İnfektif Endokardit

Dr. Enes Alıç

• The disease characterized by infective masses (vegetations)
on heart valves and a systemic inflammatory response.
• Existing valve disease is the most significant predisposing
factor, though it is not an absolute requirement; it can rarely
occur on healthy valves as well.
• It is most commonly seen in the mitral and aortic valves,
while right-sided endocarditis is typically observed in
intravenous drug users
Profilaksi
• Despite current treatments, mortality remains high,
making prophylaxis critically important.
• Infective endocarditis (IE) prophylaxis involves
administering antibiotics before procedures that may
cause bacteremia.
• Previously recommended for a much wider range of
procedures, prophylaxis is now advised only for
patients at the highest risk.
• Definition
Infective endocarditis is a severe disease that develops due to bacterial or
fungal infection on heart valves or the endocardial surface. Prophylaxis is
important for certain patient groups due to the high mortality rate.
• Who Should Receive Prophylaxis?

1.High-Risk Patient Groups

1. Prosthetic Valve or Prosthetic Material Usage
1. Mechanical or bioprosthetic valves
2. Prosthetic material used for valve repair
2. History of Previous Infective Endocarditis
3. Certain Congenital Heart Diseases
1. Cyanotic congenital heart diseases (unrepaired or partially repaired)
2. Completely repaired heart diseases (with prosthetic material) within the first 6 months
3. Residual defects after repair (in or near the prosthetic material placement area)
4. Patients Who Develop Valve Disease Following Cardiac Transplantation
• When Should Prophylaxis Be Administered?
Prophylaxis is recommended only for invasive procedures with a high risk
of causing bacteremia:

1.Dental Procedures
1. Manipulation of the gingival tissue or invasion of the periapical region
2. Procedures with the potential for mucosal tearing (e.g., tooth extraction,
periodontal surgery)

2.Respiratory Tract Procedures

1. Invasive procedures such as tonsillectomy or adenoidectomy
2. Prophylaxis may be required if bronchoscopy is performed with a biopsy

3.Intervention on Infected Tissues

1. Active infections involving the skin, soft tissues, or musculoskeletal system
 Profilaksi
• Prophylaxis is required for dental procedures involving high-risk
patients (e.g., manipulation of gingival and periapical regions or perforation of the
oral mucosa).
• SUMMARY: Infective endocarditis (IE) prophylaxis is recommended for the highest-
risk patients undergoing the riskiest procedures (in terms of bacteremia and
contamination)!!!
Profilaksi (ESC 2015)
• Diagnosis
Patients often present with signs of systemic inflammation (e.g., fever, elevated ESR,
and CRP levels).
• The presence of a murmur on examination in a patient being evaluated for fever strongly
suggests the possibility of infective endocarditis (IE).
• FEVER + MURMUR ==> INFECTIVE ENDOCARDITIS!!!!!!!!!!
• Fever and Embolic Events in IE
Infective endocarditis (IE) may present with embolic events alongside fever as part of
the clinical presentation:
• Infective emboli or abscesses in the brain, lungs, and spleen occur in 30% of
patients as the presenting symptoms!
• FEVER + EMBOLIC EVENT (SVO) ==> INFECTIVE ENDOCARDITIS!!!!!!!!!!
physical examination findings
Sign Patients Affected (%)
Fever 80-90
Heart murmur 75-85
New murmur 10-50
Changing murmur 5-20
Central neurologic abnormality 20-40
Splenomegaly 10-40
Petechiae/conjunctival hemorrhage 10-40
Splinter hemorrhages 5-15
Janeway lesions 5-10
Osler nodes 3-10
Retinal lesion or Roth spot 2-10
diagnosis
• Laboratory Findings:
Non-specific inflammatory markers are expected to be elevated, including:
• WBC ⇑ (leukocytosis)
• ESR ⇑ (elevated erythrocyte sedimentation rate)
• CRP ⇑ (C-reactive protein)
• Procalcitonin ⇑
• These findings indicate a systemic inflammatory response, which is a hallmark of
infective endocarditis.
• Imaging:
The first-line imaging modality is transthoracic echocardiography (TTE), which is
non-invasive and widely available.
• If TTE does not provide clear visualization, transesophageal echocardiography
(TEE) is performed for better resolution, especially in cases with prosthetic valves or
suspected complications.
• diagnostic Findings of Infective Endocarditis on TTE and TEE:
• Vegetation: Mobile echogenic mass attached to a valve or other
endocardial surface.
• Abscess: Echolucent area indicating a localized infection within the
cardiac tissue.
• Pseudoaneurysm: False aneurysm arising due to infection-induced
structural weakening.
• Prosthetic Valve Dehiscence: Partial or complete detachment of a
prosthetic valve, often associated with infection.
• These findings are critical in confirming the diagnosis of infective
endocarditis, with transesophageal echocardiography (TEE) offering
superior sensitivity compared to transthoracic echocardiography (TTE).
Vejetasyon
• New Imaging Modalities Recently Used in Diagnosis:

