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Infective Endocarditis




                                             Dr. Kalpana Malla
                                            MBBS MD (Pediatrics)
                                         Manipal Teaching Hospital



Download more documents and slide shows on The Medical Post [ www.themedicalpost.net ]
Definition
• Infective Endocarditis (IE): an infection of the
  heart’s endocardial surface
Classified into four groups:
  – Native Valve IE
  – Prosthetic Valve IE
  – Intravenous drug abuse (IVDA) IE
  – Nosocomial IE
Epidemiology
• The valves involved
  – Mitral              28-45%
  – Aortic              5-36%
  – Both                0-35%



  – Tricuspid           0-6%
  – Pulmonary           <1%
Epidemiology
• Incidence - varies according to location
• Males > females
• May occur at any age and increasingly
  common in elderly
• Mortality 20-30%
Predisposing Factors

                  Iv drug use
                  Central line
                  Prosthetic valve
                  Previous IE
                  Murmur
                  Dental procedure
                  Rheumatic disease
                  Miscellaneous
Risk for Endocarditis
• High risk
  – Prosthetic cardiac valve
  – Prior episodes of endocarditis
  – Complex congenital cardiac defect
  – Surgical systemic-pulmonary shunts
  – Intravenous drug abuse
  – Intravascular catheters
Risk for Endocarditis
• Moderate risk
  – PDA, VSD, primum ASD
  – Co-Aorta
  – Bicuspid aortic valve
  – Hypertrophic cardiomyopathy
  – Acquired valvular dysfunction
  – MVP with mitral regurgitation
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
Further Classification
• Acute                        • Subacute
   – Affects normal heart         – Often affects
     valves                         damaged heart
   – Rapidly destructive            valves
   – Metastatic foci              – Indolent nature
   – Commonly Staph.              – If not treated, usually
   – If not treated, usually        fatal by one year
     fatal within 6 weeks
• The terms acute and subacute are used to
  define duration of infection, however are
  older terms and should not be used
• A classification based on organism is
  preferable
Pathophysiology
1. Turbulent blood flow disrupts the
   endocardium making it “sticky”
2. Bacteremia delivers the organisms to the
   endocardial surface
3. Adherence of the organisms to the
   endocardial surface
4. Eventual invasion of the valvular leaflets
Infecting Organisms

• Common bacteria in children
  – S viridans – 50% cases
  – S. aureus – 40% cases
  – S. fecalis ,Grp D sreptococcus (Enterococci)
Less common organisms

– P. aeruginosa, Staph epidemidis
– Histoplasma, candida, Aspergillus
– Coxiella burnetti, Brucella, chlamydia
– HACEK grp –
  Hemophilus, Actinobacillus, Cardiobacterium
  hominis, Eikenella, kingella
Symptoms
• Acute                      • Subacute
   – High grade fever and       – Low grade fever
     chills
                                – Anorexia
   – SOB
                                – Weight loss
   – Arthralgias/ myalgias
                                – Fatigue
   – Abdominal pain
                                – Arthralgias/ myalgias
   – Pleuritic chest pain
                                – Abdominal pain
   – Back pain
Signs
• Fever
• Heart murmur
• Nonspecific signs – petechiae, subungal or
  “splinter”
  hemorrhages, clubbing, splenomegaly, neurol
  ogic changes
• More specific signs - Osler’s Nodes, Janeway
  lesions, and Roth Spots
Petechiae


1. Nonspecific
2. Often located on extremities
   or mucous membranes
Splinter Hemorrhages


1. Nonspecific
2. Nonblanching
3. Linear reddish-brown lesions found under the nail
   bed
4. Usually do NOT extend the entire length of the nail
Osler’s Nodes


1. More specific
2. Painful and erythematous nodules
3. Located on pulp of fingers and toes
4. More common in subacute IE
Janeway Lesions


