Amen Corner:Amen Corner:Endocarditis Endocarditis ProphylaxisProphylaxis

Jimmy Klemis, MDJimmy Klemis, MD

Cardiology ConferenceCardiology Conference

April 18 2002April 18 2002

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 opportunityto prevent it doesn’t get to say “Amen”

Case PresentationCase Presentation

60 M admitted for 5 wk history of “not 60 M admitted for 5 wk history of “not feeling well”; c/o, fatigue, DOE, and feeling well”; c/o, fatigue, DOE, and nocturnal angina. Patient states was nocturnal angina. Patient states was doing well until 1-2d after recent doing well until 1-2d after recent colonoscopy/bx for hx heme + stools. colonoscopy/bx for hx heme + stools. Found to have colon polyp, Found to have colon polyp, discharged to f/u with PCP. discharged to f/u with PCP.

PMHx: CAD/LAD stent 12wk ago, HLP, PMHx: CAD/LAD stent 12wk ago, HLP, hx mild AI/AShx mild AI/AS

Denies drug/etohDenies drug/etoh

Case PresentationCase Presentation

PE: T 99.8 HR 95 BP 102/62PE: T 99.8 HR 95 BP 102/62 HNT: poor dentition, no jvd, nl HNT: poor dentition, no jvd, nl

carotid pulsationcarotid pulsation CV: nl S1/2, +S3, no S4, 2/6 diastolic CV: nl S1/2, +S3, no S4, 2/6 diastolic

decr m LSB, 2/6 sys m RUSBdecr m LSB, 2/6 sys m RUSB RESP: basilar ralesRESP: basilar rales ABD: nt/ndABD: nt/nd EXT: no edemaEXT: no edema

Case PresentationCase Presentation

Admitted for eval new CP, suspected Admitted for eval new CP, suspected endocarditis – empiric Abx started, Bld endocarditis – empiric Abx started, Bld Cx 4/4 + for S. viridansCx 4/4 + for S. viridans

TEE: 4+AI, vegetation NCC AV, EF 60%TEE: 4+AI, vegetation NCC AV, EF 60% Abx continued, CT surg consulted. Pt Abx continued, CT surg consulted. Pt

initially hemodynamically stable and initially hemodynamically stable and defervesced. ~10d into hosp course pt defervesced. ~10d into hosp course pt decompensated – decompensated – tachy/hypotension/EMDtachy/hypotension/EMD

Unsuccessful resucitation, pt diedUnsuccessful resucitation, pt died

EndocarditisEndocarditis

Bacteremia (daily activites, Bacteremia (daily activites, procedures, infections)procedures, infections)

adherence/colonization on platelet adherence/colonization on platelet fibrin aggregates which have formed fibrin aggregates which have formed on valve endothelium due to on valve endothelium due to congenital or acquired dzcongenital or acquired dz

if host defenses overwhelmed if host defenses overwhelmed ENDOCARDITIS ENDOCARDITIS

Endocarditis ProphylaxisEndocarditis Prophylaxis No randomized or controlled clinical trials No randomized or controlled clinical trials

proving that antimicrobial prophylaxis proving that antimicrobial prophylaxis prevents IE in structurally abnl hearts after prevents IE in structurally abnl hearts after proceduresprocedures

Overall incidence of procedure-related Overall incidence of procedure-related endocarditis is lowendocarditis is low

However, significant literature establishing However, significant literature establishing certain hi-risk conditions more likely certain hi-risk conditions more likely predisposed to endocarditis and certain predisposed to endocarditis and certain procedures which may have higher incidence procedures which may have higher incidence of bacteremia with aggressive pathogens of bacteremia with aggressive pathogens known to cause endocarditisknown to cause endocarditis

Determining RiskDetermining Risk

Cardiac conditionsCardiac conditions Type of ProcedureType of Procedure

Cardiac conditions which Cardiac conditions which predispose pt for IEpredispose pt for IE

