Endocarditis infecciosa

ENDOCARDITIS INFECCIOSAHospital Regional Valentín Gómez Farías

Luis Ulises Flores Martínez

Endocarditis infecciosa

Colonización e invasión de las válvulas cardíacas o el endocardio mural por microorganismos, que produce formación de vegetaciones voluminosas y friables, compuestas de restos trombóticos y microorganismos, asociadas con destrucción de los tejidos cardíacos subyacentes.

o En la era actual la presentación suele ser aguda.

Etiología● S. aureus — 31 percent● Viridans group streptococci — 17 percent● Enterococci — 11 percent● Coagulase-negative staphylococci — 11 percent● Streptococcus bovis — 7 percent● Other streptococci — 5 percent● Non-HACEK gram-negative bacteria — 2 percent● Fungi — 2 percent● HACEK — 2 percent

Etiologíao La presencia de VIH no tiene impacto

general demostrado sobre los agentes que la causan.

o En 5 % los cultivos son negativos. 33-55% debido a exposición previa a antibióticos.

Patogeniao Presencia de daño endocárdicoo Agregado fibrionoplaquetarioo Invasión del microorganismo al

agregado fibrinoplaquetario.

Manifestaciones clínicas

Manchas Janeway

Manchas Roth

Nódulos de Osler

Manifestaciones clínicas

o Las petequias son la manifestaciones dérmicas más comunes; menos específicas

Petechiae in subacute bacterial endocarditis

Splinter hemorrhages in infective endocarditis

o Las lesiones de Janeway, nódulos de Osler y manchas de Roth son más especídicas, suelen presentarse más en los cuadros crónicos, por lo que actualmente son raros.

Las lesiones de Janeway son lesiones maculares, eritematosas, no dolorosas en palmas y plantas

o Los nódulos de Osler son dolorosos, violáceos, encontrados en purplejos en manos y pies y se observan más en los casos subagudos.

o Las manchas de Roth son lesiones hemorrágicas exudativas edematosas de la retina.

Diagnósticoo Se basa en la sospecha clínica, la

realización de hemocultivos o pruebas serológicas para gérmenes de cultivo dificultoso y en el estudio ecocardiográfico.

o Transesofágica 90%o Transtorácica 70% (endocarditis de

localización tricuspídea

Diagnósticoo Para el diagnóstico de las

endocarditis por Coxiella burnetii, Chlamydophila psittaci y Bartonella quintana es útil la serología; el diagnóstico de endocarditis por Legionella spp. requiere medios de cultivo muy especiales.

Criterios de Dukeo La documentación de dos criterios

mayores, un criterio mayor y tres menores o de cinco criterios menores ayuda a establecer diagnóstico.

Cultivoso Se deben de obtener al menos 3

series de cultivos.o Si se ha iniciado antibioticoterapia,

pueden requerirse más cultivos.o En presenaciones subagudas o

crónicas, si el paciente no está en estado crítico, se puede retrasar la antibioticoterapia hasta obtener cultivos y otros estudios diagnósticos

o En presentación aguda o paciente crítico se deben obtener 3 series de cultivos en menos de una hora e iniciar tratamiento empírico.

CultivosIn one series including 206 cases of endocarditis, the initial blood culture in patients with streptococcal endocarditis was positive in 96 percent of cases, and one of the first two blood cultures was positive in 98 percent. In patients with IE caused by organisms other than streptococcus, the first blood culture was positive in 82 percent of cases and one of the first two cultures was positive in 100 percent of cases.

Studies on the bacteremia of bacterial endocarditis.Werner AS, Cobbs CG, Kaye D, Hook

CultivosAgentes con cultivos negativosCoxiella burnetii• Brucella mellitensis• Grupo HACEK (gramnegativos)• Legionella pneumophila• Bartonella quintana y Bartonella henselae• Tropheryma whipplei• Chlamydophila psittaci• Hongos {Candida y Aspergillus)• Estreptococos nutricionalmente variantes (AbiotrophiayGranulicatella)

Estudios de laboratorioNo específicoso ↑ VSG, Prot. C reactivao Anemia normocítica normocrómicao En presentaciones subagudas de

endocarditis la WBC puede ser normal o elevada; la mayoría de los pacientes con endocarditis estafilocóccica tienen leucocitosis y algunos trombocitopenia.

o ●Hiperglobulinemia, crioglobulinemia, complejos inmunes circulantes, hipocomplementemia, títulos elevados de FR y falsos positivos en serología para sífilis pueden estar presentes.