1. More specific
2. Erythematous, blanching macules
3. Nonpainful
4. Located on palms and soles
The Essential Blood Test
• Blood Cultures
   – Minimum of three blood cultures
   – Three separate venipuncture sites
   – 5- 10mL in children
   – ½ to 1hr apart
   – Out of three one should be for anaerobic organisms
• Positive Result
   – Typical organisms present in at least 2 separate samples
   – Detects over 95% of cases
Negative blood culture
• Previous antibiotic
• Technical errors
• Unusual organisms- anaerobic
  organisms,fungus
Additional supportive Labs
•   CBC
•   ESR and CRP
•   Urinalysis-microscopic hematuria in 95%
•   Immunologic tests –
•   Increase in gamma globulins
•   Presence of cryoglobulin
•   Low Complement levels (C3, C4)
•   RF- positive (59%)
Imaging
• Chest x-ray
  – Look for multiple focal infiltrates and calcification
    of heart valves
• EKG
  – Rarely diagnostic
  – Look for evidence of ischemia, conduction
    delay, and arrhythmias
• Echocardiography- diagnostic tool for culture
  negative cases
mitral valve vegetation
Making the Diagnosis
• Pelletier and Petersdorf criteria (1977)
• Von Reyn criteria (1981)
• Duke criteria (1994)
• Modified Duke Criteria
Diagnostic (Duke) Criteria

• Major criteria
  – Positive blood culture for IE
  – Evidence of endocardial involvement
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 locus) 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 a majority of 4 or more separate blood
        cultures, with first and last drawn at least 1 hr apart
Duke’s Major Criteria
• Evidence of endocardial involvement
   – positive echocardiogram for endocarditis
Duke’s Minor Criteria
• 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
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)
Modified Duke Criteria
• Definite IE
   – Microorganism (via culture or histology) in a
     valvular vegetation, embolized vegetation, or
     intracardiac abscess
   – Histologic evidence of vegetation or intracardiac
     abscess

• Possible IE
   – 2 major
   – 1 major and 3 minor
   – 5 minor
Modified Duke Criteria
• Rejected IE
  –Resolution of illness with four days or
    less of antibiotics
Treatment
• Parenteral antibiotics

• Surgery
  – Intracardiac complications


• Surveillance blood cultures
Antimicrobial Therapy
• Antibiotics IV for 2-6 weeks
1. Penicillin-susceptible streptococcal (PSSE) on native
  cardiac valves:
• Penicillin G - 4 weeks or
• Penicillin G or ceftriaxone + gentamicin - 2 wks
2. Penicillin-resistant streptococcal (PRSE) on native
  cardiac valves –
• Penicillin, ampicillin, or ceftriaxone for 4 weeks +
  gentamicin for the first 2 weeks
Antimicrobial Therapy
3.PSSE on prosthetic valve-
• penicillin, ampicillin, or ceftriaxone - 6 wks +
  gentamicin for the first 2 wks.
4. PRSE on prosthetic valve –
 penicillin, ampicillin, or ceftriaxone for 6 weeks
  + gentamicin for first 2 wks
Antimicrobial Therapy
5. Enterococcal infection on native valves -
  penicillin or ampicillin + gentamicin for 4-6
  weeks
Antimicrobial Therapy
6.Methicillin-susceptible S aureus (MSSA) on
   native valves :
- Nafcillin or oxacillin for at least 6 weeks +
   gentamicin for 3-5 days is optional
7. Methicillin-resistant S aureus (MRSA) on
   native valves:
 - vancomycin for at least 6 weeks, with or
   without 3-5 days of gentamicin
Antimicrobial Therapy
8. MSSA infection on prosthetic valve :
- Nafcillin or oxacillin + rifampin for at least 6
   weeks, in combination with gentamicin for 2
   weeks.
9. MRSA infection on prosthetic valve:
- Vancomycin + rifampin for at least 6 weeks, in
   combination with gentamicin for 2 weeks
Antimicrobial Therapy
10. Gram negative endocarditis caused by
  HACEK organisms: - ceftriaxone or ampicillin
  plus gentamicin for 4 weeks
Culture Negative Endocarditis
• Intracellular organisms
  – Bartonella henselae
  – Coxiella burnetti
  – Mycoplasma pneumonia
  – Legionella pneumophila
• Diagnosis is made by checking IgM/IgG
  serologies
Culture Negative Endocarditis
             Treatment

