Infective Endocarditis


Published on

Published in: Health & Medicine

Infective Endocarditis

  1. 1. Infective Endocarditis Dr. Kalpana Malla MBBS MD (Pediatrics) Manipal Teaching HospitalDownload more documents and slide shows on The Medical Post [ ]
  2. 2. Definition• Infective Endocarditis (IE): an infection of the heart’s endocardial surfaceClassified into four groups: – Native Valve IE – Prosthetic Valve IE – Intravenous drug abuse (IVDA) IE – Nosocomial IE
  3. 3. Epidemiology• The valves involved – Mitral 28-45% – Aortic 5-36% – Both 0-35% – Tricuspid 0-6% – Pulmonary <1%
  4. 4. Epidemiology• Incidence - varies according to location• Males > females• May occur at any age and increasingly common in elderly• Mortality 20-30%
  5. 5. Predisposing Factors Iv drug use Central line Prosthetic valve Previous IE Murmur Dental procedure Rheumatic disease Miscellaneous
  6. 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. 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. 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. 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. 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. 11. Pathophysiology1. Turbulent blood flow disrupts the endocardium making it “sticky”2. Bacteremia delivers the organisms to the endocardial surface3. Adherence of the organisms to the endocardial surface4. Eventual invasion of the valvular leaflets
  12. 12. Infecting Organisms• Common bacteria in children – S viridans – 50% cases – S. aureus – 40% cases – S. fecalis ,Grp D sreptococcus (Enterococci)
  13. 13. Less common organisms– P. aeruginosa, Staph epidemidis– Histoplasma, candida, Aspergillus– Coxiella burnetti, Brucella, chlamydia– HACEK grp – Hemophilus, Actinobacillus, Cardiobacterium hominis, Eikenella, kingella
  14. 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. 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. 16. Petechiae1. Nonspecific2. Often located on extremities or mucous membranes
  17. 17. Splinter Hemorrhages1. Nonspecific2. Nonblanching3. Linear reddish-brown lesions found under the nail bed4. Usually do NOT extend the entire length of the nail
  18. 18. Osler’s Nodes1. More specific2. Painful and erythematous nodules3. Located on pulp of fingers and toes4. More common in subacute IE
  19. 19. Janeway Lesions1. More specific2. Erythematous, blanching macules3. Nonpainful4. Located on palms and soles
  20. 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. 21. Negative blood culture• Previous antibiotic• Technical errors• Unusual organisms- anaerobic organisms,fungus
  22. 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. 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
  24. 24. mitral valve vegetation
  25. 25. Making the Diagnosis• Pelletier and Petersdorf criteria (1977)• Von Reyn criteria (1981)• Duke criteria (1994)• Modified Duke Criteria
  26. 26. Diagnostic (Duke) Criteria• Major criteria – Positive blood culture for IE – Evidence of endocardial involvement
  27. 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. 28. Duke’s Major Criteria• Evidence of endocardial involvement – positive echocardiogram for endocarditis
  29. 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. 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. 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. 32. Modified Duke Criteria• Rejected IE –Resolution of illness with four days or less of antibiotics
  33. 33. Treatment• Parenteral antibiotics• Surgery – Intracardiac complications• Surveillance blood cultures
  34. 34. Antimicrobial Therapy• Antibiotics IV for 2-6 weeks1. Penicillin-susceptible streptococcal (PSSE) on native cardiac valves:• Penicillin G - 4 weeks or• Penicillin G or ceftriaxone + gentamicin - 2 wks2. Penicillin-resistant streptococcal (PRSE) on native cardiac valves –• Penicillin, ampicillin, or ceftriaxone for 4 weeks + gentamicin for the first 2 weeks
  35. 35. Antimicrobial Therapy3.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. 36. Antimicrobial Therapy5. Enterococcal infection on native valves - penicillin or ampicillin + gentamicin for 4-6 weeks
  37. 37. Antimicrobial Therapy6.Methicillin-susceptible S aureus (MSSA) on native valves :- Nafcillin or oxacillin for at least 6 weeks + gentamicin for 3-5 days is optional7. Methicillin-resistant S aureus (MRSA) on native valves: - vancomycin for at least 6 weeks, with or without 3-5 days of gentamicin
  38. 38. Antimicrobial Therapy8. 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. 39. Antimicrobial Therapy10. Gram negative endocarditis caused by HACEK organisms: - ceftriaxone or ampicillin plus gentamicin for 4 weeks
  40. 40. Culture Negative Endocarditis• Intracellular organisms – Bartonella henselae – Coxiella burnetti – Mycoplasma pneumonia – Legionella pneumophila• Diagnosis is made by checking IgM/IgG serologies
  41. 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. 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. 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. 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. 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. 46. Complications of Endocarditis• Cardiac 33-50%• Neurologic 25-35%• Emboli 15-35%• Metastatic Abscesses <5%
  47. 47. Neurologic Complications• Acute encephalopathy• Meningitis• Embolic stroke• Cerebral hemorrhage• Brain abscess
  48. 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. 49. Metastatic Spread of Infection• Metastatic abscess – Kidneys, spleen, brain, soft tissues• Meningitis and/or encephalitis• Vertebral osteomyelitis• Septic arthritis
  50. 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
  51. 51. Septic Pulmonary Emboli
  52. 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. 53. Thank youDownload more documents and slide shows on The Medical Post [ ]