Tratamientoo Suggested regimens for therapy of native valve endocarditis

due to penicillin-susceptible viridans streptococci and Streptococcus bovis (MIC ≤0.12 mcg/mL)

American Heart AssociationBritish Society for Antimicrobial Chemotherapy

European Society of Cardiology

Adult(for patients with normal renal function)

Pediatric(not to exceed dose of normal adult)

4-week regimens*: 4-week regimens: 4- to 6-week regimens: 4-week regimens¶:

Aqueous penicillin G 12 to 18 million units per 24 hours IV either continuously or in four or six equally divided dosesorCeftriaxone 2 g per 24 hours IV or IM in one doseorVancomycinΔ 30 mg/kg per 24 hours IV in two equally divided doses not to exceed 2 g per 24 hours unless concentrations in serum are inappropriately low

Aqueous penicillin G 200,000 units/kg per 24 hours IV in four or six equally divided dosesorCeftriaxone 100 mg/kg per 24 hours IV or IM in one doseorVancomycinΔ 40 mg/kg per 24 hours IV in two or three equally divided doses

Benzylpenicillin¥ 1.2 g every 4 hours IVorCeftriaxone 2 g per 24 hours IV/IM

Aqueous penicillin G* 12 to 18 million units per 24 hours IV in six equally divided dosesorAmoxicillin 100 to 200 mg/kg per 24 hours IV in four to six equally divided dosesorAmpicillin 12 g per 24 hours (or 100 to 200 mg/kg per 24 hours) IV in six equally divided dosesorCeftriaxone*‡ 2 g per 24 hours IV or IM in one doseorVancomycinΔ 30 mg/kg per 24 hours IV in two equally divided doses


due to strains of viridans streptococci and Streptococcus bovis relatively resistant to penicillin G (MIC >0.12 mcg/mL and ≤0.5 mcg/mL)*American Heart Association British Society for

Antimicrobial Chemotherapy

European Society of Cardiology¶



Either aqueous penicillin G 24 million units per 24 hours IV either continuously or in four or six equally divided doses for four weeksorCeftriaxone 2 g per 24 hours IV or IM in one dose for four weeksplusGentamicinΔ 3 mg/kg per 24 hours IV or IM in one dose or in two to three equally divided doses for two weeksorMonotherapy withVancomycin◊ 30 mg/kg per 24 hours IV in two equally divided doses for four weeks; not to exceed 2 g per 24 hours unless concentrations in serum are inappropriately low

Either aqueous penicillin G 300,000 units/kg per 24 hours IV in four or six equally divided doses for four weeksorCeftriaxone 100 mg/kg per 24 hours IV or IM in one dose for four weeksplusGentamicinΔ 3 mg/kg per 24 hours IV or IM in one dose or in three equally divided doses for two weeksorMonotherapy withVancomycin◊ 40 mg/kg per 24 hours IV in two or three equally divided doses for four weeks

Benzylpenicillin§ 2.4 g every 4 hours IV for four to six weeksplusGentamicin 1 mg/kg every 12 hours IV for two weeks

Either aqueous penicillin G 24 million units per 24 hours IV in six equally divided doses for four weeksorAmoxicillin 200 mg/kg per 24 hours IV in four or six equally divided doses for four weeksorAmpicillin 12 g per 24 hours (200 mg/kg per 24 hours) in six equally divided doses for four weeksorVancomycin◊ 30 mg/kg per 24 hours IV in two equally divided doses for four weeksplusGentamicinΔ 3 mg/kg per 24 hours IV or IM in one dose for first two weeks


due to enterococcal strains susceptible to penicillin, gentamicin, and vancomycinAmerican Heart Association British Society for


European Society of Cardiology*¶



GentamicinΔ 3 mg/kg per 24 hours IV or IM in three equally divided doses for four to six weeks◊