• One should cover for the HACEK
  organisms, alpha streptococci & last slide

• Ceftriaxone 2 grams IV daily + vancomycin 1 g
  q 12 - 6 weeks
New Treatments
• Right-sided infective endocarditis due to methicillin-
  susceptible S aureus (MSSA) in IV drug users
   – 2-wk therapy with a penicillinase-resistant penicillin and
     an aminoglycoside
   – 2-wk monotherapy with IV cloxacillin
   – short-term therapy is inappropriate if complicated by
     ostomyelitis, meningitis, myocardial abscess, or
     concomitant left-sided involvement
New Treatments
• Highly penicillin-susceptible Streptococcus viridans
  or bovis
   – Once-daily ceftriaxone for 4 wks
      • cure rate > 98%
      • easily administered as outpatient, avoid hospitalization, offers
        significant cost savings
   – Once-daily ceftriaxone 2 g for 2wks followed by oral
     amoxicillin qid for 2 wks
   – Once-daily ceftriazone and netilmicin for 2 wks
New Treatments
• Prosthetic valve endocarditis due to fluconazole-
  susceptible Candida species
   – many are due to bloodstream invasion
   – chronic oral suppressive therapy with fluconazole for
     inoperable disease
Surgical Treatment
• 15-25% of patients with IE are treated
  surgically
• Indications -
  – Antibiotic therapy fails
  – Persistent vegetation after systemic
    embolization
  – Increase in vegetation size after antimicrobial
    therapy
  – Valvular dysfunction
  – Fungal endocarditis
Complications of Endocarditis
• Cardiac                33-50%

• Neurologic             25-35%

• Emboli                 15-35%

• Metastatic Abscesses    <5%
Neurologic Complications

•   Acute encephalopathy
•   Meningitis
•   Embolic stroke
•   Cerebral hemorrhage
•   Brain abscess
Embolic Phenomena

• Stroke
• Ischemic extremities
• Pulmonary emboli
• Paralysis due to embolic infarction of
  either the brain or spinal cord
• Hypoxia from pulmonary emboli
• Abdominal pain (splenic or renal infarction
Metastatic Spread of Infection
• Metastatic abscess
  – Kidneys, spleen, brain, soft tissues
• Meningitis and/or encephalitis
• Vertebral osteomyelitis
• Septic arthritis
Local Spread of Infection
• Heart failure
   – Extensive valvular damage
• Paravalvular abscess (30-40%)
   – Most common in aortic valve, IVDA, and S. aureus
   – May extend into adjacent conduction tissue causing
     arrythmias
   – Higher rates of embolization and mortality
• Pericarditis
• Fistulous intracardiac connections
Septic Pulmonary Emboli
Poor Prognostic Factors
•   Female             •   Diabetes mellitus
•   S. aureus          •   Low serum albumen
•   Vegetation size    •   Apache II score
•   Aortic valve       •   Heart failure
•   Prosthetic valve   •   Paravalvular abscess
•   Older age          •   Embolic events
Thank you
Download more documents and slide shows on The Medical Post
               [ www.themedicalpost.net ]

