Infective endocarditis


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Infective endocarditis

  1. 1. Infective EndocarditisPRATIK KUMAR080201186
  2. 2. DefinitionInfection of the endocardial surface of heart characterized by - Colonization or invasion of the heart valves (native orprosthetic) or the mural endocardium by a microbe, - leading to formation of bulky, friable vegetation composedof thrombotic debris and organisms - often associated with destruction of underlying cardiactissue.
  3. 3. Sites involved• Heart valves• Ventricular septum defects• Mural endocardium• Intracardiac devices• INFECTIVE ENDARTERITIS – analogus
  4. 4. Classification ACUTE ENDOCARDITIS SUBACUTE ENDOCARDITIS• Destructive and tumultuous • Organisms of low virulence infection, frequently of a causing infection in a previously normal heart valve, previously abnormal heart, with a highly virulent particularly on deformed organism valves.• Hematogenoulsy seeds • Disease appear insidiously and pursue a protracted course of• If untreated, leads to death weeks to month within weeks • Recover after appropriate antibiotic treatment
  5. 5. Predisposing factors CARDIAC AND VASCULAR ABNORMALITIES HOST FACTORS• RHD • Neutropenia• Myxomatous mitral valve • Immunodeficiency• Degenerative calcific valvular • Malignancy stenosis • Therapeutic immunosuppression• Bicuspid aortic valves • Diabetes mellitus• Prosthetic valves • Alcohol • IV drug abuse
  6. 6. Microbiology• Staphylococcus aureus (35%) : Either healthy or deformed valves, IV drug abusers (polymicrobial), devices• Streptococcus viridans (32%) : Native but previously damaged/abnormal valves• Enterococci (8 %)• CoNS - S. epidermidis (4%): Prosthetic valve endocarditis, devices• G –ve bacilli of HACEK group (4%)• Yeast and Fungi(1%)• Culture negative endocarditis (5 %)
  7. 7. PathogenesisPortal of entry:◦ Dental / Surgical Procedures◦ Contamination by IV drug use◦ Obvious infections (RS/Skin)◦ Occult source from gut, oral cavity◦ Trivial injuries.◦ Intravascular catheter infection◦ Nosocomial wounds◦ Chronic invasive procedures
  8. 8. Endothelial Injury Uninfected Platelet-Fibrin thrombus (NBTE) Transient bacteremia and attachment at NBTE Proliferation and pro-coagulant state Infected, friable, bulky vegetation
  9. 9. Morphology• Friable, bulky vegetation containing fibrin, inflammatory cells, and microbes• Aortic and mitral valves involved most commonly.• Right side valve involvement in iv drug users.
  10. 10. Clinical features Symptoms Constitutional symptoms - Damage to intracardiac --- Cytokine release ?structures - Embolization of vegetationfragments - Hematogenous infection - Immune complex
  11. 11. Sub-acute Endocarditis• Persistent fever• Constitutional symptoms• New signs of valve dysfunction• Heart failure• Embolic Stroke• Peripheral arterial embolism• Other features
  12. 12. Modified Dukes Criteria for diagnosisof Infective Endocarditis Definitive Endocarditis if, - Two major or, - One major and three minor or, - five minor Possible Endocarditis if, - One major and one minor or, - Three minor
  13. 13. Major CriteriaPositive blood culture◦Typical organism from two cultures◦Persistent positive blood cultures taken > 12 hours apart◦Three or more positive cultures taken over more than 1 hour.Endocardial involvement◦Positive echocardiographic findings of vegetations◦New valvular regurgitation
  14. 14. Minor Criteria• Predisposition: Predisposing valvular or cardiac abnormality• Intravenous drug misuse• Pyrexia ≥38°C (≥100.4°F)• Embolic phenomenon• Vasculitic/ immunologic phenomenon• Blood cultures suggestive: -organism grown but not achieving major criteria• Suggestive echocardiographic findings
  16. 16. .Microbiology Blood cultures:Key diagnostic investigation in infective endocarditis.Isolation of microorganism from culture is important for diagnosis and also for treatment.At least 3 sets of samples should be taken from different venepuncture sites over 24 hours.
  17. 17. Serology Can be sent when the diagnosis is suspected and the cultures are negative.They aid in cases where the organisms will not grow in blood cultures(Coxiella,Legionella,Bartonella)ECG To detect complications like MI,conductionabnormalities.CHEST X RAY
  18. 18. .EchocardiographyIt can identify the presence and size of vegetations,detect intracardiac complications and assess cardiac function.Transthoracic echocardiography is noninvasive and has high specificity for visualising vegetations.Transoesophageal echocardiography is more sensitive than TTE.It can detect small vegetations,prosthetic endocarditis and intra cardiac complications.
  19. 19. .Complete blood counts may show anamia and increased WBC counts.Urea and Creatinine: may be elevated due to glomerulonephritisLiver biochemistry: Serum alkaline phosphatase may be increasedInflammatory markers CRP,ESR are increased in infection .CRP also helps in monotoring response to therapy.Urine proteinuria and hematuria occur frequently.
  20. 20. TREATMENTAntimicrobial Therapy Therapy requires identification of specific pathogen and its susceptibility to antimicrobials. Empirical therapy should be started as soon as possible targeting most likely pathogens. Bactericidal drugs should be used.
  21. 21. Resolution of fever occurs in 5 to 7 days.if feverpersists patient should be evaluated for complicationslike paravalvular abscess and extracardiac abscess. Serologic abnormalities resolve slowly and do notreflect response to treatment.
  22. 22. Antibotic regimen for infective endocarditis Streptococci Benzyl penicillin (1.2g 4 hourly) 4-6 weeks Gentamicin (1mg/kg 8-12 hourly) 4-6 weeksEnterococcio Ampicillin sensitive Ampicillin (2 g 4 hourly) 4-6 weeks, and Gentamicin (1mg/kg 8-12 hourly)o Ampicillin resistant Vancomycin(1g 12hourly) 4-6 weeks, and Gentamicin (1mg/kg 8-12 hourly)
  23. 23. StaphycoccioPenicillin sensitive Benzyl penicillin I.V(1.2 g 4 hourly)oPenicillin resistant but methicillin sensitive Flucloxacillin I.V (2g 4 hourly )oBoth penicillin and methicillin resistant Vancomycin I.V (1g 12 hourly) and Gentamicin
  24. 24. .Surgery Indications patients with direct extension of infection to myocardial structuires.Prosthetic valve dysfunction.Congestive heart failure.Badly damaged valves.IE caused by fungi or gram-ve or resistant organisms.Large vegetations on echocardiographyRecurrent embolic attacks.
  25. 25. Prophylaxis High risk category prosthetic cardiac valvesPrevious bacterial endocarditis,even in absense of heart disease.Complex cyanotic congenital heart disease(TGA,TOF) Surgically constructed systemic pulmonary shunts.
  26. 26. Moderate risk categoryRheumatic and other valvular dysfunctionCongenital cardiac malformationsHypertrophic cardiomyopathyMitral valve prolapse with valvular regurgitation
  27. 27. Regimen for IE prophylaxis Standard oral regime Amoxicillin 2 g 1hr before procedure Inability to take oral medication Ampicillin 2g IV or IM 1hr before procedurePenicillin allergy Clindamycin 600 mg Clarithromycin 500 mg Cephalexin 2 g.
  28. 28. Thank you.