INFECTIVE ENDOCARDITIS

Elena SamohvalovDoctor of medicine

“A small number of diseases present such serious difficulties of diagnosis than malignant endocarditis, difficulties that in many cases are insurmountable.”

“Gulstonian Lectures on Malignant Endocarditis”

W. Osler 1885

European Guidelines for Prevention, Diagnosis and Treatment of IE, 2009

Infective endocarditis is a microbial endovascular infection of cardiovascular structures (native valves, ventricular or atrial endocardium), including endarteritis of large intrathoracic vessels (in arterio-venous shunts, in aortarctia, in patent ductus arteriosus), or foreign intracardiac bodies (prosthetic valves, pacemaker or intracardiac defibrillator) reflected in the bloodstream.

The early lesion characteristic for IE is vegetation of various sizes (composed of fibrin, platelets, red cells, inflammatory cells and microorganisms), while the destruction, ulceration or abcesses are alterations that can be detected earlier echocardiographically before the appearance of vegetation

European Guidelines for Prevention, Diagnosis and Treatment of IE, 2009

ESC guidelines, Cardiovascular Medicine, 2011

Mortality - 20-25%

Incidence - 3– 10 episodes/

100.000 persons per year

In the last 4-5 decades, the pattern of the disease has changed significantly, particularly in the Western countries

Netzer R, Zolinger E., Seiler C., Cerny A. Infective endocarditis: clinical spectrum, prezentation and outcome. An analisis of 212 cases 1980-1995.// Cardiovascular Medicine 2000.// Heart 2000; 84: 25-30

The patients’ age

With the increase of life

expectancy, the age of patients has grown. Patients over 65 years old constitute more than 30% of cases of IE.

IE, paternal change

John L.Brusch, Wesley W.Emmons, Fransisco Talavera, Tomas M.Kerkering, Eleftherios Mylonakis, Burke A Cunha. Infective endocarditis. eMedicine, December 2007

IE, patient profile = 408

65%

35%

0%

10%

20%

30%

40%

50%

60%

70%

267 men, 141 women

MenWomen

IE, the age of patients = 408

The average age is

45±0,6 years

3.70%

40.90%48.80%

6.60%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

Age distribution

<2021-4445-64>65

Degenerative valvular diseases, valvular prostheses, the prolapse of mitral valve have replaced the rheumatical chronic heart diseases, which were the most spread cardiac predisposal in the past

Favori

ng

con

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ion

s

Prendergast B.D. The changing face of infective endocarditisHeart 2006;92:879-885

IE, paternal change

New risk factors have emerged : intravenous drug use and a wide spectrum of invasive diagnostic and therapeutic procedures: valvular prosthesis intravenous catheters hemodialysis pacemaker implants intracardiac defibrillator implants

Текст надписи

IE, paternal change

Ris

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M.Heiro, H.Helenius, S.Makila, T.Savunen,E.Engblom, J.Nikoskelainen, P.Kotilainen. Infective endocarditis in a Finish teaching hospital: a study on 326 episodes treated during 1980-2004 //Heart 2006;92: 1.457-1.462

IE, predisposing cardiac conditions

infections dental careoptimization respiratory tract

interventions dental care (dental extractions) heart

UDIV hemodialysis

IE, the morbid circumstances that ensured the bacteriemia

The change of

Predisposing factors

Risk factors

Etiological spectrum of IE

Streptococci

StaphylococciBacilli Gr.-

Co-morbidities

Diabetes mellitus

Cirrhosis

Cancer Alcoholism

Kidney failure Pulmonary diseases

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5

10

15

20

25

30

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33 28 16 16 103 2 2 2

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IE, associated diseases, 113 pts

Etiology

The pathogenic agent (%)

Streptococcus viridans30-40

Enterococci 5-10

Other streptococci 10-25

Staphylococcus aureus 10-27

coagulaso-negative Staphylococi 1-3

Gram-negative Bacilli 2-13

Fungi 2-4

Other pathogenic agents 5

“negative Cultures" 5-24

American Health Association

IE, negative hemocultures

Administration of antibiotics cures before taking over the hemocultures

Pathogenic agents difficult to diagnose ( Chlamydia, viruses, rickettsia, fungi, etc.)