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Infective Endocarditis

  • 1. Infective Endocarditis Dr. Kalpana Malla MBBS MD (Pediatrics) Manipal Teaching Hospital Download more documents and slide shows on The Medical Post [ www.themedicalpost.net ]
  • 2. Definition • Infective Endocarditis (IE): an infection of the heart’s endocardial surface Classified into four groups: – Native Valve IE – Prosthetic Valve IE – Intravenous drug abuse (IVDA) IE – Nosocomial IE
  • 3. Epidemiology • The valves involved – Mitral 28-45% – Aortic 5-36% – Both 0-35% – Tricuspid 0-6% – Pulmonary <1%
  • 4. Epidemiology • Incidence - varies according to location • Males > females • May occur at any age and increasingly common in elderly • Mortality 20-30%
  • 5. Predisposing Factors Iv drug use Central line Prosthetic valve Previous IE Murmur Dental procedure Rheumatic disease Miscellaneous
  • 6. Risk for Endocarditis • High risk – Prosthetic cardiac valve – Prior episodes of endocarditis – Complex congenital cardiac defect – Surgical systemic-pulmonary shunts – Intravenous drug abuse – Intravascular catheters
  • 7. Risk for Endocarditis • Moderate risk – PDA, VSD, primum ASD – Co-Aorta – Bicuspid aortic valve – Hypertrophic cardiomyopathy – Acquired valvular dysfunction – MVP with mitral regurgitation
  • 8. 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
  • 9. Further Classification • Acute • Subacute – Affects normal heart – Often affects valves damaged heart – Rapidly destructive valves – Metastatic foci – Indolent nature – Commonly Staph. – If not treated, usually – If not treated, usually fatal by one year fatal within 6 weeks
  • 10. • The terms acute and subacute are used to define duration of infection, however are older terms and should not be used • A classification based on organism is preferable
  • 11. Pathophysiology 1. Turbulent blood flow disrupts the endocardium making it “sticky” 2. Bacteremia delivers the organisms to the endocardial surface 3. Adherence of the organisms to the endocardial surface 4. Eventual invasion of the valvular leaflets
  • 12. Infecting Organisms • Common bacteria in children – S viridans – 50% cases – S. aureus – 40% cases – S. fecalis ,Grp D sreptococcus (Enterococci)
  • 13. Less common organisms – P. aeruginosa, Staph epidemidis – Histoplasma, candida, Aspergillus – Coxiella burnetti, Brucella, chlamydia – HACEK grp – Hemophilus, Actinobacillus, Cardiobacterium hominis, Eikenella, kingella
  • 14. Symptoms • Acute • Subacute – High grade fever and – Low grade fever chills – Anorexia – SOB – Weight loss – Arthralgias/ myalgias – Fatigue – Abdominal pain – Arthralgias/ myalgias – Pleuritic chest pain – Abdominal pain – Back pain
  • 15. Signs • Fever • Heart murmur • Nonspecific signs – petechiae, subungal or “splinter” hemorrhages, clubbing, splenomegaly, neurol ogic changes • More specific signs - Osler’s Nodes, Janeway lesions, and Roth Spots
  • 16. Petechiae 1. Nonspecific 2. Often located on extremities or mucous membranes
  • 17. Splinter Hemorrhages 1. Nonspecific 2. Nonblanching 3. Linear reddish-brown lesions found under the nail bed 4. Usually do NOT extend the entire length of the nail
  • 18. Osler’s Nodes 1. More specific 2. Painful and erythematous nodules 3. Located on pulp of fingers and toes 4. More common in subacute IE
  • 19. Janeway Lesions 1. More specific 2. Erythematous, blanching macules 3. Nonpainful 4. Located on palms and soles
  • 20. The Essential Blood Test • Blood Cultures – Minimum of three blood cultures – Three separate venipuncture sites – 5- 10mL in children – ½ to 1hr apart – Out of three one should be for anaerobic organisms • Positive Result – Typical organisms present in at least 2 separate samples – Detects over 95% of cases
  • 21. Negative blood culture • Previous antibiotic • Technical errors • Unusual organisms- anaerobic organisms,fungus
  • 22. Additional supportive Labs • CBC • ESR and CRP • Urinalysis-microscopic hematuria in 95% • Immunologic tests – • Increase in gamma globulins • Presence of cryoglobulin • Low Complement levels (C3, C4) • RF- positive (59%)
  • 23. Imaging • Chest x-ray – Look for multiple focal infiltrates and calcification of heart valves • EKG – Rarely diagnostic – Look for evidence of ischemia, conduction delay, and arrhythmias • Echocardiography- diagnostic tool for culture negative cases
  • 25. Making the Diagnosis • Pelletier and Petersdorf criteria (1977) • Von Reyn criteria (1981) • Duke criteria (1994) • Modified Duke Criteria
  • 26. Diagnostic (Duke) Criteria • Major criteria – Positive blood culture for IE – Evidence of endocardial involvement
  • 27. 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 locus) 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 a majority of 4 or more separate blood cultures, with first and last drawn at least 1 hr apart
  • 28. Duke’s Major Criteria • Evidence of endocardial involvement – positive echocardiogram for endocarditis
  • 29. Duke’s Minor Criteria • 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