Based on risk of progression to Based on risk of progression to severe endocarditis with substantial severe endocarditis with substantial morbidity and mortality (not simply morbidity and mortality (not simply risk of developing IE)risk of developing IE)

Classified intoClassified into– HIGH riskHIGH risk - prophylaxis- prophylaxis– MODERATE riskMODERATE risk - prophylaxis- prophylaxis– NEGLIGIBLE risk NEGLIGIBLE risk - no prophylaxis- no prophylaxis

Cardiac Conditions – High Cardiac Conditions – High RiskRisk11

Prosthetic Valves (400x riskProsthetic Valves (400x risk22)) Previous endocarditisPrevious endocarditis CongenitalCongenital

– Complex cyanotic dz (Tetralogy, Transposition, Single Complex cyanotic dz (Tetralogy, Transposition, Single Vent)Vent)

– Patent Ductus ArteriosusPatent Ductus Arteriosus– VSDVSD– CoarctationCoarctation

Valvular:Valvular:– Aortic Stenosis/ Aortic RegurgAortic Stenosis/ Aortic Regurg– Mitral RegurgitationMitral Regurgitation– Mitral Stenosis with RegurgMitral Stenosis with Regurg

Surgically constructed systemic pulmonary Surgically constructed systemic pulmonary shunts or conduits shunts or conduits

2Steckleberg, et al. Inf Dis Clin N Amer 1993

1Durack, et al. NEJM 1995Mod Risk per 1997 AHA guidelines

Cardiac Conditions - Moderate Cardiac Conditions - Moderate RiskRisk11

ValvularValvular– MVP + regurg and/or thickened leafletsMVP + regurg and/or thickened leaflets– pure Mitral Stenosispure Mitral Stenosis– TR/TSTR/TS– Pulmonic StenosisPulmonic Stenosis– Bicuspid AV/ Aortic SclerosisBicuspid AV/ Aortic Sclerosis– degenerative valve dz in elderydegenerative valve dz in eldery

Asymmetric Septal Hypertrophy/HOCMAsymmetric Septal Hypertrophy/HOCM surgically repaired intracardiac lesions surgically repaired intracardiac lesions

w/o hemodynamic abnormality, < 6 mos w/o hemodynamic abnormality, < 6 mos after surgafter surg

1Durack, et al. NEJM 1995

Negligible Risk (no Negligible Risk (no prophylaxis)prophylaxis)

MVP no regurgMVP no regurg Physiologic/innocent murmurPhysiologic/innocent murmur Pacemaker/ICDPacemaker/ICD Isolated Secundum ASDIsolated Secundum ASD prev CABGprev CABG surgical repair ASD/VSD/PDA , no surgical repair ASD/VSD/PDA , no

residua > 6mos after surgeryresidua > 6mos after surgery

Procedures Procedures

1930’s – studies linking significant 1930’s – studies linking significant bacteremia induced after extraction of bacteremia induced after extraction of teethteeth11

Serratia marcesens introduced as Serratia marcesens introduced as sentinal organism shown to be present sentinal organism shown to be present in venous blood immediately after in venous blood immediately after tooth extractiontooth extraction22

incidental bacteremia also seen in incidental bacteremia also seen in control groups, less often, less virulentcontrol groups, less often, less virulent

1Okell, et al. Lancet. 1935 2Burket, et al. J Dent Res 1937

Procedure related Procedure related bacteremiabacteremia11

Procedure related bacteremias are short Procedure related bacteremias are short livedlived

highest freq + Bld Cx 30 secs after tooth highest freq + Bld Cx 30 secs after tooth extractionextraction

episodes bacteremia from dental episodes bacteremia from dental procedures generally last < 10 minprocedures generally last < 10 min

most pt have sxs within 1-2 wks of most pt have sxs within 1-2 wks of procedure and can occur as early as 1-2 procedure and can occur as early as 1-2 days; if sxs occur later less likely days; if sxs occur later less likely procedurally relatedprocedurally related