Plus one of the following◊:Aqueous penicillin G 18 to 30 million units per 24 hours IV either continuously or in six equally divided doses for four to six weeks◊

orAmpicillin 12 g per 24 hours IV in six equally divided doses for four to six weeks◊

orVancomycin§ 30 mg/kg per 24 hours IV in two equally divided doses for six weeks; not to exceed 2 g per 24 hours unless concentrations in serum are inappropriately low

GentamicinΔ 3 mg/kg per 24 hours IV or IM in three equally divided doses for four to six weeks◊

Plus one of the following:Aqueous penicillin G 300,000 units/kg per 24 hours IV in four to six equally divided doses for four to six weeks◊

orAmpicillin 300 mg/kg per 24 hours IV in four to six equally divided doses for four to six weeks◊

orVancomycin§ 40 mg/kg per 24 hours IV in two or three equally divided doses for six weeks

GentamicinΔ 1 mg/kg every 12 hours IV for four to six weeksPlus one of the following:Amoxicillin 2 g every four hours IV for four to six weeksorPenicillin 2.4 g every four hours IV for four to six weeksorVancomycin§ 1 g IV every 12 hours for four to six weeksorTeicoplanin¥ 10 mg/kg IV once every 24 hours for four to six weeks

GentamicinΔ 3 mg/kg per 24 hours IV or IM in two or three equally divided doses for four to six weeks◊

Plus one of the following:Amoxicillin 200 mg/kg per 24 hours IV in four to six equally divided doses for four to six weeks◊

orAmpicillin 12 g per 24 hours (200 mg/kg per 24 hours) IV in six equally divided doses for four to six weeks◊

orVancomycin§ 30 mg/kg per 24 hours IV in two equally divided doses for six weeks


due to enterococcal strains resistant to penicillin and susceptible to aminoglycoside and vancomycin

American Heart AssociationBritish Society for Antimicrobial Chemotherapy European Society of Cardiology*Adult

(for patients with normal renal function)


Beta-lactamase producing:One of the following:Gentamicin• 3 mg/kg per 24 hours IV or IM in three equally divided doses for six weeksplus eitherAmpicillin-sulbactamΔ 12 g per 24 hours IV in four equally divided doses for six weeksorVancomycin◊ 30 mg/kg per 24 hours IV in two equally divided doses for six weeks; not to exceed 2 g per 24 hours unless concentrations in serum are inappropriately low

Beta-lactamase producing:One of the following:Gentamicin• 3 mg/kg per 24 hours IV or IM in three equally divided doses for six weeksplus eitherAmpicillin-sulbactamΔ 300 mg/kg per 24 hours IV in four divided doses for six weeksorVancomycin◊ 40 mg/kg per 24 hours IV in two or three equally divided doses for six weeks

One of the following:Gentamicin¥ 1 mg/kg IV every 8 to 12 hours for ≥4 weeksplus eitherVancomycin◊ 1 g IV every 12 hours for ≥4 weeksorTeicoplanin‡ 10 mg/kg IV once daily for ≥4 weeks

Beta-lactamase producing:One of the following:Gentamicin• 3 mg/kg per 24 hours IV or IM in two or three equally divided doses for four to six weeks†

plus eitherAmpicillin-sulbactamΔ 12 g per 24 hours (or 300 mg/kg per 24 hours) IV in four equally divided doses for four to six weeks†

orAmoxicillin-clavulanateΔ 200 mg/kg (amoxicillin component) per 24 hours IV in six equally divided doses for four to six weeks†

orVancomycin◊ 30 mg/kg per 24 hours IV in two equally divided doses for six weeks

Intrinsic penicillin resistance§:Vancomycin◊ 30 mg/kg per 24 hours IV in two divided doses for six weeksplusGentamicin• 3 mg/kg per 24 hours IV or IM in three equally divided doses for six weeks

Intrinsic penicillin resistance§:Vancomycin◊ 40 mg/kg per 24 hours IV in two or three divided doses for six weeksplusGentamicin• 3 mg/kg per 24 hours IV or IM in three equally divided doses for six weeks

Intrinsic penicillin resistance§:Vancomycin◊ 30 mg/kg per 24 hours IV in two equally divided doses for six weeksplusGentamicin• 3 mg/kg per 24 hours IV or IM in two or three equally divided doses for six weeks

