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ENFECTIVE ENDOCARDITIS
M.RASOOLINEJAD, MD
DEPARTMENT OF INFECTIOUS DISEASE
TEHRAN UNIVERSITY OF MEDICAL SCIENCE
INFECTIVE ENDOCARDITIS
Infection of the endocardial surface
INFECTIVE ENDOCADITIS
INTRUDUCTION
•Clinical manifestations are so varied.
•All of medical subspecialist must encounter
•Successful management Medical & Surgical.
EPIDEMIOLOGY
20% of cases are categorized as definite
Mean age of patients are increased
Underlying heart disease
Rheumatic heart disease
Degenerative heart disease
Congenital heart disease
Nosocomial endocarditis
Intracardiac prostheses
Injection Drug Users ( IDU )
PATHOGENESIS
Endothelium
(Trauma, Turbulance,
metabolic change )
Mucus membrane
or
Colonized tissue
Local factor
Bacteriocins
IgA protease
Bacterial adherence
Plt - fib deposition
Trauma
NBTE
Bacteremia
Adherence
Complement
Antibody
Colonization
Mature Vegetation
PATHOGENESIS
Nonbacterial Thrombotic Endocarditis (NBTA)
Hemodynamic factor
Transient Bacteremia
Microorganisms
Immunopathologic
ETIOLOGIC AGENTS
Streptococci ( viridance, Fecalis,… )
60 – 80 %
Staphylococci ( +ve Or -ve coagolase )
20 – 30 %
Gram -ve bacteria
1.5 – 13%
Fungi
2 - 4%
Culture negative
5 – 25 %
Others
1–2%
CULTURE – NEGATIVE ENDOCARDITIS
Subacute right – side infective endocarditis
Chronic course > 3 months
Uremia supervening chronic course
Mural IE as in VSD
Pacemaker wires infection
CULTURE - NEGATIVE ENDOCARDITIS
HACEK*
Brucella spp,
Prior administration of antibiotics
Rickettsiae, Chlamydia, Virus
Noninfective endocarditis
* Haemophilus spp, Actinobacillus spp, Cardiobacterium spp,
Eikenella, Kingella
PATHOLOGY
HEART:
•Vegetation ( fibrin, Plt, bacteria, PMN, RBC )
•Valve change perforation.
•Rupture of chordae tendinae, septum and
papillary muscle
•Ring abscess
•Valvular stenosis
•Valvular regurgitation
•Myocardial abscess
•Pericarditis, effusions
•Coronary emboli
PATHOLOGY
RENAL
Renal architecture
is abnormal in all cases,
Even in the absence of
clinical or biochemical
of renal disease
PATHOLOGY
RENAL
Focal glomerulonephritis
Diffuse glomeruonephritis
Membranoproliferative glomerulonephritis
Renal infarction
Renal abscess
PATHOLOGY
CNS
Emboli (middle cerebral artery )
Infarction
Arteritis
Abscess
Mycotic aneurysms
Hemorrhage:Intracerebral or Subarachnoid
Encephalomalacia
Meningitis
PATHOLOGY
MYCOTIC ANEURYSMS
Usually during active IE
Occasionally mons or years after successful treatment
Direct bacterial invasion abscess
Septic embolic to vasa vasorum
Immun complex deposition
Cerebral vessels, abdominal aorta, sinus of Valsalva
Clinically silent until rupture
PATHOLOGY
SPLEEN: Infarction, Abscess, Enlargement
LUNG: Emboli, Acute Pneumonia,
Pleural Effusion
SKIN:
Ptechiae,
Osler node ( Arteriolar intimal proliferation )
Janeway lesions ( Becteria, Necrosis, PMN, Hemorrhage)
EYE: Roth spots ( Lymphocyte, Edema, Hemorrhage )
CLINICAL
MANIFESTATION
JOINT
CNS
FUO
FEVER
SEPTIC
EMBOLI
IE
ICTER
EYE
KIDNEY
HEART
SKIN
PAIN
LUNG
IE & IDU
More common in cocain users
Febrile IDU = IE
No underlying heart disease
More common in tricuspid valve
Aortic > Aortic + Mitral > Mitral valve
Pumonary septic emboli
S aureous, P aueroginosa
IDU & HIV / AIDS
IE & ELDERLY
Increased incidence in elderly
Prolonged survival with CVD, PHV in elderly,
Intravascular monitoring devises, Surgical implant material.
No specific symptoms & sings
Strep faecalis & bovis are common.
Diagnosis may be difficult.
Prompt empirical therapy : Vancomycin + Gentamycin
Cardiac complications :
 CHF, Conduction abnormality, Arrhythmias,
 Myocarditis, Myocardial abscess.
