Infective endocarditis


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Infective endocarditis

  1. 1. Infective Endocarditis
  2. 2. Etiology and sources of infection
  3. 3. A consequence of 2 factors <ul><li>Presence of organism in blood stream </li></ul><ul><li>Abnormal cardiac endothelium facilitating adherence and growth. </li></ul>
  4. 4. <ul><li>Aortic and mitral valves are most commonly involved in infective endocarditis apart from intravenous drug users in whom right sided lesions are more common . </li></ul>
  5. 5. Culture negative Endocarditis <ul><li>Coxiella burnetti </li></ul><ul><li>Bortenella sp. </li></ul><ul><li>Chlamydia sp. </li></ul><ul><li>Legionella </li></ul><ul><li>Prior antibiotic therapy. </li></ul>
  6. 6. Clinical features
  7. 7. High clinical suspicion if….
  8. 8. Diagnostic criteria (Modified Duke’s Criteria) <ul><li>Major criteria: </li></ul><ul><li>A positive blood culture for IE. Typical organism growing in 2 cultures in absence of a primary focus. </li></ul><ul><li>A persistently positive blood culture </li></ul><ul><li>A positive serological test for Q fever. </li></ul><ul><li>ECHO evidence-mass, abscess, dehiscence. </li></ul><ul><li>New valvular regurgitation. </li></ul>
  9. 9. <ul><li>Minor criteria: </li></ul><ul><li>Predisposition: predisposing heart condition or intravenous drug use. </li></ul><ul><li>Fever: temperature ≥ 38°C (100.4°F). </li></ul><ul><li>Vascular phenomena : major arterial emboli , septic pulmonary infarcts , mycotic aneurysm, intracranial haemorrhage, conjunctival haemorrhages, Janeway’s Lesion. </li></ul><ul><li>Immunologic phenomena : glomerulonephritis, Osler’s nodes, Roth’s spots , rheumatoid factor. </li></ul><ul><li>Microbiological evidence: a positive blood culture but not meeting a major criterion as noted above, or serological evidence of an active infection with an organism that can cause infective endocarditis. </li></ul><ul><li>Echocardiogram: findings consistent with infective endocarditis but not meeting a major criterion as noted above. </li></ul>
  10. 10. <ul><li>The diagnosis of infective endocarditis is definite when: </li></ul><ul><li>A microorganism is demonstrated by culture of a specimen from a vegetation, an embolism or an intracardiac abscess </li></ul><ul><li>Active endocarditis is confirmed by histological examination of the vegetation or intracardiac abscess </li></ul><ul><li>Two major clinical criteria, one major and three minor criteria, or five minor criteria are met. </li></ul>
  11. 11. ECHO <ul><li>TTE-high specificity. Sensitivity 60-75%. </li></ul><ul><li>TOE-high sensitivity >90%. </li></ul><ul><li>A negative echocardiogram does not exclude a diagnosis of endocarditis. </li></ul>
  12. 13. Treatment <ul><li>Blood cultures should be taken prior to empirical antibiotic therapy. </li></ul><ul><li>Antibiotic treatment should continue for 4–6 weeks. </li></ul><ul><li>Serum levels of gentamicin and vancomycin need to be monitored to ensure adequate therapy and prevent toxicity. </li></ul>
  13. 15. Causes of persistent fever <ul><li>Most patients with infective endocarditis should respond within 48 hours of initiation of appropriate antibiotic therapy. </li></ul><ul><li>If persistent fever consider: </li></ul><ul><li>perivalvular extension of infection and possible abscess formation. </li></ul><ul><li>Drug reaction (the fever should promptly resolve after drug withdrawal) </li></ul><ul><li>Nosocomial infection (i.e. venous access site, urinary tract infection) </li></ul><ul><li>Pulmonary embolism (secondary right-sided endocarditis or prolonged hospitalization). </li></ul>
  14. 16. Antibiotic prophylaxis
  15. 17. Possible questions. <ul><li>Name the organisms associated with the following locations/situations causing IE: </li></ul><ul><li>Dental disease or procedures. </li></ul><ul><li>Prolonged indwelling vascular catheters. </li></ul><ul><li>Gut and perineum </li></ul><ul><li>Bowel malignancy </li></ul><ul><li>Native and prosthetic valve endocarditis-early and late. </li></ul><ul><li>Soft tissue infection </li></ul>
  16. 18. <ul><li>IE in IVDU-name the organism, site, Rx. </li></ul><ul><li>Name the organisms with negative culture for IE. </li></ul><ul><li>The following are high clinical suspicion for IE except? </li></ul><ul><li>The following are major criterion for IE except? </li></ul>
  17. 19. <ul><li>Treatment choices for the following clinical situation: </li></ul><ul><li>Clinical endocarditis, culture results awaited, no suspicion of staphylococci. </li></ul><ul><li>Suspected staphylococcal endocarditis (IVDU, recent intravascular devices or cardiac surgery, acute infection) </li></ul><ul><li>Streptococcal endocarditis </li></ul><ul><li>Enterococcal endocarditis </li></ul><ul><li>Staphylococcal endocarditis </li></ul>
  18. 20. <ul><li>A person treated for IE has persistent fever after 48 hours of treatment. What are the possible explanation for this? </li></ul>