For the Final year MBBS student

1. Physician’s aim:Physician’s aim:

2. Infective EndocarditisInfective Endocarditis

3. Infective Endocarditis - DefinitionInfective Endocarditis - Definition
It is an endovascular infection ofIt is an endovascular infection of
cardiovascular structures, including –cardiovascular structures, including –
 cardiac valvescardiac valves
 atrial and ventricular endocardiumatrial and ventricular endocardium
 large intrathoracic vesselslarge intrathoracic vessels
 foreign bodies like prosthetic valves,foreign bodies like prosthetic valves,
and pacemaker leadsand pacemaker leads

4. Two typesTwo types::
Acute illness – Changing murmurs and high feverAcute illness – Changing murmurs and high fever
Insidious illness – low grade fever and non-specificInsidious illness – low grade fever and non-specific
symptoms, requiring high index of suspicion.symptoms, requiring high index of suspicion.
OrganismsOrganisms::
Bacteria, Rickettsia, Chlamydia or FungiBacteria, Rickettsia, Chlamydia or Fungi
Without treatment - 100% mortalityWithout treatment - 100% mortality
Even with treatment significant morbidity &Even with treatment significant morbidity &
mortalitymortality

5. PathogenesisPathogenesis
Two factorsTwo factors::
1)1) Presence of organisms in the bloodPresence of organisms in the blood
streamstream
2)2) Abnormal cardiac endotheliumAbnormal cardiac endothelium
facilitating adherence and growth offacilitating adherence and growth of
bacteriabacteria

6. Factors causing Bacteremia:Factors causing Bacteremia:
 Poor dental hygienePoor dental hygiene
 IV drug abuseIV drug abuse
 Soft tissue infectionSoft tissue infection
 Iatrogenic – dental treatment,Iatrogenic – dental treatment,
intravascular cannulae, cardiacintravascular cannulae, cardiac
surgery or permanent pacemakerssurgery or permanent pacemakers

7. Genesis of vegetations:Genesis of vegetations:
 Damaged vascular endotheliumDamaged vascular endothelium
promotes platelet and fibrinpromotes platelet and fibrin
deposition.deposition.
 These small thrombi allow organismsThese small thrombi allow organisms
to adhere and grow.to adhere and grow.
 More fibrin and platelets areMore fibrin and platelets are
deposited leading on to a infecteddeposited leading on to a infected
vegetation.vegetation.

8. Damaged vascular endotheliumDamaged vascular endothelium – can– can
result from lesions that cause highresult from lesions that cause high
pressure jet flow of blood.pressure jet flow of blood.
Eg) AR, MR, VSD, PDAEg) AR, MR, VSD, PDA
Right heart endocarditisRight heart endocarditis – occurs in IV– occurs in IV
drug abuse, placement of centraldrug abuse, placement of central
venous catheter, temporaryvenous catheter, temporary
pacemaker.pacemaker.

9. Organisms responsible:Organisms responsible:
Alpha hemolytic streptococciAlpha hemolytic streptococci – usually from– usually from
the oral cavity (Streptococcus Viridans)the oral cavity (Streptococcus Viridans)
Staphylococcus & CandidaStaphylococcus & Candida - through skin- through skin
following IV cannula & IVDAfollowing IV cannula & IVDA
EnterococciEnterococci – in GU and GI related– in GU and GI related
procedures and diseasesprocedures and diseases
HACEK organismsHACEK organisms - living on dental gums- living on dental gums
Haemophilus, Actinobacillus, Cardiobacterium, Eikenella,Haemophilus, Actinobacillus, Cardiobacterium, Eikenella,
KingellaKingella

10. Culture negative endocarditisCulture negative endocarditis - occurs- occurs
in 5 to 10%.in 5 to 10%.
May be due to previous antibioticMay be due to previous antibiotic
therapy.therapy.
May be due to organisms failing toMay be due to organisms failing to
grow in normal cultures – Coxiellagrow in normal cultures – Coxiella
burneti, Chlamydia, Bartonella,burneti, Chlamydia, Bartonella,
LegionellaLegionella

11. Clinical Presentation:Clinical Presentation:
Two typesTwo types::
1) Acute illness 2) Subacute insidious1) Acute illness 2) Subacute insidious
illness.illness.
Clinical signsClinical signs due to -due to -
1.1. Systemic features of infectionSystemic features of infection
2.2. Cardiac lesionsCardiac lesions
3.3. Vascular phenomena (embolization)Vascular phenomena (embolization)
4.4. Immunological phenomenaImmunological phenomena
(Immune complex deposition -(Immune complex deposition -
vasculitis)vasculitis)

12. GeneralGeneral: Malaise, Clubbing, Arthralgia,: Malaise, Clubbing, Arthralgia,
PyrexiaPyrexia
CardiacCardiac: new murmur, signs of failure,: new murmur, signs of failure,
conduction block due to perivalvularconduction block due to perivalvular
abscess, MIabscess, MI
Skin lesionsSkin lesions: Osler’s nodes, Splinter: Osler’s nodes, Splinter
hemorrhages, Janeway lesions, Petechiaehemorrhages, Janeway lesions, Petechiae