1.CT (Computed Tomography):

1. Particularly useful in prosthetic valve endocarditis.
2. High sensitivity and specificity comparable to TTE/TEE for detecting complications such as:
1. Abscesses
2. Fistulas
3. Pseudoaneurysms

2.SPECT/PET (Single Photon Emission Computed Tomography/Positron

Emission Tomography):
1. Uses labeled WBC or FDG (fluorodeoxyglucose).
2. Increased metabolic activity detected on PET indicates active inflammation, aiding in
diagnosing infective endocarditis, especially in challenging cases or prosthetic valve
infections.
• Blood Culture in Microbiological Diagnosis
• Blood culture is the most important method for:
• Identifying the causative pathogen.
• Performing antibiotic susceptibility testing.
• Procedure for Patients Suspected of Infective Endocarditis
(IE):
• Obtain 3 separate blood cultures using sterile technique
at 30-minute intervals (each sample should be at least 10 mL).
• Initiate standard antibiotic therapy immediately after collecting
the samples (do not wait for fever episodes).
• the Most Common Pathogens: Gram-Positive Cocci

1.Viridans Streptococci
1. Examples: Streptococcus sanguis, Streptococcus oralis (mitis), Streptococcus salivarius.
2. Significance: Worldwide, viridans streptococci are the most common cause of infective
endocarditis in both native and prosthetic heart valves!
3. Clinical Course: Endocarditis caused by viridans streptococci is typically characterized by
a subacute progression.

2.Streptococcus gallolyticus (formerly S. bovis)

1. Association: Commonly linked to gastrointestinal (GI) pathologies, particularly colorectal
cancer (colon cancer).

• These organisms are key culprits in infective endocarditis, and their presence often
provides diagnostic and therapeutic insights, including the need to investigate underlying
GI conditions.
• 2. Staphylococci
• Staphylococcus aureus:
• Causes acute and fulminant infective endocarditis.
• Its incidence is increasing, particularly in healthcare-associated infections.
• Prosthetic valve endocarditis caused by S. aureus has a very high mortality rate.

• 3. Enterococci
• The incidence increases with age.
• Typically originates from the genitourinary system.
• 4. HACEK Group
• Refers to a group of fastidious Gram-negative bacteria (Haemophilus, Aggregatibacter,
Cardiobacterium, Eikenella, Kingella).
• Colonizes the oropharynx and upper respiratory tract.
• Associated with community-acquired, subacute infective endocarditis.
• Culture-Negative Endocarditis
• Most Common Causes:
• Prior antibiotic use:
 Antibiotics started before blood cultures are obtained can suppress microbial growth, leading
to negative results.

