Infective Endocarditis: Hariprasad K

Infective
Endocarditis
Hariprasad k
Definition
Infection of the endocardial surface of the heart
characterized by colonization or invasion of the heart valves
or endocardium by a microbe, leading to formation of
vegetation composed of thrombotic debris.
Classification
ACUTE ENDOCARDITIS SUBACUTE ENDOCARDITIS
• Infection of a previously • Organisms of low virulence (degree

normal heart valve, with a of pathogenicity) causing infection
highly virulent organism and in a previously abnormal or
can manifest as a rapidly deformed valves.
progressive illness • Disease appear insidiously and
• If untreated, leads to death extent a course of weeks to months
within weeks • Recover after appropriate antibiotic
treatment
Other classifications
BASED ON CAUSE BASED ON SITE OF INVOLVEMENT
• IV drug abuse IE (IVDA IE) •Prosthetic valve

endocarditis (PVE)
• Fungal endocarditis
•Valvular endocarditis
(mitral, tricuspid, aortic)
Causative organisms
• Staphylococcus aureus (35%) : Either healthy or deformed valves, IV drug
abusers , devices
• Streptococcus viridans (32%)
• Enterococci (8 %)
• Staphylococci epidermidis (4%): Prosthetic valve endocarditis, devices
• Fungi(1%)
• Viruses
Predisposing factors
CARDIAC AND VASCULAR ABNORMALITIES HOST FACTORS
• Previous endocarditis , RHD • Immunodeficiency
• Acquired valve disease like mitral • Malignancy
valve prolapse • Hospital acquired
• Cardiac lesions , Pacemakers, bacteremia
Prosthetic heart valves
• Diabetes mellitus
• Cardiomyopathy, Congenital heart
disease and Marfans • IV drug abuse
syndrome(inherited disorder that
affects connective tissue)
Procedure associated risks
Portal of entry:
◦ Dental / Surgical Procedures ◦ Intravascular catheter infection
◦ Contamination by IV drug use ◦ Nosocomial wounds
◦ Occult source from gut, oral cavity ◦ Respiratory tract incision like biopsy
◦ Trivial injuries. ◦ Tonsillectomy and adenoidectomy
◦ Wound infection
PATHOPHYSIOLOGY
Due to etiological factors and risk factors
Entry of infective organisms to the body and reach to the heart
IE occurs when blood turbulence within the heart allows the causative
organism to infect previously damaged (occurs in individuals who have
underlying risk factors) or healthy valves and endocardium
Vegetations occurs as primary lesions of IE
Vegetations consist of fibrin, leukocytes, platelets and microbes which stick
to the valve surface and endocardium
Fragile vegetations moves into the circulation and causes emboli
Systemic embolization and local heart valve damage
Systemic embolization
Left sided heart vegetation
Vegetation moves to various organs like brain, kidneys, liver, spleen and
extremities causing limb infarction
right sided heart vegetation
Vegetation moves to lungs, resulting in pulmonary emboli
local heart valve damage
Valve damage of heart leads to dysryhthmias, valve dysfunction and
eventual invasion to the myocardium leading to heart failure, sepsis and
heart block
Clinical features
Nonspecific symptoms and can involve multiple
organ systems
• Low grade fever
• Chills, weakness, malaise, fatigue and anorexia
• Arthralgias, myalgias, back pain, abdominal discomfort, weight
loss, headache and clubbing of fingers – mainly seen in
subacute type
Vascular and integumentary
manifestations Oslers node – painful, tender, red
or purple, pea size lesions
• Splinter hemorrhages -are tiny blood
• It is found on the fingertips or toes
clots that tend to run vertically under
the nails. Janeway’s lesions – flat, painless,
small, red spots
• Petechiae (small red or purple spot
caused by bleeding into the skin) due • Mainly seen in palms and soles
to fragmentation and Fundoscopic examination can
microembolization of vegetative reveal hemorrhagic retinal lesions
lesions – roths spots
• Petechiae can occur in conjunctiva,
lips , buccal mucosa, palate and over
ankles, feet and antecubital and
popliteal areas
Cardiovascular changes
New or changing murmur ,Aortic and mitral valves are most often affected.
Heart failure occurs mostly in aortic valve endocarditis (80%)
Due to embolization
• Spleen – sharp, left upper quadrant pain and splenomegaly, local
tenderness and abdominal rigidity
• Kidneys – flank pain, hematuria and renal failure
• Small peripheral blood vessels – ischemia and gangrene
• Brain – neurologic damage resulting hemiplegia, ataxia, aphasia, visual
changes and change in consciousness
• Lungs – pulmonary embolization leads to dyspnea, chest pain, hempotysis
and respiratory arrest
Diagnostic measures
.
Investigations
 Blood cultures:
Key diagnostic investigation in infective endocarditis.
Isolation of microorganism from culture is important for diagnosis and also
for treatment.
At least 2 sets of samples should be taken 30 minutes apart from 2 different
venepuncture sites over 24 hours – will be positive in 90% cases
Negative culture is often associated with antibiotic usage within the
previous 2 weeks , in that case the culture should keep for 3 weeks for slow
growing of organisms
Serology
 Can be sent when the diagnosis is suspected and the cultures are
negative.
ECG
To detect complications like MI, conduction abnormalities. ECG shows
first or second degree AV block (cardiac valves are located near to the
conductive tissues especially AV node)
CHEST X RAY
• To detect cardiomegaly
.
Cardiac catheterization
• To evaluate valve functioning and to assess the coronary arteries when
surgical intervention is considered
Echocardiography
It can identify the presence and size of vegetations, detect intracardiac
complications and assess cardiac function.
.
Complete blood counts

