Infective endocarditis

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Infective Endocarditis
Hasan Al_Farhan
A. Prof. of cardiology
FACC,FICSM Cardiol,DIC.DM

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Pathogenesis
• Disruption of the endocardial layer
as a complication of abnormal blood
flow associated with underlying
cardiac defect
• Bacterium-endothelium interaction
with bacterial attachment and
invasion of endothelial cells

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Epidemiology
• Underlying valvular abnormality
predisposing to infective endocarditis
– rheumatic fever
a common cause in the past
– mitral valve prolapse
currently represents the most common
underlying cardiac abnormality

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mitral valve prolapse
• risk for infective ednocarditis is 5x-8x
• mitral regurgitation increases the risk
• leaflet redundancy with myxomatous
degeneration is a frequent finding
• age <20 , female predominate
age >20 , male accounts for 60%
age >50 , male accounts for 68%

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Causative Agents
• 1 .Streptococci
2 .Staphylococci
3 .Gram –negative bacilli
4 .Haemophillus
5 .Anaerobes
6 .Other : Rickettsia ,fungi

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Predisposing Factors
Polymicrobial Infective Endocarditis
Iv drug use
Central line
Prosthetic valve
Previous IE
Murmur
Dental procedure
Rheumatic disease
Miscellaneous

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Infective Endocarditis;
clinical features
1. Clinical course
2.Clinical feature

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Diagnostic (Duke) Criteria
• Definitive infective endocarditis
– pathologic criteria
• microorganisms or pathologic lesions:
demonstrated by culture or histology in a
vegetation, or in a vegetation that has
embolized, or in an intracardiac abscess
– clinical criteria (see below)
• two major criteria, or one major and three
minor criteria, or five minor criteria

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Diagnostic (Duke) Criteria
• Possible infective endocarditis
– findings consistent of IE that fall short of
“definite”, but not “rejected”
• Rejected
– firm alternate Dx for manifestation of IE
– resolution ofmanifestations of IE, with
antibiotic therapy for  4 days
– no pathologic evidence of IE at surgery or
autopsy, after antibiotic therapy for  4 days

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Diagnostic (Duke) Criteria
• Major criteria
– positive blood culture for IE
– evidence of endocardial involvement
• Minor criteria
– predisposition (heart condition or IV drug use)
– fever of 38 c or higher
– vascular or immunologic phenomena
– microbiologic or echocardiographic evidence
not meeting major criteria

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Duke’s Major Criteria
• positive blood culture for IE
– typical microorganism (strep viridans, strep
bovis, HACEK group, staph aureus or
enterococci in the absence of a primary focus)
for endocarditis from two separate blood
cultures
– persistently positive blood culture from:
• blood cultures drawn more than 12 hr apart, or
• all of 3 or more separate blood cultures,taken over
more than 1 hr .

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Duke’s Major Criteria
• Evidence of endocardial involvement
– positive echocardiogram for endocarditis
• oscillating intracardiac mass on valve or supporting
structure, or in the path of regurgitant jets, or on
implanted material, in the absence of an alternate
anatomic explanation
• abscess
• new partial dehiscence of prosthetic valve
– new valvular regurgitation (increase or change
in pre-existing murmur not sufficient)

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Duke’s Minor Criteria
• predisposition (predisposing heart
condition or iv drug use)
• fever of 100.40F or higher
• vascular phenomena (major arterial
emboli, septic pulmonary infarcts, mycotic
aneurysm, intracranial hemorrhage,
conjunctive hemorrhages, Janeway
lesions)

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Duke’s Minor Criteria
• immunologic phenomena
(glomerulonephritis, Osler’s nodes, Roth
spots, rheumatoid factor)
• microbiologic evidence (positive blood
culture not meeting major criteria or
serologic evidence of active infection with
organism consistent with IE)
• echocardiogram (consistent with IE but
not meeting major criteria)

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Risk for Endocarditis
• High risk
– prosthetic cardiac valve
– prior episodes of endocarditis
– complex congenital cardiac defect
– surgically constructed systemic-
pulmonary shunts or conduits

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Risk for Endocarditis
• Moderate risk
– patent ductus arteriosus
– VSD, primum ASD
– coarctation of the aorta
– bicuspid aortic valve
– hypertrophic cardiomyopathy
– acquired valvular dysfunction
– MVP with mitral regurgitation

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Risk for Endocarditis
• Low risk
– isolated secundum atrial septal defect
– ASD, VSD, or PDA >6 months past
repair
– “innocent” heart murmur by
auscultation in the pediatric population
– “innocent” heart murmur by
echocardiography in adult patients

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Treatment
– ……………….??

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SBE Prophylaxis
Standard general prophylaxis amoxicillin
Unable to take oral meds ampicillin
Allergic to penicilin clindamycin
cephalexin
azithromycin
clarithromycin
Allergic to penicillin and unable clindamycin
to take oral medications cefazolin