Low-cost microbiological laboratory techniques

The suspect presence of IE requires the collection of 3 or more HC in the first 24 hours;

From every venous puncture must be obtained one culture

Cultures must be separated at least 30-60 minutes of each other to prove continuous bacteriemia;

If the initiation of antibiotic treatment is an emergency will be collected at least 3 hemocultures at the range of an hour

If the patient has taken antibiotics for a short period of time, it will be expected at least 3 days after treatment is completed before the new hemocultures will be taken.

The hemoculture (HC)

The hemocultures taken after a long treatment with antibiotics may remain negative for 6-7 days

HC must be performed regularly during the treatment, HC become negative after a few days of therapy;

HC must be performed after 2 and 4 weeks from the disruption of therapy, because it will be detected the most majority of recurrences of IE.

THE HEMOCULTURE

For hemocultures are necessary two pots with 50 ml of environment for aerobic and anaerobic cultures. It will be taken at least 5 ml (10 ml for adults, 1 – 5 ml from children) of venous blood. It has to be used both techniques, for anaerobic and aerobic ones.

Insemination from the excised valves during surgery and from septic emboli is compulsory;

The microorganisms depicted in positive HC must be stored and kept for at least one year, for comparison in cases of relapse or recurrence of IE.

THE HEMOCULTURE

Months

IE, period of determining the diagnosis

Stirbul A., Grejdieru A, Mazur M, et al. "Infective endocarditis: clinical profile, presentation and development (study on a group of 408 patients in the retrospective of 16 years - 1992-2007)," Bulletin of the Academy of Sciences , 4 (18), Chisinau 2008..

0 2 4 6 8 10 12 14 160

20

40

60

80

100

120

51

96 93

58

41

2618

9 5 2 4 3 2 1

1 2 3 41 6 7 8 9 11 12 13 14

The average period – 1,7 months months

IE, late diagnosis

lack of specific signs, patognomonical, clinical and laboratory.

The unjustified administration of antibiotics for febrile cardiac patients, prior taking the hemocultures

Deficient use of the key investigations (blood culture and EcoCG)

Tornos P, Iung B. Permanyel-Miralda G. Baron G, Delahaye F., et.al.Infective endocarditis in Europe: lessons from the Euro heart survey.Heart 2005; 91: 571-575

IE, regional differences

Socio-economic factors

Bacterial environment

Race differences

Life style

IN

WHICH

HABITATE

POPULATIONCabell CH, Jollis JG, Peterson GE, Corey GR, Anderson DJ, Sexton DJ,

Woods CW, Reller LB, Ryan T, Fowler VG Jr. Changing patient characteristics and the effect on mortality in endocarditis. Arch Intern Med. 2002; 162: 90–94.

By evolution: Acute form

Subacute formBy the origin: Primary on intact valve Secondary on native valve:

rheumatic heart disease congenital heart disease

degenerative heart disease

CLASSIFICATION OF IE

Infectious Endocarditis of denture valve (IEDV) early :

valvular dentures infection up to 1 year after the valve surgery

Infectious Endocarditis of denture valve (IEDV) tardy:

valvular dentures infection over 1 year after the valve surgery

IEDV

After activity: Active form Treated form

Recurrent form (after the eradication of the infection) Persistent form (the infection has never been

permanently eliminated)

CLASSIFICATION OF IE

The First episode Recurrence

Relapse Reinfection

The National Clinical

Protocol Reinfection “Infectious Endocarditis in adults ' refreshed 2011

CLASSIFICATION OF IE

IE with persistent fever and Positive hemocultures or Active inflammatory

morphology found at surgery or patient that is still under antibiotic treatment

Or histopathology enable of IE

The active infective endocarditis

iradicatin of infection normal body temperature VSH in normal ranges Negative hemocultures within

a year after finishing the term of treatment

THE CURED INFECTIOUS ENDOCARDITIS

Relapse repeating the episode of IE with the same

micro-organism < 6 months after the initial episode.

reinfection infection with a different micro-

organisms or repeating the episode of IE with the same

micro-organism < 6 months from the initial episode.

