Amen Corner: Endocarditis Prophylaxis

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Amen CornerEndocarditis Prophylaxis

• Jimmy Klemis, MD
• Cardiology Conference
• April 18 2002

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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
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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

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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

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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

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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

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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

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Determining Risk

• Cardiac conditions
• Type of Procedure

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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

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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
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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
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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

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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
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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
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Procedures

• Highest risk oral/dental
• Int risk GU/Pulm
• Low risk GI

1Durack, et al. NEJM 1995
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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
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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
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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
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?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

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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
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Prophylactic RegimensDental/Oral, Respiratory,
Esophageal
Dajani, et al. Circ 1997
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Prophylactic RegimensGU/GI (excluding esophageal)
Dajani, et al. Circ 1997
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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

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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

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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