Prosthetic Valve Infective Endocarditis. Tat Yam Department of Infection Southampton University Hospitals NHS TRust

Transcription

1 Prosthetic Valve Infective Endocarditis Tat Yam Department of Infection Southampton University Hospitals NHS TRust

2 Case History: Episode 1 in MB 73 yr old male, Nigerian PMHx: Hypertension Congestive cardiac failure TURP April 2009 at DGH X with suprapubic urinary catheter situ because of traumatic transurethral catheterisation Suprapubic catheter replaced in Aug 2009 Enterococci in CSU Aug 2009 but antibiotic not given Last travel to Nigeria May /09/09 Admitted to local DGH Y c/o intermittent pyrexia and wt loss >10kg since TURP and 2 weeks h/o progressive dyspnoea; 1 splinter haemorrhage in thumb nail

3 o/e Temp 38.3C; O2 sat 94% on air, RR 25 WCC 16.2; ESR 79 bibasal pleural effusion??diastolic murmur Investigations: Blood cultures X 3 USS liver ECHO Urinary pneumococcal antigen Blood film for malaria HIV, Hep B & C Sputum for MC+S and AFBs Resp review How would you manage this patient at this stage?

4 Initial treatment: IV Benzyl penicillin 1.2 G qds and oral doxycycline 11/09/09 Streptococci in blood culture reported Would you change the initial treatment?

5 11/09/09 Changed to IV benzyl penicillin 1.2G 4hrly 12/09/09 Identified as Enterococcus faecalis in all 6 bottles of BCs Would you change the current antibiotic regimen?

6 12/09/09 Enterococcus faecalis in all 6 bottles of BCs (penicillin mic 1.0; amoxicillin mic 0.5) Switched to iv amoxicillin 2G 4hrly and iv gentamicin 1mg/kg (70mg) bd 17/09/09 Unsuccessful attempt of TOE due to cricoid spasm TTE showed severe AR and severe MR with rupture of chordae; large vegetations on AMVL & NCC of AoV; Highly suspicious of aortic root abscess

7 21/09/09 Transferred to regional cardiac centre due to worsening cardiac function and pulmonary oedema 25/09/09 tavr, tmvr, TV repair, reconstruction of aorto mitral fibrous skeleton, LA roof repair with 2 bovine patches Findings: Aortic noncoronary cusp completely destroyed and ruptured into ventricle; Vegetations present in other 2 leaflets; One large and one smaller hole with vegetations in aorto mitral fibrous curtain; Vegetations in both anterior and posterior leaflet of mitral valve. Culture of tissue & valves: no growth

8 28/09/09 Day 3 post op Pyrexia 38.5 C Anuric and septic with VAP Blood cultures & ETA sent CXR bibasal collapse and consolidation How would you manage the patient now in terms of antibiotic treatment?

9 28/09/09 Amoxicillin and gent dose reduced IV ciprofloxacin for 5 days Blood cultures no growth; coliforms (NLF) in ETA Both mitral and aortic valve cultures negative 01/10/09 Extubated; ciprofloxacin stopped For 4 weeks of iv amoxicillin and gent post op T/F back to DGH Y; CRP 29 on 26/10/09

10 Note: No records of any extra surgical prophylaxis given apart from treatment regimen of iv amoxicillin and gentamicin Should prophylaxis have been given? If so, which agents?

11 Episode 2 18/01/10 Readmitted to DGH Y with increasing SOBOE, coughing up frothy phlegm Bilateral pleural effusion 19/01/10 TTE: MV dehiscence Blood cultures taken

12 22/01/10 (Friday) 7 out of 8 BC bottles yielded Staph epidermidis (MSSE) Was to start high dose iv flucloxacillin (but did not happen) 23/09/10 (in early hours) T/F regional cardiac centre on no antibiotics Further BCs taken and started on iv vancomycin and gentamicin empirically on micro advice 25/01/10 (Monday) Initial BC results received from DGH Sens to meticillin (oxacillin mic 0.19 e test) and vancomycin Resistant to fusidic acid, gentamicin (mic 8.0) and rifampicin; temp 38.3; CRP climbing Further 4 out of 6 BCs bottles taken on 23/09 now positive Based on this information, would you change antibiotic treatment?

