Infective endocarditis: prognosis and management


Infective endocarditis: prognosis and management

Poor prognostic factors

  • Staph aureus infection (see below)
  • prosthetic valve (especially 'early', acquired during surgery)
  • culture negative endocarditis
  • low complement levels

Mortality according to organism

  • staphylococci - 30%
  • bowel organisms - 15%
  • streptococci - 5%




Current antibiotic guidelines (source: British National Formulary)

Scenario
Suggested antibiotic therapy
Initial blind therapy
Native valve

  • amoxicillin, consider adding low-dose gentamicin

If penicillin allergic, MRSA or severe sepsis

  • vancomycin + low-dose gentamicin

If prosthetic valve

  • vancomycin + rifampicin + low-dose gentamicin
Native valve endocarditis caused by staphylococci
Flucloxacillin

If penicillin allergic or MRSA

  • vancomycin + rifampicin
Prosthetic valve endocarditis caused by staphylococci
Flucloxacillin + rifampicin + low-dose gentamicin

If penicillin allergic or MRSA

  • vancomycin + rifampicin + low-dose gentamicin
Endocarditis caused by fully-sensitive streptococci (e.g. viridans)
Benzylpenicillin

If penicillin allergic

  • vancomycin + low-dose gentamicin
Endocarditis caused by less sensitive streptococci
Benzylpenicillin + low-dose gentamicin

If penicillin allergic

  • vancomycin + low-dose gentamicin

Indications for surgery

  • severe valvular incompetence
  • aortic abscess (often indicated by a lengthening PR interval)
  • infections resistant to antibiotics/fungal infections
  • cardiac failure refractory to standard medical treatment
  • recurrent emboli after antibiotic therapy

passmedicine 2017

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