Infective Endocarditis

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Infective Endocarditis

  1. 1. INFECTIVE ENDOCARDITIS Infection of the endocardial surface of the heart – valve (native or prosthetic), heart chamber or a congenital anomaly.
  2. 2. <ul><li>Two types : </li></ul><ul><li>Acute – Fulminating infection </li></ul><ul><li>Insidious – Subacute Bacterial Endocarditis </li></ul><ul><li>Bacteria, Rickettsia, Chlamydia or Fungi </li></ul><ul><li>Without treatment - 100% mortality </li></ul><ul><li>Even with treatment significant morbidity & mortality </li></ul>
  3. 3. Etiology: <ul><li>Two factors : </li></ul><ul><li>Presence of organisms in the blood stream </li></ul><ul><li>Abnormal cardiac endothelium facilitating adherence and growth of bacteria </li></ul>
  4. 4. Factors causing Bacteremia: <ul><li>Poor dental hygiene </li></ul><ul><li>IV drug abuse </li></ul><ul><li>Soft tissue infection </li></ul><ul><li>Iatrogenic – dental treatment, intravascular cannulae, cardiac surgery or permanent pacemakers </li></ul>
  5. 5. Genesis of vegetations: <ul><li>Damaged vascular endothelium promotes platelet and fibrin deposition. </li></ul><ul><li>These small thrombi allow organisms to adhere and grow. </li></ul><ul><li>More fibrin and platelets are deposited leading on to a infected vegetation. </li></ul>
  6. 6. <ul><li>Damaged vascular endothelium – can result from lesions that cause high pressure jet flow of blood. </li></ul><ul><li>Eg) AR, MR, VSD, PDA </li></ul><ul><li>Right heart endocarditis – occurs in IV drug abuse, placement of central venous catheter, temporary pacemaker. </li></ul>
  7. 7. Organisms responsible: <ul><li>Alpha hemolytic streptococci – usually from the oral cavity (Streptococcus Viridans) </li></ul><ul><li>Staphylococcus & Candida - through skin following IV cannula & IVDA </li></ul><ul><li>Enterococci – in GU and GI related procedures and diseases </li></ul><ul><li>HACEK organisms - living on dental gums </li></ul><ul><li>Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella </li></ul>
  8. 8. <ul><li>Culture negative endocarditis - occurs in 5 to 10%. </li></ul><ul><li>May be due to previous antibiotic therapy. </li></ul><ul><li>May be due to organisms failing to grow in normal cultures – Coxiella burneti, Chlamydia, Bartonella, Legionella </li></ul>
  9. 9. Clinical Presentation: <ul><li>Two types : 1) Acute illness 2) Subacute insidious illness. </li></ul><ul><li>Clinical signs due to following processes: </li></ul><ul><li>Systemic features of infection </li></ul><ul><li>Cardiac lesions </li></ul><ul><li>Vascular phenomena (embolization) </li></ul><ul><li>Immunological phenomena (Immune complex deposition - vasculitis) </li></ul>
  10. 10. <ul><li>General : Malaise, Clubbing, Arthralgia, Pyrexia </li></ul><ul><li>Cardiac : new murmur, signs of failure, conduction block due to perivalvular abscess, MI </li></ul><ul><li>Skin lesions : Osler’s nodes, Splinter hemorrhages, Janeway lesions, Petechiae </li></ul><ul><li>Eyes – Roth spots, Conjunctival splinter hemorrhages </li></ul><ul><li>Neurological : Cerebral emboli, Mycotic aneurysm </li></ul><ul><li>Splenomegaly (40%), Renal – Hematuria, </li></ul><ul><li>Peripheral embolism : Spleen, Kidneys, Brain, Bowel </li></ul>
  11. 11. Investigations: <ul><li>Blood culture - Minimum of 3 samples from 3 different sites (gap of 1 hour between first and last sample). For Atypical organisms – over 24 hours. </li></ul><ul><li>Complete blood count </li></ul><ul><li>Liver function, Renal function, Electrolytes </li></ul><ul><li>Inflammatory markers – ESR, CRP </li></ul><ul><li>Urine – hematuria </li></ul><ul><li>Immunoglobulins – increased </li></ul><ul><li>Complement level – decreased </li></ul><ul><li>ECG (MI or AV block), CXR, Echo – TTE, TOE </li></ul>
  12. 12. Duke’s criteria: <ul><li>Diagnosis of IE made if there are 2 major (or) 1 major and 3 minor (or) 5 minor criteria. </li></ul><ul><li>Major criteria : (1) Positive blood culture . Typical organisms in two separate samples or persistently positive culture for atypical organisms in samples drawn 12 hours apart. (2) Evidence for endocardial involvement . Echo finding of oscillating intracardiac mass, new valvular regurgitation, abscess, partial dehiscence of prosthetic valve </li></ul><ul><li>Minor criteria : Fever, Predisposing heart lesion, Immunological phenomena, Vascular phenomena </li></ul>
  13. 13. Treatment: <ul><li>Principles : Difficult to treat because organisms reside within a avascular protected site within vegetations. </li></ul><ul><li>High concentration of IV antibiotics required for prolonged duration for a successful outcome. </li></ul><ul><li>Empirical antibiotic treatment started after cultures are taken. Regimen adjusted according to culture results. Treatment continued for 4 to 6 weeks. </li></ul><ul><li>Usually - Penicillin 1.2 g 4 hrly and Gentamicin 80 mg 12 hrly started. Vancomycin 1 g 12 hrly, if allergic to penicillin. </li></ul>
  14. 14. Indications for surgery: <ul><li>Extensive damage to valve </li></ul><ul><li>Prosthetic valve endocarditis </li></ul><ul><li>Persistent infection despite therapy </li></ul><ul><li>Large vegetations </li></ul><ul><li>Serious embolization </li></ul><ul><li>Myocardial abscess </li></ul><ul><li>Fungal endocarditis </li></ul><ul><li>Progressive cardiac failure </li></ul>
  15. 18. Roth spot
  16. 20. Janeway lesion

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