• Pathogens not detected by standard blood cultures or slow-growing

organisms, including:
 Fungi
 Coxiella burnetii
 Bartonella species
 Brucella species
 Tropheryma whipplei
 Legionella species

• In cases of culture-negative endocarditis, specialized diagnostic methods (e.g.,

serologic tests, molecular techniques, or specific culture media) may be necessary
to identify the causative pathogen.
Diagnostic Criteria for Infective Endocarditis - Duke Criteria

• Major Criteria for Infective Endocarditis Diagnosis

1.Positive Blood Culture

1. Isolation of typical microorganisms consistent with infective endocarditis.

2.Imaging Findings
1. Echocardiography (TTE/TEE):
1. Vegetation
2. Abscess
3. Fistula
4. Pseudoaneurysm
5. Valve perforation
6. Prosthetic valve dehiscence
2. CT Scan:
1. Evidence of prosthetic valve dysfunction.
3. SPECT/PET:
1. Increased uptake around prosthetic valve, indicating inflammatory or infectious activity.
• Minor Criteria for Infective Endocarditis (Duke Criteria):
• Predisposition:
• Presence of a predisposing heart condition (e.g., valve disease).
• Intravenous drug use.

• Fever:
• Temperature >38.0ºC.

• Vascular Phenomena:
• Arterial emboli.
• Septic pulmonary infarcts.
• Infectious aneurysm.
• Intracranial hemorrhage.
• Janeway lesions.

• Immunologic Phenomena:
• Glomerulonephritis.
• Osler nodes.
• Roth spots.
• Rheumatoid factor (RF).

• Microbiological Evidence:
• Positive blood cultures for microorganisms not meeting the major criteria.
• Definite Infective Endocarditis (IE) Diagnosis
• The diagnosis of definite IE requires the following combinations of Duke
Criteria:
• 2 Major Criteria
 (e.g., positive blood cultures and evidence of endocardial involvement).

• OR
• 1 Major + 3 Minor Criteria
 (e.g., positive blood culture, fever, predisposing heart condition, and vascular
phenomenon).

• OR
• 5 Minor Criteria
 (e.g., fever, predisposing condition, vascular and immunologic phenomena, and
microbiological evidence).
 Treatment
• Antibiotic Selection Based on Isolated Pathogen
• For native valve endocarditis caused by Oral streptococci or Streptococcus bovis:

1.Penicillin-sensitive strains:
1. Penicillin G, Amoxicillin, or Ceftriaxone for 4 weeks.

2.Penicillin-resistant strains:
1. Add Gentamicin to one of the above antibiotics.

3.For patients with beta-lactam allergy:

1. Replace the above antibiotics with Vancomycin.
Treatment-surgery
• In Complex Cases, Both Antibiotic and Surgical Treatment Are Required
• 1. Heart Failure:
• Occurs due to:
• Acute severe regurgitation/stenosis of the aortic or mitral valves caused by native valve
endocarditis (NVE) or prosthetic valve endocarditis (PVE).
• Valve perforation.

• Clinical consequences:
• Pulmonary edema.
• Cardiogenic shock.

• Surgical intervention is often crucial in such cases to address mechanical

complications and stabilize the patient.
Treatment-surgery
• 2. Uncontrolled Infection
• Surgical intervention is often required in cases of persistent or uncontrolled infection due
to:
• Complications such as:
• Abscess formation.
• Fistula.
• Pseudoaneurysm development.
• Enlargement of vegetations.

• Specific pathogens:
• Fungal infections or highly resistant organisms.

• Failure of antibiotic therapy:

• Persistent positive control blood cultures despite appropriate antibiotic treatment.

• Prosthetic valve endocarditis caused by staphylococci:

• Particularly challenging due to high virulence and resistance potential.

• These situations necessitate surgical intervention to manage the infection and prevent
further complications.
Treatment-surgery
• Emboli Prophylaxis
• Vegetation Size and Risk:
• Vegetations larger than 10 mm are associated with a high risk of embolism.

• Surgical Consideration:
• If the vegetation size does not decrease despite antibiotic treatment, surgery should be
considered.
• In patients who experience embolic events while on antibiotics and have vegetations >10 mm,
surgery is also indicated.

• This approach aims to prevent further embolic complications in high-risk patients with
infective endocarditis.