Tratamientoo Suggested regimens for therapy of native or prosthetic valve

endocarditis due to enterococcal strains resistant to penicillin, aminoglycoside, and vancomycin*

TratamientoAmerican Heart Association British Society for

Antimicrobial Chemotherapy European Society of Cardiology Adult (for patients with normal

renal function) Pediatric (not to exceed dose of normal adult)

E. faecium:One of the following:Linezolid• 1200 mg per 24 h IV or PO in 2 equally divided doses for ≥8 wksorQuinupristin-dalfopristinΔ 22.5 mg/kg per 24 h IV in 3 equally divided doses for ≥8 wks

E. faecium:One of the following:Linezolid• 30 mg/kg per 24 h IV or PO in 3 equally divided doses for ≥8 wksorQuinupristin-dalfopristinΔ 22.5 mg/kg per 24 h IV in 3 equally divided doses for ≥8 wks One of the following:

Linezolid• 1200 mg per 24 h IV or PO in 2 equally divided doses for ≥6 wksorQuinupristin-dalfopristinΔ 22.5 mg/kg per 24 h IV in 3 equally divided doses for ≥6 wksorTeicoplanin◊ 10 mg/kg IV once daily for ≥6 wksorCombinations of antibiotics according to in vitro susceptibility

E. faecium¥:Linezolid• 1200 mg per 24 h IV or PO in 2 equally divided doses for ≥ 8 wksorQuinupristin-dalfopristinΔ 22.5 mg/kg per 24 h IV in 3 equally divided doses for ≥8 wksorCombinations of antibiotics according to in vitro susceptibility‡E. faecalis§:Imipenem-cilastatin 2 g per 24 h (or 60-100 mg/kg per 24 h) IV in 4 equally divided doses for ≥8 wksplusAmpicillin 12 g per 24 h (or 300 mg/kg per 24 h) IV in 6 equally divided doses for ≥8 wksorCeftriaxone 2 g per 24 h (or 100 mg/kg per 24 h) IV or IM in 1 dose for ≥8 wksplusAmpicillin 12 g per 24 h (or 300 mg/kg per 24 h) IV in 6 equally divided doses for ≥8 wksorCombinations of antibiotics according to in vitro susceptibility‡

E. faecalis§:Imipenem-cilastatin 2 g per 24 h IV in 4 equally divided doses for ≥8 wksplusAmpicillin 12 g per 24 h IV in 6 equally divided doses for ≥8 wksorCeftriaxone 4 g per 24 h IV or IM in 2 equally divided doses for ≥8 wks†plusAmpicillin 12 g per 24 h IV in 6 equally divided doses for ≥8 wks

E. faecalis§:Imipenem-cilastatin 60-100 mg/kg per 24 h IV in 4 equally divided doses for ≥8 wksplusAmpicillin 300 mg/kg per 24 h IV in 4 to 6 equally divided doses for ≥8 wksorCeftriaxone 100 mg/kg per 24 h IV or IM in 2 equally divided doses for ≥8 wksplusAmpicillin 300 mg/kg per 24 h IV in 4 to 6 equally divided doses for ≥8 wks


due to staphylococcusAmerican Heart Association British Society for


European Society of Cardiology*



Oxacillin-susceptible strains•Δ

Oxacillin-susceptible strains• Methicillin-sensitive Methicillin-susceptible

strainsNafcillin or oxacillin 12 g per 24 h IV in 4 or 6 equally divided doses for 6 wks, plus optional addition of gentamicin◊ 3 mg/kg per 24 h IV or IM in 2 or 3 equally divided doses for 3 to 5 daysorCefazolin§ 6 g per 24 h IV in 3 equally divided doses for 6 wks, plus optional addition of gentamicin◊ 3 mg/kg per 24 h IV or IM in 2 or 3 equally divided doses for 3 to 5 days

Nafcillin or oxacillin 200 mg/kg per 24 h IV in 4 or 6 equally divided doses for 6 wks plus optional addition of gentamicin◊ 3 mg/kg per 24 h IV or IM in 3 equally divided doses for 3 to 5 daysorCefazolin§ 100 mg/kg per 24 h IV in 3 equally divided doses for 6 wks plus optional addition of gentamicin◊ 3 mg/kg per 24 h IV or IM in 3 equally divided doses for 3 to 5 days

