Infective endocarditis refers to an infection in the lining of the heart but also affects the valves. It often affects the muscles of the heart.

1. ‫الرحیم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬

2. INFECTIVE
ENDOCARIDITIS
Prepare By: Dr.Mohebullah Faqiri

3. ETIOPATHOGENESIS
(rapid flow+injury of the
Endocardium+bateremia)
Surgical shunt(blalock tausing s)
CHD(PDA,pul ste,vsd)
RHD(Mitral and Aortic veg)
Prothetic valve/cardiac surgry
Others side of the body infection
prodcedure

4. PATHOGENESISE
•Microbs load ,count
•VSD
•AS/A Coartation
•AR
•Prothetic Valve/Cardaic surgry
+procedure,infection center=

5. PATHOGENESIS

6. CONT…
•Modes of endothelial injury
•High velocity jet
•Flow from high pressure to low pressure
chamber
•Flow across narrow orifice of high velocity

7. Variable in size
Amorphous mass of fibrin &
platelets
Abundant organisms
Few inflammatory cells
vegitation

11. EPIDEMIOLOGY
• 1.7 to 6.2 cases per 100,000 population per year in US
• 3 to 6% at 5 years; the risk is greatest during the first 6
months after valve replacement.
• Men predominate in most case series, with male-to-
female ratios ranging from 2:1 to 9:1

12. RISK FACTORS FOR IE
• Structural heart disease
–Rheumatic, congenital HD, 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

13. THE CAUSITVE ORGANISM OF IE
•Viridans Streptococci
•Enterococcus
•Staphylococci
•Gm Negative organisms
•Fungi
•Other Organisms

14. VIRIDANS STREPTOCOCCI
•30-65% of native valve endocarditis
•Normal oral commensals
•A group, composed of several species:
•S. mitior, S. sanguis, S. mutans,etc.
•Alpha-hemolytic, non-typable

15. ENTEROCOCCUS
•Normal inhabitant of GI tract.
•Frequently encountered in UTIs.
•Difficult to treat due to drug resistance.

16. STAPHYLOCOCCI
• Coagulase Positive (Staph. aureus)
• a major causative agent in all populations of IE
• typically produces “acute” IE
• fulminant, rapidly progressive with few
immunologic signs.
• CNS complications in 30-50%
• Coagulase Negative (Staph. Epi)
• cause 3-8% IE

17. GM NEGATIVE ORGANISMS
•Gram negative inhabitants of the upper
airways.
•Large vegetations, high likelihood of
embolization.

18. OTHER ORGANISMS
• Pseudomonas
• Diphtheroids
• Listeria
• Bartonella
• Coxiella,Legionella,salmonella,brucella
• Chlamydia,Abiotropia
• Bartonella ,tropheryma, streptobacillus

19. FUNGI
• Commonly encountered agents:
–Candida, Blastomycis,coccidomycis, Aspergillus
• Predispositions
–Prosthetic valves
–IVDA(iv Drug Abuse)
–Immunosupression
–Hyperalimentation
–Prolonged antibiotic treatment
• Large vegetations and frequent embolic events.

20. PROSTHETIC VALVE IE
• Affects 3% of prosthesis patients.
• Highest risk in first 6 months post op.
• Accounts for 10-20% of all IE cases.
• Increased risk in…
• Males
• Blacks
• Multiple valve replacement

21. IV DRUG USERS
•Accounts for 25% of cases of
IE in US.
•5:1 male:female
•Pre-existing valvular diseases
uncommon.
•Variable microbiology.
AV
6%
MV
24%
TV
70%

22. LABORATORY TEST
•Culture
•CBC
•Urine

23. BLOOD CULTURE
• Blood culture sterile in 31 % (western data)
• Sterile culture in India – 48 to 54 %
• Blood culture is positive only on 67.7% of the cases in
recently published data from India

25. 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
infection
Cardiac
involvement
Immunological
Response

26. CONT…
• Fever is the most common symptom and sign in patients with IE.
Fever may be absent or minimal in
• elderly
• in those with CHF,
• severe debility,
• chronic renal failure

27. CARDIAC MURMUR
• New changing regurgitant murmur is the hallmark of IE
• Murmurs are heard in only 30 to 45 percent of
patients on initial evaluation but are ultimately noted
in 75 to 85 percent.