Appelant Infectious Endocarditis

IE, new clinical forms

IE at elderly

IE nozocomial iIE Dentary

IE for pts subjected to hemodialysis

IE of right heart

IE at UDIV

Cabell CH, Jollis JG, Peterson GE, Corey J., Anderson D, Sexton DJ, Woods CW, Reller LB, Ryan T, Fowler VG

“Changing patient characteris-tics and the effect on mortality in endocarditis.

Arch Intern Med. 2002; 162: 90–94

IE at patients with DI

I. Positive hemocultures from 2 separate cultures:

virids Streptococci and gr. D the golden Stafilococci Enterococci Germ from the group HACEK Coxiela burnetti (HC single positive) or an antibody IgG phase I > 1:800

DUKE major criteria (Durack 1994)

DUKE major criteria (Durack 1994)

II. EcoCG (evidence of endocardial involvement)

Vegetation (presence of oscillating masses located on:

Heart valves Support structures in the path of Geta Prosthetic materials

Ring abscess New partial dehiscence of prosthetic valve New appeared valvular Regurgity

DUKE minor criteria (Durack 1994)

Cardiac predisposing conditions and UDIV

Fever > 38.0°C Vascular phenomena :

septic pulmonary embolisms Septic pulmonary infarcts mycotic aneurysms intracranial bleeding Conjunctively bleeding Janeway injuries

DUKE minor criteria (Durack 1994)

imunological phenomena: glomerulonephritis Osler nodules Roth stains rheumatoid factor positive microbiological Signs: positive blood culture in

a sample or other microorganisms (diphteroizi, anaerobi baccili, cocci gr.+, etc.)

EcoCG sighs: that is not included in the major criteria

IE, clinical picture

Fever

Loss of weight

Dyspnea

Arthralgia

Embolic phenomena

Chills Sweats

Fatigability

Palpitations

Arthritis Myalgia

The suspection of infectious endocarditis - the temperature must be measured every 3 hours..

fever: hectic or ondulant, associated with chills, night sweats;

subfeverishness (the elderly, imunocompromised people, patients with congestive heart failure, with renal failure);

Altered general state, headache, myalgia, arthralgia, low back pain, fatigue, inapetencia, weight loss;

Objective data

New spirit emerged, modification of the existing

Palpitations

Hemorrhage ”in splinter”

Pallor of your skin

Janeway Injuries Osler nodules

BP diastolica low

Extracardiac signs Moderate splenomegaly Ocular manifestation:

Roth spots (oval retinal hemorrhages with clear central, pale)

Optic neuritis Embolic episode:

Cerebral embolisms – in IE caused by Staphylococci aureus with vegetation on the aortic valve

Femoral artery emboli – often the result of fungal IE Pulmonary emboli–in IE of right heart of UDIV

Renal manifestation: Kidney failure due to

Renal emboli or Glomerulonephritis with complex immune

Janeway injuries

Eruption

IE, touvh of periferic

Hemorrhage in splinter

Osler nodules

Roth spots

Hipocratic fingers

A

B

C

Eruptions A. skinnedB. conjunctivalC. On lining of the oral cavity

Osler nodules

Osler nodules are vasculits The pacient T. 46 years,

Of small vessels- IE subacute streptococci etiology mediated imunologically with the affectation of VA(Va will

bicuspid)

Leziuni Janeway

Janeway injuries :Septic vasculitischaracteristicfor acute staphilococic IE(Staphylococci. aureus)Patient L. 42 yearsIE of prothesis, acute, staphilococic etiology

Hemorrhages in splinterLinear

hemorrhages in splinter, With localizationOn the nail bedIn hands andfeetThe patient O. 24

years, IE acute,

Staphilococicetiology, (Stph.aureus) withTrivalvular

affectation, and

The debut with Tromboembolic

signs

Roth spots

RetinalHemorrhages - Dried branches Localized on the

retina The patient C. 35 y,IE streptococic etiologyPyogenes St. , with The afectation of VA, Cusp prosthetic

rupture,

Hipocratic fingersFingers of

specific form of a chronic process

(in IEWith trenant

evolution )The patient D. 33 yearsIE subacute, Streptococal etiology

withThe afection VM şi VT.Diagnosed after11 months after the

debut.

