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Emerging Issues in Infective Endocarditis Beverley C

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Emerging Issues in Infective Endocarditis Beverley C HISTORICAL REVIEW Emerging Issues in Infective Endocarditis Beverley C. Millar* and John E. Moore* Infective endocarditis, a serious infection of the endo- Endocarditis is usually curable provided an early diagno- cardium of the heart, particularly the heart valves, is asso- sis is made, and the patient receives the appropriate ciated with a high degree of illness and death. It generally antimicrobial treatment; the time needed for recovery is occurs in patients with altered and abnormal heart architec- approximately 6–8 weeks. The patient generally requires ture, in combination with exposure to bacteria through trau- long-term antimicrobial drugs (4–6 weeks), hospitaliza- ma and other potentially high-risk activities involving transient bacteremia. Knowledge about the origins of endo- tion, and in some cases, valve replacement. A number of carditis stems from the work of Fernel in the early 1500s, complications may be associated with the disease such as and yet this infection still presents physicians with major blood clots, stroke, heart rhythm problems, abscesses, and diagnostic and management dilemmas. Endocarditis is other infections. Infective endocarditis is associated with caused by a variety of bacteria and fungi, as well as emerg- severe illness and death and generally occurs in patients ing infectious agents, including Tropheryma whipplei, with altered and abnormal heart architecture who have Bartonella spp., and Rickettsia spp. We review the evolu- been exposed to bacteria through trauma and other poten- tion of endocarditis and compare its progression with dis- tially high-risk activities. coveries in microbiology, science, and medicine. In 1885, Sir William Osler presented three Gulstonian Lectures on the topic of malignant endocarditis, which ndocarditis is a noncontagious chronic infection of gave a comprehensive account of the disease and outlined Ethe valves or lining of the heart, mainly caused by the difficulties in its diagnosis (2). The disease had, in fact, bacteria, although fungi can also be associated with this been described by a French Renaissance physician, Jean infection (1). The risk of infection of heart valves in per- François Fernel, approximately 350 years previously (3). sons predisposed to acquiring infective endocarditis More than 100 years after Osler’s lectures, this serious increases with the following conditions: congenital heart infection can still remain a diagnostic and therapeutic disease, rheumatic fever, major dental treatment, open dilemma. Its name has been changed several times, first to heart surgery, and genitourinary procedures. New evi- “bacterial endocarditis” and subsequently to “infective dence is growing that changes in social behavior, such as endocarditis” after the observation that microbiologic an increase in the incidence of body piercing, excessive agents other than bacteria may cause the disease. In the alcohol consumption, and the use of intravenous self- early years of the new millennium, infective endocarditis administered illicit drugs may also predispose a suscepti- still proves to be difficult to diagnose and is associated ble person to an increased risk of acquiring endocarditis. with a high death rate (21%–35%). Although many devel- The patient may exhibit any of the following signs and opments have taken place with respect to antimicrobial symptoms: fatigue and weakness; weight loss; fever and drug therapy in the treatment of the disease, its incidence chills; night sweats; heart murmur; aches and pains; is continuing to rise, with 3.3 cases per 100,000 population painful nodes in the pads of fingers and toes; red spots on per year in the United Kingdom, with similar figures for skin of palms and soles; nail abnormalities; swelling of the United States and 1.4–4.0 cases per 100,000 population feet, legs, and abdomen; shortness of breath with activity; per year in Europe as a whole (4). The reasons for this rise and blood in the urine. A medical history, physical exam- are the following: 1) longer survival of patients with ination, and echocardiogram are usually performed. degenerative heart diseases, 2) increased use of antibiotics, Blood samples are usually taken, and the physical and 3) increased incidence of prosthetic heart valves, 4) con- biochemical properties of the blood are investigated. genital heart disease in younger children, 5) increase in bicuspid valve disease, 6) advances in medical and surgi- cal treatments, 7) increase in the number of injection drug *Belfast City Hospital, Belfast, Northern Ireland, United Kingdom 1110 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 10, No. 6, June 2004 Infective Endocarditis