  • 30. 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)
  • 31. Modified Duke Criteria • Definite IE – Microorganism (via culture or histology) in a valvular vegetation, embolized vegetation, or intracardiac abscess – Histologic evidence of vegetation or intracardiac abscess • Possible IE – 2 major – 1 major and 3 minor – 5 minor
  • 32. Modified Duke Criteria • Rejected IE –Resolution of illness with four days or less of antibiotics
  • 33. Treatment • Parenteral antibiotics • Surgery – Intracardiac complications • Surveillance blood cultures
  • 34. Antimicrobial Therapy • Antibiotics IV for 2-6 weeks 1. Penicillin-susceptible streptococcal (PSSE) on native cardiac valves: • Penicillin G - 4 weeks or • Penicillin G or ceftriaxone + gentamicin - 2 wks 2. Penicillin-resistant streptococcal (PRSE) on native cardiac valves – • Penicillin, ampicillin, or ceftriaxone for 4 weeks + gentamicin for the first 2 weeks
  • 35. Antimicrobial Therapy 3.PSSE on prosthetic valve- • penicillin, ampicillin, or ceftriaxone - 6 wks + gentamicin for the first 2 wks. 4. PRSE on prosthetic valve – penicillin, ampicillin, or ceftriaxone for 6 weeks + gentamicin for first 2 wks
  • 36. Antimicrobial Therapy 5. Enterococcal infection on native valves - penicillin or ampicillin + gentamicin for 4-6 weeks
  • 37. Antimicrobial Therapy 6.Methicillin-susceptible S aureus (MSSA) on native valves : - Nafcillin or oxacillin for at least 6 weeks + gentamicin for 3-5 days is optional 7. Methicillin-resistant S aureus (MRSA) on native valves: - vancomycin for at least 6 weeks, with or without 3-5 days of gentamicin
  • 38. Antimicrobial Therapy 8. MSSA infection on prosthetic valve : - Nafcillin or oxacillin + rifampin for at least 6 weeks, in combination with gentamicin for 2 weeks. 9. MRSA infection on prosthetic valve: - Vancomycin + rifampin for at least 6 weeks, in combination with gentamicin for 2 weeks
  • 39. Antimicrobial Therapy 10. Gram negative endocarditis caused by HACEK organisms: - ceftriaxone or ampicillin plus gentamicin for 4 weeks
  • 40. Culture Negative Endocarditis • Intracellular organisms – Bartonella henselae – Coxiella burnetti – Mycoplasma pneumonia – Legionella pneumophila • Diagnosis is made by checking IgM/IgG serologies
  • 41. Culture Negative Endocarditis Treatment • One should cover for the HACEK organisms, alpha streptococci & last slide • Ceftriaxone 2 grams IV daily + vancomycin 1 g q 12 - 6 weeks
  • 42. New Treatments • Right-sided infective endocarditis due to methicillin- susceptible S aureus (MSSA) in IV drug users – 2-wk therapy with a penicillinase-resistant penicillin and an aminoglycoside – 2-wk monotherapy with IV cloxacillin – short-term therapy is inappropriate if complicated by ostomyelitis, meningitis, myocardial abscess, or concomitant left-sided involvement
  • 43. New Treatments • Highly penicillin-susceptible Streptococcus viridans or bovis – Once-daily ceftriaxone for 4 wks • cure rate > 98% • easily administered as outpatient, avoid hospitalization, offers significant cost savings – Once-daily ceftriaxone 2 g for 2wks followed by oral amoxicillin qid for 2 wks – Once-daily ceftriazone and netilmicin for 2 wks
  • 44. New Treatments • Prosthetic valve endocarditis due to fluconazole- susceptible Candida species – many are due to bloodstream invasion – chronic oral suppressive therapy with fluconazole for inoperable disease
  • 45. Surgical Treatment • 15-25% of patients with IE are treated surgically • Indications - – Antibiotic therapy fails – Persistent vegetation after systemic embolization – Increase in vegetation size after antimicrobial therapy – Valvular dysfunction – Fungal endocarditis
  • 46. Complications of Endocarditis • Cardiac 33-50% • Neurologic 25-35% • Emboli 15-35% • Metastatic Abscesses <5%
  • 47. Neurologic Complications • Acute encephalopathy • Meningitis • Embolic stroke • Cerebral hemorrhage • Brain abscess
  • 48. Embolic Phenomena • Stroke • Ischemic extremities • Pulmonary emboli • Paralysis due to embolic infarction of either the brain or spinal cord • Hypoxia from pulmonary emboli • Abdominal pain (splenic or renal infarction
  • 49. Metastatic Spread of Infection • Metastatic abscess – Kidneys, spleen, brain, soft tissues • Meningitis and/or encephalitis • Vertebral osteomyelitis • Septic arthritis
  • 50. Local Spread of Infection • Heart failure – Extensive valvular damage • Paravalvular abscess (30-40%) – Most common in aortic valve, IVDA, and S. aureus – May extend into adjacent conduction tissue causing arrythmias – Higher rates of embolization and mortality • Pericarditis • Fistulous intracardiac connections
  • 52. Poor Prognostic Factors • Female • Diabetes mellitus • S. aureus • Low serum albumen • Vegetation size • Apache II score • Aortic valve • Heart failure • Prosthetic valve • Paravalvular abscess • Older age • Embolic events
  • 53. Thank you Download more documents and slide shows on The Medical Post [ www.themedicalpost.net ]