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Infective endocarditis


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Infective endocarditis

  2. 2. Definition Infective endocarditis (IE) is defined as an infection of the endocardial surface of the heart, which may include one or more heart valves, the mural endocardium, or a septal defect. Its intracardiac effects include severe valvular insufficiency, which may lead to intractable congestive heart failure and myocardial abscesses. If left untreated, IE is generally fatal.(medscape)
  3. 3. Infective endocarditis (IE) is a microbial infection of the endothelial surface of the heart or iatrogenic foreign bodies like prosthetic valves or other intracardiac devices
  4. 4. Types Native valve endocarditis (NVE), acute and subacute Prosthetic valve endocarditis (PVE),[10] early and late Intravenous drug abuse (IVDA) endocarditis
  5. 5. •Risk factors •Structural heart disease –Rheumatic, congenital, aging –Prosthetic heart valves •Injected drug use •Invasive procedures (Intracardiac pacemaker, ICD , AV Fistula) •Indwelling vascular devices •Other infection with bacteremia (e.g. pneumonia, meningitis) •Immunocompromised states •History of infective endocarditis
  6. 6. Bacterial Staphylococcus aureus followed by Streptococci of the viridans group and Coagulase negativ Staphylococci are the three most common organisms responsible for infective endocarditis. Other Streptococci and Enterococci ar e also a frequent cause of infective endocarditis.
  7. 7. Fungal and Viral Candida albicans, a yeast, is associated with endocarditis in IV drug users and immunocompromised patients. Other fungi demonstrated to cause endocarditis are Histoplasma capsulatum and Aspergillus
  8. 8. HACEK organisms Hemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella
  9. 9. Nonbacterial Thrombotic Endocarditis Endothelial injury Hypercoagulable state Lesions seen at coaptation points of valves Atrial surface mitral/tricuspid Ventricular surface aortic/pulmonic
  10. 10. Clinical features •Symptoms –Fever, sweats, chills –Anorexia, malaise, weight loss •Signs –Anemia (normochromic, normocytic) –Splenomegaly –Microscopic hematuria, proteinuria –New or changing heart murmur, CHF –Embolic or immunologic dermatologic signs –Hypergammaglobulinemia, elevated ESR, CRP, RF
  11. 11. Cardiac Pathologic Changes  Vegetations on valve closure lines  Destruction and perforation of valve leaflet  Rupture of chordae tendinae, intraventricular septum, papillary muscles  Valve ring abscess  Myocardial abscess  Conduction abnormalities
  12. 12. S. Aureus mitral valve vegetation, anterior leaflet
  13. 13.  Pathologic Changes  Kidney ◦ Immune complex glomerulonephritis ◦ Emboli with infarction, abscess  Aortic mycotic aneurysms
  14. 14. Pathologic Changes  Splenic enlargement, infarction  Septic or bland pulmonary embolism  Skin ◦ Petechiae ◦ Osler nodes: diffuse infiltrate of neutrophils, and monocytes in the dermal vessels with immune complex deposition. Tender and erythematous ◦ Janeway lesions: septic emboli with bacteria, neutrophils and S/C hemorrhage and necrosis. Blanching and non-tender. Palms and soles
  15. 15. Splinter Hemorrhages 1. Nonspecific 2. Nonblanching 3. Linear reddish-brown lesions found under the nail bed 4. Usually do NOT extend the entire length of the nail
  16. 16. Osler’s Nodes 1. More specific 2. Painful and erythematous nodules 3. Located on pulp of fingers and toes 4. More common in subacute IE
  17. 17. Janeway Lesions 1. More specific 2. Erythematous, blanching macules 3. Nonpainful 4. Located on palms and soles
  18. 18. Roth spots
  19. 19. Modified Duke Criteria
  20. 20. Two major criteria, OR One major and three minor criteria, OR Five minor criteria allows a clinical diagnosis of definite endocarditis.
  21. 21. Other tests  Electrocardiogram ◦ Conduction delays ◦ Ischemia or infarction  Chest X-ray ◦ Septic emboli in right-sided IE ◦ Valve calcification ◦ CHF
  22. 22. Antimicrobial Therapy  Blood culture become sterile within 2 days  Fever resolves in 4 to 7 days  If fever persists despite 7 days of antibiotics evaluate for paravalvular or extracardiac abscess  Combination therapy most important for ◦ Shorter course regimens ◦ Enterococcal endocarditis ◦ Prosthetic valve infections
  23. 23. Streptococci susceptible to pencillin
  24. 24. NVE  Fungal ◦ Amphotericin ◦ Fluconazole ◦ Caspofungin, little data ◦ Surgery usually necessary 1-2 weeks into treatment