13. EyesEyes – Roth spots, Conjunctival– Roth spots, Conjunctival
splinter hemorrhagessplinter hemorrhages
NeurologicalNeurological: Cerebral emboli, Mycotic: Cerebral emboli, Mycotic
aneurysmaneurysm
SplenomegalySplenomegaly (40%),(40%), RenalRenal ––
Hematuria,Hematuria,
Peripheral embolismPeripheral embolism: Spleen, Kidneys,: Spleen, Kidneys,
Brain, BowelBrain, Bowel

14. Investigations:Investigations:
Blood culture - Minimum of 3 samples fromBlood culture - Minimum of 3 samples from
3 different sites (gap of 1 hour between3 different sites (gap of 1 hour between
first and last sample). For Atypicalfirst and last sample). For Atypical
organisms – over 24 hours.organisms – over 24 hours.
Complete blood countComplete blood count
Liver function, Renal function, ElectrolytesLiver function, Renal function, Electrolytes

15. Inflammatory markers – ESR, CRPInflammatory markers – ESR, CRP
Urine – hematuriaUrine – hematuria
Immunoglobulins – increasedImmunoglobulins – increased
Complement level – decreasedComplement level – decreased
ECG (MI or AV block), CXR, Echo –ECG (MI or AV block), CXR, Echo –
TTE, TOETTE, TOE

16. Modified Duke’s criteria:Modified Duke’s criteria:
Diagnosis of IEDiagnosis of IE made if there are –made if there are –
 2 major (or)2 major (or)
 1 major and 3 minor (or)1 major and 3 minor (or)
 5 minor criteria.5 minor criteria.

17. Major Criteria:Major Criteria:
(1) Positive blood culture(1) Positive blood culture..
 Typical organisms in two separate samples, orTypical organisms in two separate samples, or
 persistently positive culture for atypicalpersistently positive culture for atypical
organisms in samples drawn 12 hours apart.organisms in samples drawn 12 hours apart.
(2)(2) Evidence for endocardial involvementEvidence for endocardial involvement..
 Echo finding of oscillating intracardiac massEcho finding of oscillating intracardiac mass
 new valvular regurgitationnew valvular regurgitation
 myocardial abscessmyocardial abscess
 partial dehiscence of prosthetic valvepartial dehiscence of prosthetic valve

18. Minor criteria:Minor criteria:
 Predisposing heart condition orPredisposing heart condition or
intravenous drug use.intravenous drug use.
 Fever: temperature ≥38°C (100.4°F).Fever: temperature ≥38°C (100.4°F).
 Any of the Vascular phenomenaAny of the Vascular phenomena
 Any of the Immunologic phenomenaAny of the Immunologic phenomena
 Positive blood culture or serologicalPositive blood culture or serological
evidence of an active infectionevidence of an active infection
 Echocardiogram: findings consistent withEchocardiogram: findings consistent with
infective endocarditisinfective endocarditis

19. Treatment:Treatment:
PrinciplesPrinciples: Difficult to treat because: Difficult to treat because
organisms reside within a avascularorganisms reside within a avascular
protected site within vegetations.protected site within vegetations.
High concentration of IV antibiotics requiredHigh concentration of IV antibiotics required
for prolonged duration for a successfulfor prolonged duration for a successful
outcome.outcome.

20. Empirical antibiotic treatmentEmpirical antibiotic treatment startedstarted
after cultures are taken. Regimenafter cultures are taken. Regimen
adjusted according to culture results.adjusted according to culture results.
Treatment continued for 4 to 6Treatment continued for 4 to 6
weeks.weeks.
Usually - Penicillin 1.2 g 4 hrly andUsually - Penicillin 1.2 g 4 hrly and
Gentamicin 80 mg 12 hrly started.Gentamicin 80 mg 12 hrly started.
Vancomycin 1 g 12 hrly, if allergic toVancomycin 1 g 12 hrly, if allergic to
penicillin.penicillin.

21. Indications for surgery:Indications for surgery:
 Extensive damage to valveExtensive damage to valve
 Prosthetic valve endocarditisProsthetic valve endocarditis
 Persistent infection despite therapyPersistent infection despite therapy
 Large vegetationsLarge vegetations
 Serious embolizationSerious embolization
 Myocardial abscessMyocardial abscess
 Fungal endocarditisFungal endocarditis
 Progressive cardiac failureProgressive cardiac failure

22. Infective endocarditis - VegetationsInfective endocarditis - Vegetations

23. Petechial HemorrhagesPetechial Hemorrhages

24. Roth spotRoth spot

25. Osler’s nodeOsler’s node

26. Splinter hemorrhagesSplinter hemorrhages

27. Janeway lesionJaneway lesion