergoing procedures known to cause significant
    bacteremia

21
Prophylaxis
  • No randomized trials (would req 6000 pt with
    cardiac dz, ?ethical)
  • Retrospective analysis of 533 pt with prosthetic
    valves undergoing dental/ surgical procedures
  • No prophylaxis 6/229 pt endocarditis
  • Prophylaxis 0/304

Horstkotte, et al. Eur Heart J 1987
22
Prophylactic RegimensDental/Oral, Respiratory,
Esophageal
Dajani, et al. Circ 1997
23
Prophylactic RegimensGU/GI (excluding esophageal)
Dajani, et al. Circ 1997
24
Theoretical/Other Concerns with over prophylaxis
  • Microbial Resistance
  • Incidence of anaphylaxis (IV preps) may override
    benefit when looking at overall population if
    given in nonselective fashion

25
Our Patient - ? Missed opportunity
  • low risk procedure (colonoscopy/bx) and
    organism common to oral mucosa
  • BUT, significant association of sxs with
    24-48hrs after colonoscopy/bx
  • current guidelines would prophylax hi risk pt
    but AI/AS not included in this group

26
Conclusions
  • Recognize at risk patients in your care
  • Educate them on importance of prophylaxis (you
    may not get consulted prior to procedures and not
    everyone knows the risks pt may have to act as
    his own advocate )
  • Err on the side of caution
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