13 25/01/10 (Monday) Switched iv vancomycin to high dose iv flucloxacillin 27/01/10 Further blood cultures yielded heterogenous Staph epidermidis Ox resist mic >256, Gent mic 16 Isolate from initial BCs retested and confirmed Ox resistance. Switched back to iv vancomycin and gentamicin 28/01/10 Redo AVR & MVR, reconstruction to LA/aorta (9.5 hours long) False aneurysm between aorta and LA Same Staph epidermidis isolated from AV and tissue

14 S. epidermidis Hosp Y Isolate 1 Isolate 2 MV tissue BC 19/01 BC 23/01 BC 23/01 28/01/10 Fluclox R; >256 R; >256 R; >256 R Erythro R S R R Vanc S; 0.75 S; 1.0 S; 1.5 S Teico S S S S Gent R; 8.0 R R R Rifamp R R R R Fusidic R R R R Doxy R R R R Cipro R R R R Dapto 0.19

15 15/02/10 Good post op recovery. PPM inserted for CHB. CRP 14 In view of the presence of large amount of prosthesis (double tissue valves & two bovine patches); presence of viable organism at the time of redo surgery, what is your long term treatment plan?

16 15/02/10 Good post op recovery. PPM inserted for CHB. CRP 14 28/02/10 Discharge back to DGH Y to complete a total of 8 weeks iv vancomycin and gentamicin post op; CRP 4 Aim vancomycin pre dose level 15 20mg/l Followed by 3 mth of po doxy 100mg bd and R/V 20/04/10 R/V at Cardiac OP No issues. TTE satisfactory

17 Note: It was only revealed in later discussion that there was MRSE in 1 out of 7 sets of blood cultures at DGH Y. This piece of information was not passed on at the first instance.

18 Episode 3 19/05/10 Admitted to local DGH Y with 1wk h/o SOBOE, malaise, Several splinter haemorrhages both thumb nails, bilateral pleural effusion, WCC 13, ESR 48, CRP 70 Levofloxacin by GP Still on po doxy 100mg bd; started on empiric iv vanc and gent T/F regional cardiac centre 20/05/10 What is your empirical treatment of choice?

19 Started on empiric iv vanc and gent 25/05/10 Low grade temp 37.5C, CRP 136, WCC 14.6 Heterogenous coagulase negative staph in BCs taken on 19, 20, 21/05 Vanc pre dose level 22.7,?treatment failure What would you do with antibiotic treatment?

20 25/05/10 Switched to iv vanc and gent to iv daptomycin 500mg (~6mg/kg) od 26/05/10 TTE: severe mitral dehisence with vegetations plus aortic paravalvular leak 27/05/10 Vanc mic 4.0; gent mic 16.0; dapto mic 0.5 CRP still high 144. Increased dapto to 850mg (~10mg/kg) od Note: surgeon in charge of this case was on annual leave at this time.

21 03/06/10 CRP 237; deranged LFTs, bili 78, Alk phos 291, ALT 354?On going sepsis/ie;?antibiotic related. Iv daptomycin reduced back to 500mg od Surgery cancelled 16/06/10 CRP 68; bili 94, Alk phos 80, ALT 48 Still on iv daptomycin 500mg od 2 nd redo AVR, MVR and reconstruction of LA/Aortic root (11 hours) Same Staph epidermidis isolated from both valves and patch Multi system failure developed. RIP on 17/06/10

22 Anything could have been done differently? Surgical prophylaxis Timing of antibiotics Choice of antibiotics Dosing of antibiotics Timing of surgical intervention Methodology of sensitivity testing Disc method vs breakpoint vs Vitek Baddour et al., AHA Infective endocarditis treatment guidelines