1Durack, et al. NEJM 1995

ProceduresProcedures

Highest risk oral/dentalHighest risk oral/dental Int risk GU/PulmInt risk GU/Pulm Low risk GILow risk GI

1Durack, et al. NEJM 1995

Dental/Oral ProceduresDental/Oral Procedures PROPHYLAXISPROPHYLAXIS Procedures with Procedures with

gingival/mucosal gingival/mucosal bleedingbleeding

extractions, extractions, periodontal, periodontal, endodontal endodontal proceduresprocedures

professional cleaning professional cleaning or scalingor scaling

orthodontic bandsorthodontic bands

NO PROPHYLAXISNO PROPHYLAXIS Minimal/no bleedingMinimal/no bleeding simple fillings above simple fillings above

gumlinegumline Restorative dentistry*Restorative dentistry* adjustment of adjustment of

orthodontic appliancesorthodontic appliances xray, injections, xray, injections,

fluoride treatmentsfluoride treatments

*clinical judgement if potentially significant bleeding

GI/GU ProceduresGI/GU Procedures PROPHYLAXISPROPHYLAXIS Esoph dilatationEsoph dilatation Sclerotherapy for Sclerotherapy for

esoph varicesesoph varices ERCP with biliary ERCP with biliary

obstructionobstruction Biliary surgeryBiliary surgery Surgery involving Surgery involving

intestinal mucosaintestinal mucosa Prostatic SurgeryProstatic Surgery CystoscopyCystoscopy Ureteral dilatationUreteral dilatation

NO PROPHYLAXISNO PROPHYLAXIS TEE*TEE* Endoscopy w/wo bx*Endoscopy w/wo bx*11

Ureteral Ureteral catheterizationcatheterization

D&CD&C ““Therapeutic” AbTherapeutic” Ab Vaginal hysterectomy*Vaginal hysterectomy* Vaginal delivery* Vaginal delivery*

(<5% risk)(<5% risk) IUD insertion/removalIUD insertion/removal

*Optional for High Risk pt 1<10 cases of IE after dx GI/endoscopyDurack, et al. NEJM 1995

Other ProceduresOther Procedures PROPHYLAXISPROPHYLAXIS TonsillectomyTonsillectomy Rigid BronchoscopyRigid Bronchoscopy Surgery involving resp Surgery involving resp

mucosamucosa

NO PROPHYLAXISNO PROPHYLAXIS Endotracheal Endotracheal

intubationintubation Flex Bronchoscopy Flex Bronchoscopy

w/wo biopsy*w/wo biopsy* Cardiac cath/stentCardiac cath/stent Pacer/ICD Pacer/ICD

implantationimplantation Incision/Bx of Incision/Bx of

surgically scrubbed surgically scrubbed skinskin

*Optional for High risk pt

?Evidence linking IE to ?Evidence linking IE to proceduresprocedures

Largely circumstantial, unproven but based Largely circumstantial, unproven but based on organisms involved and temporal relation on organisms involved and temporal relation to proceduresto procedures

Animal studies 1970’s showed endocarditis Animal studies 1970’s showed endocarditis preventable with prophylaxis in rabbitspreventable with prophylaxis in rabbits

Estimates show only ~ 6% of endocarditis Estimates show only ~ 6% of endocarditis cases preventable with prophylaxis (240-480 cases preventable with prophylaxis (240-480 cases annually in US) but extensive cases annually in US) but extensive morbidity/mortality associated should sway morbidity/mortality associated should sway toward appropriate identification and toward appropriate identification and prophylaxis of at risk pt undergoing prophylaxis of at risk pt undergoing procedures known to cause significant procedures known to cause significant bacteremiabacteremia

ProphylaxisProphylaxis

No randomized trials (would req 6000 No randomized trials (would req 6000 pt with cardiac dz, ?ethical)pt with cardiac dz, ?ethical)