Flucloxacillin 2 g IV every 4 to 6 hours for 4 wks

Oxacillin or cloxacillin or flucloxacillin 12 g per 24 h IV in 4-6 equally divided doses for 4 to 6 wks plus optional addition of gentamicin◊ 3 mg/kg per 24 h IV or IM divided in 2 or 3 doses for 3 to 5 daysorVancomycin¥ 30 mg/kg per 24 h IV in 2 equally divided doses for 4 to 6 wks plus optional addition of gentamicin◊ 3 mg/kg per 24 h IV or IM in 2 or 3 equally divided doses for 3 to 5 days

Oxacillin-resistant strains

Oxacillin-resistant strains Methicillin resistant Methicillin resistant

strainsVancomycin¥ 30 mg/kg per 24 h IV in 2 equally divided doses for 6 wks; not to exceed 2 g per 24 h unless concentrations in serum are inappropriately low

Vancomycin¥ 40 mg/kg per 24 h IV in 2 or 3 equally divided doses for 6 wks

Vancomycin¥ 1 g IV every 12 h for 4 wksplusRifampin 300 to 600 mg PO every 12 h for 4 wks

Vancomycin¥ 30 mg/kg per 24 h IV in 2 doses for 4 to 6 wks plus optional addition of gentamicin◊ 3 mg/kg per 24 h IV or IM in 2 or 3 equally divided doses for 3 to 5 days


due to HACEK* microorganismAmerican Heart Association

British Society for Antimicrobial Chemotherapy

European Society of Cardiology Adult (for patients with

normal renal function) Pediatric (not to exceed dose of normal adult)

One of the following:Ceftriaxone• 2 g per 24 h IV or IM in 1 dose for 4 wksorAmpicillin-sulbactam 12 g per 24 h IV in 4 equally divided doses for 4 wksorCiprofloxacin§ 1000 mg per 24 h PO or 800 mg per 24 h IV in 2 equally divided doses for 4 wks

One of the following:Ceftriaxone• 100 mg/kg per 24 h IV or IM in 1 dose for 4 wksorAmpicillin-sulbactam 300 mg/kg per 24 h IV in 4 equally divided doses doses for 4 wksorCiprofloxacin§ 20-30 mg/kg per 24 h IV or PO in 2 equally divided doses for 4 wks

EitherAmpicillinΔ 2 g IV every 4 to 6 h for 4 wksorCeftriaxone• 2 to 4 g per 24 h IV or IM in 1 dose for 4 wksplusGentamicin◊ 1 mg/kg IV every 8 to 12 h for 2 wks

One of the following:Ceftriaxone• 2 g per 24 h IV or IM in 1 dose for 4 wksorCombination therapy with: ampicillinΔ 12 g per 24 h IV in 4 or 6 equally divided doses plus gentamicin◊ 3 mg/kg per 24 h IV or IM in 2 or 3 equally divided doses for 4 wksorCiprofloxacin§ 1000 mg per 24 h PO or 800 mg per 24 h IV in 2 equally divided doses for 4 wks

Tratamientoo Suggested regimens for therapy of culture-negative native

valve endocarditisAmerican Heart AssociationBritish Cardiac Society European Society of

CardiologyAdult(for patients with normal renal function)


One of the following:Ampicillin-sulbactam 12 g per 24 h IV in 4 equally divided doses for 4-6 wksplusGentamicin sulfateΔ 3 mg/kg per 24 h IV or IM in 3 equally divided doses for 4-6 wksORVancomycin• 30 mg/kg per 24 h IV in 2 equally divided doses for 4-6 wks; not to exceed 2 g per 24 h unless concentrations in serum are inappropriately lowplusGentamicinΔ 3 mg/kg per 24 h IV or IM in 3 equally divided doses for 4-6 wksplusCiprofloxacin 1000 mg per 24 h PO or 800 mg per 24 h IV in 2 equally divided doses for 4 to 6 wks