LAB FINDING
 Anemia ( normochromic, normocytic, Fe, IBC )
 Thrombocytopenia ( 5 – 15 % )
 Leucocyte count (
or
or )
 Large mononuclear cells ( histiocyte )
 ESR ( mean 57 mm/hr )
 Hypergammaglobulinemia
 Positive RF ( 40 – 50 % )
 Complement ( 5 – 15 % )
 Positive VDRL & positive CIC
 U/A ( protein,RBC, WBC )
 Positive blood culture & Positive ECHO
 Serology & Teichoic acids antibody
DIAGNOSIS
Durack DT, Lukes AS, Bright DK, Criteria
Definite ( Pathologic & Clinical Criteria )
Possible
Rejected
CLINICAL CRITERIA
2 Major or
1 Major & 3 Minor or
5 Minor
MAJOR CRITERIA
Positive blood culture
Evidence of endocardial involvement
MINOR CRITERIA
Predisposing heart disease or IDU
Fever > 38
Vascular phenomena
Immunologic phenomena
ECHO
Microbiologic evidence
POSITIVE BLOOD CULTURE
Typical microorganisms:
( S. viridance, S. bovis, HACEK, Entrococci, S. aureous
in the absence of primary focus)
Persistently positive blood cultures
( B/Cs drown more than 12 hr apart, or
All of 3 or majority of 4 separate B/Cs with 1st
& last drawn at least 1 hr apart )
HACEK: Haemophilus spp, Actinobacillus spp,
Cardiobacterium homonis, Ekinella corrodence
Kingella kingae
EVIDENCE OF
ENDOCARDIAL INVOLVEMENT
Positive ECHO for IE
Oscillating intracardiac mass
Abscess
New dehiscence of prosthetic valve
New valvular regurgitation
veg
Mitral valve Vegetation
Mitral valve vegetation
TREATMENT
 Antimicrobial therapy
High dose, prolonged & IV antibiotics
 Surgical therapy
ANTIMICROBIAL THERAPY
 Empirical therapy
 Organisms based therapy
 Duration of treatment
MONITORING ANTIMICROBIAL THERAPY
•Serum concentration of antibiotic
should be monitoring.
•Antibiotic toxicities should be considered.
•Blood culture should be repeated daily  Sterile
•Rechecked B/C if there is recrudescent fever.
•Performed B/C 4 – 6 WKS after therapy
to document cure.
MONITORING ANTIMICROBIAL THERAPY
•B/C became sterile after start antibiotics:
 2 days in  S.Viridance
Enterococci
HACEK organisms
 3 – 5 days in  S. Aureus + beta lactam
 7 days in  S. Aureus + Vancomycin
MONITORING ANTIMICROBIAL THERAPY
If fever persist for 7 days in spite
appropriate AB  Evaluate patient for:
Paravalvular abscess
Extracardiac abscess
Embilic event
Vegetation became smaller with effective therapy
3 months after cure: 50% unchanged
25% are slightly larger
SURGICAL THERAPY
Refractory CHF
> One serious systemic emboli
Uncontrolled infection
Valve dysfunction ( ECHO )
Fungal & Brucella endocarditis
Mycotic aneurysms
Prosthetic valve
Local suppurative complications
Large vegetation > 1 cm
 Vegetation size after 4 WKS
Aortic valve endocarditis
Acute valve insufficiency
Recurrent endocarditis
INDICATION FOR SURGICAL INTERVENTION
Surgery required for optimal outcome
Surgery to be strongly considered
for improved outcome
INDICATION FOR SURGICAL INTERVENTION
Surgery required for optimal outcome:
*Moderate
to severe CHE due to valvular dysfunction.
*Partially dehisced unstable prosthetic valve.
*Persistent bacteremia despite optimal AB therapy.
*Lake of effective microbial therapy ( fungal, Brucella…
*S. Aureus PVIE + intra cardiac complication.
*Relapse of PVIE after optimal therapy
INDICATION FOR SURGICAL INTERVENTION
Surgery to be strongly considered for improved outcome:
*Peivalvular extension of infection
*Poorly responsive S. aureus in aortic or mitral valve.
*Large > 10 Cm hypermobile vegetation
*Persistent unexplained fever >10 days in culture -ve IE.
*Poorly responsive or relapse ( Entrococci & Gram-ve )
Valve Ring abscess
Intra operation
After repair
Intraoperative TEE
PROPHYLAXIS OF ENDOCADITIS
Potential Interventions
Alleviation of predisposing condition
Immunization against bacteria
Inhibition of bacterial adherence
Application of antiseptic in the mouth
Administration of antibiotics
Procedure Causing Bacteremia:
Oral cavity
Respiratory tract
Genitourinary tract
Gastrointestinal tract
Vascular system
RISK OF IE WITH CARDIAC DISORDERS
HIGH RISK:
PHV, PID, Cyanotic CHD, PDA, AS, MR, VSD,
Coarctation of aorta
INTERMEDIATE RISK
Prolapse +MR, MS, TS, TR
Bicaspid Aorta, Degenerative Heart Disease
LOW / NO RISK
Prolapse Mitral, ASD, Aterosclerosic Plaques,
CAD, Pacemaker.
ANTIBIOTIC PROPHYLAXIS
High risk procedures
 Recommended
&
High risk of cardiac disease
High risk procedures
 Recommended
&
Intermediate risk of cardiac disease
Low risk procedures
 Optional
&
High risk of cardiac disease
RECOMMENDED REGIMENS
Procedures: Dental, upper Res, GI, GU,
Implantation of Prosthetic Valve
Amoxicillin PO
Clindamycin Po
Ampicillin + Gentamycin
Cefazolin
Vancomycin + Gentamycin
Before
&
After