Retrospective analysis of 533 pt with Retrospective analysis of 533 pt with prosthetic valves undergoing dental/ prosthetic valves undergoing dental/ surgical proceduressurgical procedures– No prophylaxis – 6/229 pt endocarditisNo prophylaxis – 6/229 pt endocarditis– Prophylaxis – 0/304Prophylaxis – 0/304

Horstkotte, et al. Eur Heart J 1987

Prophylactic RegimensProphylactic RegimensDental/Oral, Respiratory, EsophagealDental/Oral, Respiratory, Esophageal

SituationSituation AgentAgent RegimenRegimen

StandardStandard AmoxicillinAmoxicillin 2.0g 1hr prior2.0g 1hr prior

Standard, IVStandard, IV AmpicillinAmpicillin 2.0g 30min prior2.0g 30min prior

PCN AllergyPCN AllergyClindamycinClindamycin

CephalexinCephalexin

Azithro/ClarithAzithro/Clarith

600mg600mg

2.0g2.0g

500mg 1hr prior500mg 1hr prior

PCN Allergy, IVPCN Allergy, IVClindamycinClindamycin

CefazolinCefazolin600mg600mg

1.0g 30min prior1.0g 30min priorDajani, et al. Circ 1997

Prophylactic RegimensProphylactic RegimensGU/GI (excluding esophageal)GU/GI (excluding esophageal)

SituationSituation AgentAgent RegimenRegimen

High RiskHigh Risk Ampicillin + Ampicillin + GentGent

Amp 2g Gent 1.5mg/kg Amp 2g Gent 1.5mg/kg (120max) w/in 30 min of (120max) w/in 30 min of procedureprocedure

6hr later Amp 1g IV or Amox 1g 6hr later Amp 1g IV or Amox 1g popo

High RiskHigh Risk

PCN AllergicPCN AllergicVanc + GentVanc + Gent

Vanc 1g over 1-2hr + Gent 1.5 Vanc 1g over 1-2hr + Gent 1.5 mg/kg complete infusion w/in mg/kg complete infusion w/in 30min30min

Mod RiskMod RiskAmoxicillin or Amoxicillin or

AmpicillinAmpicillinAmox 2g po 1hr before or Amox 2g po 1hr before or

Amp 2g IV/IM within 30 minAmp 2g IV/IM within 30 min

Mod RiskMod Risk

PCN AllergicPCN AllergicVancVanc

Vanc 1g over 1-2 hr complete Vanc 1g over 1-2 hr complete infusion w/in 30 min of infusion w/in 30 min of procedureprocedure

Dajani, et al. Circ 1997

Theoretical/Other Concerns Theoretical/Other Concerns with “over prophylaxis”with “over prophylaxis”

Microbial ResistanceMicrobial Resistance Incidence of anaphylaxis (IV preps) Incidence of anaphylaxis (IV preps)

may override benefit when looking at may override benefit when looking at overall population if given in overall population if given in nonselective fashionnonselective fashion

Our Patient - ? Missed Our Patient - ? Missed opportunityopportunity

“ “low risk” procedure low risk” procedure (colonoscopy/bx) and organism (colonoscopy/bx) and organism common to oral mucosacommon to oral mucosa

BUT, significant association of sxs BUT, significant association of sxs with 24-48hrs after colonoscopy/bxwith 24-48hrs after colonoscopy/bx

current guidelines would prophylax current guidelines would prophylax “hi risk pt” but AI/AS not included in “hi risk pt” but AI/AS not included in this groupthis group

ConclusionsConclusions

Recognize at risk patients in your Recognize at risk patients in your carecare

Educate them on importance of Educate them on importance of prophylaxis (you may not get prophylaxis (you may not get consulted prior to procedures and not consulted prior to procedures and not everyone knows the risks – pt may everyone knows the risks – pt may have to act as his own advocate )have to act as his own advocate )

Err on the side of cautionErr on the side of caution