users, and 8) more sensitive and specific diagnosis. For approximately the first 200 years after the disease Generally, the incidence is higher in men than in women was initially described, the anatomy of the heart and heart (2:1), and the average age group affected is in the fifth valves in the diseased state of infective endocarditis was decade (2). comprehensively elucidated in medical anatomical sketch- es made after postmortem examination. (For a comprehen- Historical Perspective sive account of the early description of endocarditis, see A historical description of developments in endocardi- Contrepois [10].) Not until the early to mid-1800s were tis closely reflects concurrent developments in laboratory descriptions recorded of the medical signs and symptoms medicine, particularly microbiology. Much of the innova- of the disease in live patients. Such descriptions included tions and developments relating to infective endocarditis the detection of cardiac murmurs, after percussion and aus- were made by physicians in Europe, particularly in France cultation. Detection of such murmurs was aided by the (Appendix). Important contributions were, however, made development of the stethoscope in 1816. From 1830 to by several German physicians, particularly in association 1840, elevated body temperature was recorded as an with the birth of bacteriology (Appendix). More recently, important symptom of the disease. However, not until the the United States has played a strong role in helping define late 1800s and early 1900s was a comprehensive synthesis guidelines and diagnostic criteria that facilitate diagnosing of information formed by various scholars in Europe and infective endocarditis, including the Beth Israel (5), Duke North America, including Sir William Osler in Canada (2) (6) (Table 1), and modified Duke criteria (7,8) (Table 2). In and Thomas Horder in England (11) (Appendix). Osler and addition, the American Heart Association has published Horder were instrumental in establishing fundamental several seminal articles on the antibiotic treatment and pre- mechanisms regarding the pathophysiology of infective vention of infective endocarditis (9). endocarditis and are, to a large degree, responsible for how Table 1. Original Duke criteria for the diagnosis and classification of infective endocarditisa Major criteria Minor criteria Diagnosis 1. Positive blood culture 1. Predisposition 1. Definite i) Typical organism in >2 blood cultures in the Heart condition 2 Major absence of a primary focus (Staphylococcus Drug abuse 1 Major and 3 minor aureus, enterococci, viridans streptococci, 5 Minor Streptococcus bovis, HACEK) pathologic/histologic findings ii) Persistently positive blood culture drawn more than 12 h apart or all ¾ drawn at least 1 h apart between first and last 2. Evidence of endocardial involvement 2. Fever 2. Possible i) Positive echocardiogram (TOE) >38°C Findings fell short of the definite but not Oscillating intracardiac mass on valve, implanted rejected categories material or supporting structures in path of regurgitant jets Abscess New partial dehiscence of prosthetic valve ii) New valvular regurgitation 3. Vascular phenomena 3. Rejected Major arterial emboli Alternate diagnosis Janeway lesions Resolution of the infection with antibiotic Septic pulmonary infarcts therapy for <4 days No pathologic evidence after antibiotic therapy 4. Immunologic phenomena Osler’s nodes Roth spots Rheumatoid factor Glomerulonephritis 5. Microbiologic evidence Positive blood culture not meeting major criteria Positive serologic finding 6. Endocardiographic evidence Consistent with infective endocarditis but not meeting the major criteria aSource: (6); HACEK, Haemophilus aphrophilus, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae group; TOE, transesophageal echocardiogram. Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 10, No. 6, June 2004 1111 HISTORICAL REVIEW Table 2. Recent suggested modifications to the Duke criteria for the diagnosis of infective endocarditis (IE)a Microbiologic Biochemical Clinical Blood culture Elevated level of CRP >100 mg/L Possible endocarditis now defined as one Bacteremia due to Staphylococcus Elevated ESR defined as more than one and a major and one minor criterion or three aureus should be considered a major half times higher than normal, i.e. , minor criteria criterion regardless of whether the >30 mm/h for patients <60 years of age Omission of criterion “echocardiogram infection is nosocomially acquired or >50 mm/h for patients >60 years of age consistent with IE but not meeting major whether a removable source of criterion” infection is present Newly diagnosed clubbing Serology Evidence of splinter hemorrhages Positive for Coxiella burnetii (major Petechiae criterion) Microscopic hematuria (disregarded for Positive for
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