11. Infective Endocarditis 7th Prt1

7/30/2019 11. Infective Endocarditis 7th Prt1

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Infective Endocarditis

DR Mohamad Jarrah

Assistatnt Professor

Cardiologist

JUST


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Definition

Infectious Endocarditis (IE): an infection of

the hearts endocardial surface

Classified into fourgroups:

Native Valve IE

Prosthetic Valve IE

Intravenous drug abuse (IVDA) IE

Nosocomial IE


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Further Classification

Acute

Affects normal heart

valves

Rapidly destructive Metastatic foci

Commonly Staph.

If not treated, usually

fatal within 6 weeks

Subacute

Often affects damaged

heart valves

Indolent nature If not treated, usually

fatal by one year


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Etiology

Native valve Endocardi t is-Streptococcus viridans, Staphylococci,HACEK

- Oral cavity, skin, upper respiratory tract

Streptococcus bovis (GIT), EnterococciIntravascular catheters, UTI, Nosocomial wound

infections, HD- transient bacteremia

Prosthet ic Valve Endocardi t is-Coagulase negative Staphylococci,S.Aureus, GNB, diptheroids, fungii

Within 2 months- intra-operative contamination


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IV Drug abuse endocardi t is:- Tricuspid valveMRSA

More varies Etiology if left sided heart valves are involved

Polymicrobial

Unusual organisms- Pseudomonas Aeruginosa, Candida, Bacillus,

Lactobacillus, Corynebacterium

Nosocomia l -Transvenous pacemaker lead- and/or implanteddefibrillator associated endocarditis

5-15% may be cultu re negative(?prior antibiotic exposure)

Or fastidious organisms- Coxiella burnetti in Europe, Brucella in the Middle

East

Tropheryma whipplei- indolent afebrile culture negative endocarditis


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Pathophysiology

1. Turbulent blood flow disrupts the

endocardium making it sticky

2. Bacteremia delivers the organisms to

the endocardial surface

3. Adherence of the organisms to the

endocardial surface

4. Eventual invasion of the valvular

leaflets


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Inherently endothelium is resistant to

infection

Turbulent blood f lowcauses endothelial

injury- direct infection

OR

Nonbacterial thrombotic endocarditis-

platelet fibrin thrombus- site of infection


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Epidemiology

Incidence difficult to ascertain and varies

according to location

Much more common in males than in

females

May occur in persons of any age and

increasingly common in elderly

Mortality ranges from 20-30%


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Risk Factors

Intravenous drug abuse

Artificial heart valves and pacemakers

Acquired heart defects Calcific aortic stenosis

Mitral valve prolapse with regurgitation

Congenital heart defectsIntravascular catheters


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Symptoms

Acute

High grade fever and

chills

SOB Arthralgias/ myalgias

Abdominal pain

Pleuritic chest pain

Back pain

Subacute

Low grade fever

Anorexia

Weight loss Fatigue

Arthralgias/ myalgias

Abdominal pain

N/V

The onset of symptoms is usually ~2 weeks or less

from the initiating bacteremia


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Signs

FeverClubbing

Splenomegaly

Neurological manifestations

Heart murmur

Peripheral manifestations- Oslers nodes,

Subungual hemorrhage, Janeway lesions,


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Anemia

Leukocytosis

Microscopic hematuriaElevated ESR, CRP

Decreased serum complement

Immune complexesRheumatoid factor


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Cardiac Manifestations

New regurgitant murmurs- 30-35% then85%

CHF- 30 to 40%- valvular damage (aortic),

myocarditis, intracardiac fistulaPerivalvular abscess

Fistulae (Root of aorta to chambers/

between cardiac chambers)Pericarditis

Heart block/ MI due to embolic

phenomena


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Septic Pulmonary Emboli

http://www.emedicine.com/emerg/topic164.htm


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Non cardiac

Septic embolization- subungual hemorrhage,Oslers nodes

Musculoskeletal

Skin, spleen, kidney, meninges, skeletal system-

infarcts

Embolic strokes

Mycotic aneurysms (infection in vasa vasorum)

Brain microabscesses

Glomerulonephritis (reduced complement)


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Petechiae

1.Nonspecific2.Often located on extremities

or mucous membranes


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Splinter Hemorrhages

1. Nonspecific2. Nonblanching

3. Linear reddish-brown lesions found under the nail bed

4. Usually do NOT extend the entire length of the nail

5. vessel damage from swelling of the blood vessels (vasculitis) or

tiny clots that damage the small capillaries (microemboli).
http://www.nlm.nih.gov/medlineplus/ency/article/000874.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000874.htm


