Infective endocarditis[1] (2)

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Infective endocarditis[1] (2)

  1. 1. Infective Endocarditis DR MOHAMMAD ALI KHALID, Assistant professor of medicine, RMC and allied teaching hospitals.
  2. 2. Definition Infectious Endocarditis (IE): an infection of the heart’s endocardial surface Classified into four groups: – Native Valve IE – Prosthetic Valve IE – Intravenous drug abuse (IVDA) IE – Nosocomial IE
  3. 3. HIGHLIGHTS Fever. Murmer. Worsening of valve dysfunction. Heart failure? Vegetations seen on echocardiography. Systemic manifestations. Positive blood cultures.
  4. 4. Further Classification Acute – Affects normal heart valves – Rapidly destructive – Metastatic foci – Commonly Staph. – If not treated, usually fatal within 6 weeks Subacute – Often affects damaged heart valves – Indolent nature – If not treated, usually fatal by one year
  5. 5. Pathophysiology 1. Turbulent blood flow disrupts the endocardium making it “sticky” 2. Bacteremia delivers the organisms to the endocardial surface 3. Adherence of the organisms to the endocardial surface 4. Eventual invasion of the valvular leaflets
  6. 6. Epidemiology Incidence difficult to ascertain and varies according to location Much more common in males than in females May occur in persons of any age and increasingly common in elderly Mortality ranges from 20-30%
  7. 7. Risk Factors Intravenous drug abuse Artificial heart valves and pacemakers Acquired heart defects – Calcific aortic stenosis – Mitral valve prolapse with regurgitation Congenital heart defects Intravascular catheters
  8. 8. Infecting Organisms Common bacteria – S. aureus – Streptococci – Enterococci Not so common bacteria – Fungi – Pseudomonas – HACEK
  9. 9. HACEK Haemophilis parainfluenzae Actinobacillus Cardiobacterium Eikenella Kingella
  10. 10. Symptoms Acute – High grade fever and chills – SOB – Arthralgias/ myalgias – Abdominal pain – Pleuritic chest pain – Back pain Subacute – – – – – – – Low grade fever Anorexia Weight loss Fatigue Arthralgias/ myalgias Abdominal pain N/V The onset of symptoms is usually ~2 weeks or less from the initiating bacteremia
  11. 11. HISTORY Rhuematic fever Valve surgery or repair Fever SOB Arthralgias Embolic phenomenon Fatigue,dizziness,palpitations.
  12. 12. Signs Fever . Heart murmur. Nonspecific signs – petechiae, subungal or “splinter” hemorrhages, clubbing, splenomegaly, neurologic changes. More specific signs - Osler’s Nodes, Janeway lesions, and Roth Spots. Features particular to a specific valve.
  13. 13. Petechiae 1. Nonspecific 2. Often located on extremities or mucous membranes dermatology.about.com/.../ blpetechiaephoto.htm Photo credit, Josh Fierer, M.D. medicine.ucsd.edu/clinicalimg/ Eye-Petechiae.html Harden Library for the Health Sciences www.lib.uiowa.edu/ hardin/ md/cdc/3184.html
  14. 14. 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
  15. 15. Osler’s Nodes American College of Rheumatology webrheum.bham.ac.uk/.../ default/pages/3b5.htm www.meddean.luc.edu/.../ Hand10/Hand10dx.html 1. More specific 2. Painful and erythematous nodules 3. Located on pulp of fingers and toes 4. More common in subacute IE
  16. 16. Janeway Lesions 1. More specific 2. Erythematous, blanching macules 3. Nonpainful 4. Located on palms and soles
  17. 17. The Essential Blood Test Blood Cultures – – – Minimum of three blood cultures1 Three separate venipuncture sites Obtain 10-20mL in adults and 0.5-5mL in children2 Positive Result – Typical organisms present in at least 2 separate samples – Persistently positive blood culture (atypical organisms) Two positive blood cultures obtained at least 12 hours apart Three or a more positive blood cultures in which the first and last samples were collected at least one hour apart
  18. 18. Additional Labs CBC ESR and CRP Complement levels (C3, C4,) RF Urinalysis Baseline chemistry
  19. 19. Imaging Chest x-ray – Look for multiple focal infiltrates and calcification of heart valves EKG – Rarely diagnostic – Look for evidence of ischemia, conduction delay, and arrhythmias Echocardiography
  20. 20. Indications for Echocardiography Transthoracic echocardiography (TTE) – First line if suspected IE – Native valves Transesophageal echocardiography (TEE) – Prosthetic valves – Intracardiac complications – Inadequate TTE – Fungal or S. aureus or bacteremia