One of the following:Ampicillin-sulbactam 300 mg/kg per 24 h IV in 4 or 6 equally divided doses for 4-6 wksplusGentamicinΔ 3 mg/kg per 24 h IV or IM in 3 equally divided doses for 4-6 wksORVancomycin• 40 mg/kg per 24 h IV in 2 or 3 equally divided doses for 4-6 wksplusGentamicinΔ 3 mg/kg per 24 h IV or IM in 3 equally divided doses for 4-6 wksplusCiprofloxacin◊ 20-30 mg/kg per 24 h IV or PO in 2 equally divided doses for 4 to 6 wks

Vancomycin• 15 mg/kg IV every 12 h for 6 wksplusGentamicin 3-5 mg/kg IV or IM per 24 h in 2 or 3 equally divided doses for 2 wks

Ampicillin-sulbactam or amoxicillin-clavulanate 12 g per 24 h IV in 4 equally divided doses for 4-6 weeksplusGentamicinΔ 3 mg/kg per 24 h IV or IM in 2 or 3 equally divided doses for 4-6 weeksORVancomycin• 30 mg/kg per 24 h IV in 2 equally divided doses for 4-6 wksplusGentamicinΔ 3 mg/kg per 24 h IV or IM in 2 or 3 equally divided doses for 4-6 wksplusCiprofloxacin◊§ 1000 mg PO or 800 mg IV in 2 equally divided doses for 4-6 wks

Tratamientoo Suggested regimens for therapy of prosthetic valve

endocarditis due to Staphylococcus

American Heart AssociationEuropean Society of CardiologyAdult

(for patients with normal renal function)


Oxacillin-susceptible strains Oxacillin-susceptible strains Methicillin-susceptible strainsOne of the following:Nafcillin or oxacillin* 12 g per 24 hours IV in six equally divided doses for ≥6 weeksorCefazolin◊ 6 g per 24 hours IV in three equally divided doses for ≥6 weeksorVancomycin§¥ 30 mg/kg per 24 hours IV in two equally divided doses for ≥6 weeksplusRifampin 900 mg per 24 hours IV or orally in three equally divided doses for ≥6 weeksplusGentamicin‡ 3 mg/kg per 24 hours IV or IM in two or three equally divided doses for 2 weeks

One of the following:Nafcillin or oxacillin* 200 mg/kg per 24 hours IV in four or six equally divided doses for ≥6 weeksorCefazolin◊ 100 mg/kg per 24 hours IV in three equally divided doses for ≥6 weeksorVancomycin§¥ 40 mg/kg per 24 hours IV in two or three equally divided doses for ≥6 weeksplusRifampin 20 mg/kg per 24 hours IV or orally in three equally divided doses for ≥6 weeksplusGentamicin‡ 3 mg/kg per 24 hours IV or IM in three equally divided doses for 2 weeks

One of the following:Oxacillin or cloxacillin or flucloxacillin 12 g per 24 hours IV in four to six equally divided doses for ≥6 weeksorVancomycin§ 30 mg/kg per 24 hours IV in two equally divided doses for ≥6 weeksplusRifampinΔ 1200 mg per 24 hours IV or orally in two equally divided doses for ≥6 weeksplusGentamicin¶ 3 mg/kg per 24 hours IV or IM in two or three equally divided doses for the first 2 weeks

Oxacillin-resistant strains Oxacillin-resistant strains Methicillin resistant strainsVancomycin¥ 30 mg/kg per 24 hours IV in two equally divided doses for ≥6 weeksplusRifampin 900 mg per 24 hours IV or orally in three equally divided doses for ≥6 weeksplusGentamicin‡ 3 mg/kg per 24 hours IV or IM in two or three equally divided doses for 2 weeks

Vancomycin¥ 40 mg/kg per 24 hours IV in two or three equally divided doses for ≥6 weeksplusRifampin 20 mg/kg per 24 hours IV or orally in three equally divided doses for≥6 weeksplusGentamicin‡ 3 mg/kg per 24 hours IV or IM in three equally divided doses for 2 weeks

Vancomycin¥ 30 mg/kg per 24 hours IV in two equally divided doses for ≥6 weeksplusRifampinΔ 1200 mg per 24 hours IV or orally in divided doses for ≥6 weeksplusGentamicin¶ 3 mg/kg per 24 hours IV or IM in three equally divided doses for first 2 weeks

Endocarditis infecciosa

Health & Medicine

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