28. CARDIAC PATHOLOGIC CHANGES
•Destruction and perforation of valve leaflet
•Rupture of chordae tendinae, intraventricular
septum, papillary muscles
•Valve ring abscess
•Myocardial abscess
•Conduction abnormalities

29. S. Aureus mitral valve vegetation, anterior leaflet

30. PATHOLOGIC CHANGES IN DIFFERENT ORGANS
•Kidney
•Immune complex glomerulonephritis
•MP GN
•Emboli with infarction, abscess

31. PATHOLOGIC CHANGES
• Splenic
•splenic enlargement, infarction
•lung
• Septic or bland pulmonary embolism,Pnemonitis,lung abscess
•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

32. MUSCULOSKELETAL
•Vertebral osteomyelitis - rare.
• Osteomyelitis -S. aureus endocarditis
•Acute septic arthritis

33. 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

34. 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

35. JANEWAY LESIONS
1. More specific
2. Erythematous, blanching macules
3. Nonpainful
4. Located on palms and soles

36. ROTH SPOTS

37. DUKE’S V/S MODIFIED DUKES
•Duke’s sensitivity -76 % in western
•Major deficiency is inability to diagnose BCNE
•Major additions in modified dukes includes Q fever serology,
staphylococcal bacteremia in the absence of other primary focus as major criteria,
serological evidence of other organism consistent with endocarditis as minor
criteria.

38. MODIFIED DUKE CRITERIA

39. Two major criteria,
OR
One major and three minor criteria,
OR
Five minor criteria allows a clinical
diagnosis of definite endocarditis.

40. BLOOD CULTURES
• MULTIPLE BLOOD CULTURES BEFORE EMPIRIC THERAPY
• If not critically ill
• 3 blood cultures over 12-24 hour period
• ? Delay therapy until diagnosis confirmed
• If critically ill
• 3 blood cultures over one hour
• No more than 2 from same venepuncture
• Relatively constant bacteremia

41. USE OF ECHO IN DIAGNOSIS OF IE
• Native Valves-ACC Guidelines:
• Detection/characterization of valvular lesions
• Detection of vegetations and characterization of
lesions in patients with CHD
• Detection of associated abnormalities
• Evaluation of patients with high suspicion of culture-
negative IE

42. USE OF ECHO IN DIAGNOSIS OF IE
• It detect the Chordae rapture and flail cusp
• Vegatation more than 2mm size
• Aorta 90%
• Pul and Tri capsid 70%
• Detection/characterisation of valvular lesions
• Detection of associated abnormalities
• Evaluation of suspected IE and negative cultures
• Evaluation of persistent fever without known source

43. TYPICAL ECHO FEATURES
• vegitaion
• Abscess
• New partial dehiscence(open of injury) of prosthetic
valve
• New valvular regurgitation

44. USE OF ECHO IN DIAGNOSIS OF IE
• TEE:
• Can detect structure up to 1 mm
• Prosthetic valves
• Poor visualization on TTE and high suspicion
• Detection of associated complications
• Preoperative

45. OTHER TESTS
• Electrocardiogram
• Conduction delays
• Ischemia or infarction
• Chest X-ray
• Septic emboli in right-sided IE
• Valve calcification
• CHF

46. SEROLOGY IN IE
• Serology
• Coxiella burnetii – endocarditis presents only during
chronic infection with coxiella
• Bartonella
• Brucella
• Legionella
• Chlamydophila

47. MOLECULAR DIAGNOSTIC TECHNIQUES
IN IE
• PCR
• RT PCR
• Proteomics ( protein signatures of the organism used to
identify the pathogens)

48. TREATMENT OF IE
•Determine the Causative organism
•Determine the antibiotic sensitivity
•Initiation of proper antibiotics
•Eradication of bacteria in the vegetation

49. 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

50. FUNGAL ENDOCARDITIS
•5-Flucysten +Amotericine B prior to sugry
2-3wks
After surgry of the Vegitaion should be use
for 6wk

51. ANTI BIOTIC THERAPY
• Strep v: pecilline+AA Ceftriaxone+AA 4Wk
• G A Stre: pencilline+AA Cefriaxone+AA 4wk
• Strep Fecalis Ampi+AA Vonco+AA 4-6wk
• Stap Aures Claoxa+Cefazoline Vonco+AA 6wk
• E-Coli Ceftria+AA Ampi+AA 6wk
• Pseudomonas Ticara+AA Mero+AA 6wk
• Culture Neg Ampi+AA Ampi+AA 6wk

52. PROPHYLAXIS
• Dental procedure
• Pencilline 2gr one hour prior to the procedure,05gr daily 6hourly for
3days
• Pecilline Crytal 1000,000iu+
• Procain pencilline 600,000
• Amoxicilline 50mg/kg/day Single dose one hour prior to the dental
procedure

53. PROSTHETIC VALVE
•Ampicilline+Gentamycine or
Streptomycine 0ne hour prior to Dental
procedure

54. GENITOURINARY PROCEDURE
•Amoxil 25mg/kg(Ihr prior) +Gentamycine 2mg
IM(0.5hr prior)
•During Gastrointestinal Surgy Metronidazol also
added

55. •Refferences:
•Ghai 8 edition
•Internet

56. Thanks