  21. 21. Making the Diagnosis Pelletier and Petersdorf criteria (1977) – Classification scheme of definite, probable, and possible IE – Reasonably specific but lacked sensitivity Von Reyn criteria (1981) – Added “rejected” as a category – Added more clinical criteria – Improved specificity and clinical utility Duke criteria (1994) – Included the role of echocardiography in diagnosis – Added IVDA as a “predisposing heart condition”
  22. 22. DUKE CRITERIA MAJOR Positve cultures Positive echo New valvular regurgitation MINOR IV drug abuser Heart disease Fever>38 C Minor echo findings(eg deformed valve but no vegetation)
  23. 23. MAJOR MINOR Vascular embolic events like janeway lesions septic pul infarcts arterial emboli. Immunological events osler nodes Roth spots GN Enlarged spleen
  24. 24. Modified Duke Criteria Definite IE – Microorganism (via culture or histology) in a valvular vegetation, embolized vegetation, or intracardiac abscess – Histologic evidence of vegetation or intracardiac abscess Possible IE – – – 2 major 1 major and 3 minor 5 minor Rejected IE – Resolution of illness with four days or less of antibiotics
  25. 25. Treatment Parenteral antibiotics – High serum concentrations to penetrate vegetations – Prolonged treatment to kill dormant bacteria clustered in vegetations Surgery – Intracardiac complications Surveillance blood cultures
  26. 26. ANTIBIOTICS Recommended Benzyl penicillin 2-4 mu QID for 2-6 wks Gentamycin 1-2mg/kg TDS for 2-6 wks. Alternatively Ceftriaxone 1 -2 gm BD Vancomycin 15mg/kg BD Piperacillin 2-4 gmQID Imepeum 250 mg QID Cefotaxime 2gm BD
  27. 27. FUNGAL Amphoterecin B 1mg/kg QID 2 wks max upto 4 wks. Donot exceed 50mg/day Flucytocine 150mg/kg oral for four days
  28. 28. Caution Highly toxic Liver and kidneys Valve replacement mandatory after 2wks therapy with amphoterecin therapy. Monitor drug levels according to manufacturers guidelines.
  29. 29. Complications Four etiologies – Embolic – Local spread of infection – Metastatic spread of infection – Formation of immune complexes – glomerulonephritis and arthritis
  30. 30. Embolic Complications Occur in up to 40% of patients with IE Predictors of embolization – Size of vegetation – Left-sided vegetations – Fungal pathogens, S. aureus, and Strep. Bovis Incidence decreases significantly after initiation of effective antibiotics
  31. 31. Embolic Complications Stroke Myocardial Infarction – Fragments of valvular vegetation or vegetation-induced stenosis of coronary ostia Ischemic limbs Hypoxia from pulmonary emboli Abdominal pain (splenic or renal infarction)
  32. 32. Septic Pulmonary Emboli http://www.emedicine.com/emerg/topic164.htm
  33. 33. Septic Retinal Embolus
  34. 34. Local Spread of Infection Heart failure – Extensive valvular damage Paravalvular abscess (30-40%) – Most common in aortic valve, IVDA, and S. aureus – May extend into adjacent conduction tissue causing arrythmias – Higher rates of embolization and mortality Pericarditis Fistulous intracardiac connections
  35. 35. Local Spread of Infection Acute S. aureus IE with perforation of the aortic valve and aortic valve vegetations. Acute S. aureus IE with mitral valve ring abscess extending into myocardium.
  36. 36. Metastatic Spread of Infection Metastatic abscess – Kidneys, spleen, brain, soft tissues Meningitis and/or encephalitis Vertebral osteomyelitis Septic arthritis
  37. 37. Poor Prognostic Factors Female S. aureus Vegetation size Aortic valve Prosthetic valve Older age Diabetes mellitus Low serum albumen Apache II score Heart failure Paravalvular abscess Embolic events
  38. 38. PROPHYLAXIS Dental/oral/Respira tory/esophageal procedures. Genitourinary/GE procedures Amoxicillin 2gm oral 1 hr before.Clindamycin 600mg or clarithromycin500mg if allergic to penicillin. – . Ampicillin 2gm +Gentamycin 1mg/kg within ½ hr of starting IV followed byAmpicillin 1gm IV 6 hrs later.
  39. 39. WHO NEEDS PROPHYLAXIS?
  40. 40. REQUIRED Prosthetic valves Previous IE CCHD MVP with regurgitation HOCM/IHSS
  41. 41. NOT REQUIRED MVP Isolated ASD CAD or CABG PPM’S or ICD’S
  42. 42. THANK YOU.

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