may show anemia and increased WBC counts.
Urea and Creatinine:
may be elevated due to glomerulonephritis
Liver biochemistry:
Serum alkaline phosphatase may be increased
Inflammatory markers
CRP, ESR are increased in infection .
Urine
proteinuria and hematuria occur frequently.
Modified Dukes Criteria for diagnosis of
Infective Endocarditis
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
Major Criteria
Positive blood culture
◦ Typical organism from two cultures
Endocardial involvement
◦ New or changed heart murmur or intra cardiac mass or
vegetation noted on echo
Minor Criteria
• Predisposition: Predisposing valvular or cardiac abnormality
• Intravenous drug misuse
• Pyrexia ≥38°C (≥100.4°F)
• Embolic symptoms
• Vasculitic/ immunologic phenomenon
• Suggestive echocardiographic findings
TREATMENT
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.
• Effectiveness of therapy is detected by blood cultures. If culture remains
positive means inappropriate selection of antibiotics or may be due to fungi
or virus or other causes
Fever – persist for several days after treatment
Treated with aspirin, acetaminophen, ibuprofen,
fluids and rest
Antibiotic regimen for infective endocarditis
 Streptococci
Benzyl penicillin (1.2g 4 hourly) 4-6 weeks
Gentamicin (1mg/kg 8-12 hourly) 4-6 weeks
Enterococci
oAmpicillin (2 g 4 hourly) 4-6 weeks, and
Gentamicin (1mg/kg 8-12 hourly)
or
oVancomycin(1g 12hourly) 4-6 weeks, and
Gentamicin (1mg/kg 8-12 hourly)
•Staphylococci
oBenzyl penicillin I.V(1.2 g 4 hourly)
oPenicillin resistant but methicillin sensitive
Flucloxacillin I.V (2g 4 hourly )
oBoth penicillin and methicillin resistant
Vancomycin I.V (1g 12 hourly) and
Gentamicin
Prophylaxis treatment - peoples with these problems should take
prohylaxis treatment while undergoing any procedures
prosthetic cardiac valves
Previous bacterial endocarditis, even in absence of heart disease.
cyanotic congenital heart disease.
Cardiac transplantation
Rheumatic and other valvular dysfunction
Congenital cardiac malformations
Hypertrophic cardiomyopathy
Mitral valve prolapse with valvular regurgitation
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.
.
Surgery – valve replacement

Indications
 patients with direct extension of infection to myocardial
structures.
Congestive heart failure.
Badly damaged valves.
IE caused by fungi or gram-ve or resistant organisms.
Large vegetations on echocardiography
Recurrent embolic attacks.
Thank you

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Infective

• Infection of a previously • Organisms of low virulence (degree

• IV drug abuse IE (IVDA IE) •Prosthetic valve

Complete blood counts

Possible Endocarditis if,

Surgery – valve replacement

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