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Infective endocarditis
- 1. PROF DR FARHAT BASHIR UNITED MEDICAL & DENTAL COLLEGE
- 3. Infection of the endocardial surface of heart characterized by - Colonization or invasion of the heart valves (native or prosthetic) or the mural endocardium by a microbe, - leading to formation of bulky, friable vegetation composed of thrombotic debris and organisms - often associated with destruction of underlying cardiac tissue.
- 4. • Heart valves • Ventricular septum defects • Mural endocardium • Intracardiac devices • INFECTIVE ENDARTERITIS – analogous
- 5. Native valve endocarditis Prosthetic valve endocarditis Intravenous drug abuser infective endocarditis Nosocomial endocarditis
- 7. ACUTE ENDOCARDITIS SUBACUTE ENDOCARDITIS Destructive and tumultuous infection, frequently of a previously normal heart valve, with a highly virulent organism Hematogenous seeding Organisms of low virulence causing infection in a previously abnormal heart, particularly on deformed valves. Disease appear insidiously and pursue a protracted course of weeks to month
- 8. Cardiac and vascular abnormalities Host factors RHD Congenital heart disease ◦ Myxomatous mitral valve ◦ Degenerative calcific valvular stenosis ◦ Bicuspid aortic valves Prosthetic valves Neutropenia Immunodeficiency Malignancy Therapeutic immunosuppression Diabetes mellitus Alcohol IV drug abuse Dental manipulation, dental caries, dental abscess Extracardiac infections Instrumentation(urinary tract, GIT, IV line) Cardiac surgery
- 9. Staphylococcus aureus (35%) : Either healthy or deformed valves, IV drug abusers (polymicrobial), devices Streptococcus viridans (32%) : Native but previously damaged/abnormal valves Enterococci (8 %) S. epidermidis (4%): Prosthetic valve endocarditis, devices G –ve bacilli of HACEK group (4%) Yeast and Fungi(1%) Culture negative endocarditis (5 %)
- 10. Pathology ◦ NVE (native) infection is largely confined to leaflets ◦ PVE (prosthetic) infection commonly extends beyond valve ring into annulus/periannular tissue Ring abscesses Septal abscesses Fistulae Prosthetic dehiscence ◦ Invasive infection more common in aortic position and if onset is early 03-03-2020 12
- 11. Portal 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 ◦ Invasive procedures
- 12. Turbulent blood flow within the heart - most often (but not always) – patient has risk factors for this Turbulent blood flow disrupts valve surface (endocardium) to produce suitable (sticky) site for bacterial attachment Platelet deposition + fibrin may lead to non-bacterial thrombus or vegetation Bacteraemia – delivers organisms to the damaged (sticky) endocardial surface resulting in adherence & colonisation Eventual invasion of valve leaflets results in infected vegetation (sheath of fibrin & platelets, ideal conditions for further bacterial multiplications, protection from polymorphs) 03-03-2020 14
- 13. Endothelial Injury Uninfected Platelet-Fibrin thrombus Transient bacteremia and attachment Proliferation and pro-coagulant state Infected, friable, bulky vegetation
- 14. Feature Acute Subacute Underlying Heart Disease Heart may be normal RHD,CHD, etc. Organism S. aureus, Pneumococcus S. pyogenes, Enterococcus viridans Streptococci, Entercoccus 03-03-2020 16
- 15. Constitutional symptoms --- Cytokine release ? Symptoms - Damage to intracardiac structures - Embolization of vegetation fragments - Hematogenous infection - Immune complex
- 16. 1. Fever. 2. Murmurs 3. Petechial and cutaneous manifestations. Roth spots, conjunctival and mucosal petechiae, splinter hemorrhages, Osler nodes and Janway lesions. 4. Splenomegaly 5. Embolism. Septic or sterile. CNS, spleen, lung, retinal vessels, coronary artery, large vessels. 6. Renal disease, infarction. Glomerulonephritis and uremia 7. CHF 8. General. Weight loss, anorexia, debilitation. 03-03-2020 18
- 17. Endocarditis • Persistent fever • Constitutional symptoms • New signs of valve dysfunction • Heart failure • Embolic Stroke • Peripheral arterial embolism
- 20. 03-03-2020 22 1. More specific 2. Erythematous, blanching macules 3. Nonpainful 4. Located on palms and soles
- 22. 03-03-2020 24 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
- 23. CBC ESR CRP Urine DR ECG CXR-PA view Serological tests BLOOD CULTURE ECHOCARDIOGRAPHY
- 24. Blood cultures: Echocardiography 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. 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. Transesophageal echocardiography is more sensitive than TTE. It can detect small vegetations, prosthetic endocarditis and intra cardiac complications.
- 27. 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
- 28. Positive 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 ◦ Myocardial abscess ◦ New partial dehiscence of prosthetic valve
- 29. 1. Predisposition: Predisposing valvular or cardiac abnormality 2. Intravenous drug misuse 3. Pyrexia ≥38°C (≥100.4°F) 4. Embolic phenomenon 5. Vasculitic/ immunologic phenomenon 6. Blood cultures suggestive: - organism grown but not achieving major criteria 7. Suggestive echocardiographic findings
- 30. Antimicrobial 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.
- 31. Resolution of fever occurs in 5 to 7 days. If fever persists patient should be evaluated for complications like paravalvular abscess and extracardiac abscess. Serologic abnormalities resolve slowly and do not reflect response to treatment.
- 32. Antibiotic regimen for infective endocarditis Streptococci Benzyl penicillin (2-3 million units 4 hourly) 4-6 weeks Gentamicin (1mg/kg 8-12 hourly) 4-6 weeks (ceftriaxone & vancomycin) Enterococci o 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)
- 33. Staphylococci o Penicillin sensitive Benzyl penicillin I.V(2-3 Munits 4 hourly) + gentamicin o Penicillin resistant but methicillin sensitive Flucloxacillin I.V (2g 4 hourly ) o Both penicillin and methicillin resistant Vancomycin I.V (1g 12 hourly) and Gentamicin
- 34. Surgery Indications patients with direct extension of infection to myocardial structures. 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.
- 35. Prophylaxis High risk category prosthetic cardiac valves Previous bacterial endocarditis, even in absence of heart disease. Complex cyanotic congenital heart disease(TGA,TOF) Surgically constructed systemic pulmonary shunts.
- 36. Moderate risk category Rheumatic and other valvular dysfunction Congenital cardiac malformations Hypertrophic cardiomyopathy Mitral valve prolapse with valvular regurgitation
- 37. High risk lesions ◦ Prosthetic valves ◦ Prior IE ◦ Cyanotic congenital heart disease ◦ PDA ◦ AR, AS, MR,MS with MR ◦ VSD ◦ Coarctation ◦ Surgical systemic-pulmonary shunts Intermediate risk ◦ MVP with murmur ◦ Pure MS ◦ Tricuspid disease ◦ Pulmonary stenosis ◦ ASH ◦ Bicuspid Ao valve with no hemodynamic significance 03-03-2020 42 Lesions at highest risk
- 38. 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.
- 39. Thank you.