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Oslers Nodes- immune

1. More specific

2. Painful and erythematous nodules

3. Located on pulp of fingers and toes

4. More common in subacute IE

American College of Rheumatology

webrheum.bham.ac.uk/.../ default/pages/3b5.htm www.meddean.luc.edu/.../

Hand10/Hand10dx.html
http://webrheum.bham.ac.uk/professional/slides/lec3b/default/pages/3b5.htmhttp://www.meddean.luc.edu/lumen/MedEd/medicine/Rheumatology/Hands/Hand10/Hand10dx.htmlhttp://www.meddean.luc.edu/lumen/MedEd/medicine/Rheumatology/Hands/Hand10/Hand10dx.htmlhttp://www.meddean.luc.edu/lumen/MedEd/medicine/Rheumatology/Hands/Hand10/Hand10dx.htmlhttp://www.meddean.luc.edu/lumen/MedEd/medicine/Rheumatology/Hands/Hand10/Hand10dx.htmlhttp://www.meddean.luc.edu/lumen/MedEd/medicine/Rheumatology/Hands/Hand10/Hand10dx.htmlhttp://webrheum.bham.ac.uk/professional/slides/lec3b/default/pages/3b5.htm


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Janeway Lesions

1. More specific

2. Erythematous, blanching macules3. Nonpain fu l

4. Located on palms and soles

5. Microabscess of the dermis with marked necrosis and

inflammatory infiltrate not involving the epidermis.
http://en.wikipedia.org/wiki/Abscesshttp://en.wikipedia.org/wiki/Dermishttp://en.wikipedia.org/wiki/Necrosishttp://en.wikipedia.org/w/index.php?title=Epidermis(skin)&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Epidermis(skin)&action=edit&redlink=1http://en.wikipedia.org/wiki/Necrosishttp://en.wikipedia.org/wiki/Dermishttp://en.wikipedia.org/wiki/Abscess


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Roth Spots

septic embolization, leukemia, lupus erythematosus, or pernicious anemia.


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TheEssentialBlood Test

Blood Cultures Minimum of three blood cultures

Three separate venipuncture sites

atleast 1 hour apart- over 24 hrs

Serology-

Brucella, bartonella, Legionella, C. Burnetti

Schiff stain for T. whippeli


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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


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Indications for Echocardiography

Transthoracic echocardiography (TTE)

First line if suspected IE

Native valves

Transesophageal echocardiography (TEE)

Prosthetic valves

High risk patients

Intracardiac complications

Inadequate TTE

Fungal or S. aureus or bacteremia


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Major Criteria

1. Posi t ive blood cu l tureTypical organism from 2 separate cultures-

Viridans streptococci, Strptococcus bovis,

HACEK, S. aureus, enterococci

OR

Persistently + blood culture- all of three/ majority

4 blood cultures

OR

Single +ve blood culture for Coxiella or phase

IgG > 1:800


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2. Evidence of endocardial involvement

ECHO- oscillating intracardiac massOR

Abscess

ORNew partial deheiscence of prosthetic

valve/ new regurgitation


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Minor criteria

Predisposing heart condition

Fever > 100.4F

Vascular- Emboli, pulmonary infarct,mycotic aneurysm, Janeway lesions

Immune- Oslers nodes, Roth spots,

glomerulonephritis

Microbiological evidence


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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

2 Major 1 Major + 3 minor

5 Minor

Possible IE

1 major and 1 minor

3 minor


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Treatment

Parenteral antibiotics

High serum concentrations to penetrate

vegetations

Prolonged treatment to kill dormant bacteriaclustered in vegetations

Surgery

Intracardiac complications

Surveillance blood cultures


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Monitor for side effects

Improvement in 5-7 days

Repeat blood cultures till sterileAgain 4-6 weeks after therapy


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Prophylaxis

Amoxicillin 2 g PO I hour before procedure

Ampicillin 2 g iv within 1 hr

Clarithromycin/ Azithromycin 500 mg

Cephalexin 2 g

Clindamycin 600 mg

Cefazolin/ceftriaxone 1 g iv 30 min before procedure

Clindamycin 600 mg iv


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WHO prophylaxis

Prosthetic heart valves

Prior history

Unrepaired cyanotic congenital heart disease

Completely repaired congenital heart disease within 6

months of repair

Incompletely repaired CHD

Valvulopathy after cardiac transplantation


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Poor Prognostic Factors

Female

S. aureus

Vegetation size

Aortic valve

Prosthetic valve

Older age

Diabetes mellitus

Low serum albumen

Heart failure

Paravalvular abscess

Embolic events

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11. Infective Endocarditis 7th Prt1