IE, echocardiographic changes

Vegetations

Valvular Extravalvular

cordage papilar muscules

Ascending aorta

DSV membrane

The ejection tract of VD Bifurcation trunk

AP

IE, echocardiographical changes

The rift of cordages

The rift of valve

Films of valve

Cardiac Abcesses

Paraprotetic fistulas

IE, vegetation on AVo

Patient R., 67 yearsIE nosocomial, aftersurgery (pancreatic cancer )Enterococcic etiology with the Ejection of VA Vegetation on VA of 11 mm

IE , izolated damage of VTs

Patient Z., 23 YearsIE of right heart, Staphylococci etiology(Stph.aureus), UDIVVegetation24 mm on VT

IE , trivalvular damage

VD

AD

VS

AS

Ao

AS

VS

VM

Pacient O. 24 ani, primary IE, staphylococci etiology(Staphyloccocus aureus), trivalvular afection . Big vegetations on VA – 7 mm,On VM– 18 mm and on VT – 11 mm.Anterior cordage rupture of the VM

IE, cusp rift VM

the Pacient C. 48 yIE Secondary heart RHEUMATISM, unidentified etiologyWith VM, cusp rift anterior to the VM

Laboratory Investigations Blood count : (anaemia, accelerated ESR,

leucocitoza ± neutrofilie ± monocitoză) Urine count (sediment urinar pathologic

(microhematuria ± proteinuria ± cilindrurie) general protein (dysproteinemia + hiper-γ-

globulinemia) Urea, creatinina ( elevated in renal impairment)

Laboratory examinations are not suggestive only for IE, but may be characteristic for other

Infectious pathology

Laboratory investigations elevated rheumatoid factor Increased C-reactive protein Elevated circulating immune complexes Polymerase chain reaction,

which demonstrate bacterial DNA is performed in patients:

with negative blood cultures and

Binding on all patients undergoing cardiac surgery

Laboratory investigations Serological tests for :

Rickettsiae (Coxiella burnetii) Chlamidya (Chlamydia psittaci, Chlamydia

pneumoniae şi Chlamydia trachomatis) Brucella Bartonella Spirochete (Spirillum minus) These serological tests is performed when is

maintaining a high level of clinical suspicion but blood cultures over 7 days after the harvest are negative

ECG Changes caused by congenital clinic sugestiv,

depending on the length of the process, the level of activity and the endocardium and myocardium injury

LV hypertrophy with systolic overload, RV hypertrophy, atrial hypertrophy

atrial fibrillation, flutter, fluter block of ram left and/or right to beam His rheumatic and congenital heart disease .

atrioventricular block gr. II, gr. III (during the first 3 days after the prosthesis or anastomotic parainelar abscess)

ECG in myocardial ischemia array of clinically suggestive context, caused by embolisms coronary artery:

Radiological examination of the rib cage is informative in tracing : Progress of the rheumatic heart patients with IE Progress in IE law heart: to heart UDIV :

Destructive multifocal pneumonia, Lung abscesses Radiological signs of pulmonary emboli

The patients with IE left heart,on the merits of congenital heart disease with left-right cardiac shunts-radiological signs of pulmonary emboli

In IE prosthesis valve, x-ray examination can be determined by the valve prosthesis dysfunction

Further investigation in the case of complications in IE

USG internal organs – for the detection of spleen and renal lymphocytes,

Doppler cerebral vessels, renal and lower limb artery used for specifying the dynamic artery in process

Dynamic Scintigraphy of the kidneys CT cerebral internal organs – in case of cerebral

embolisms, renal, mesenteric, spleen MRI-splenic lymphocytes mycotic aneurysms,

intracerebral aneurysms, cerebral embolisms septic; Holter monitoring ECG – arrhythmias and

disturbances in conductibility

Congestive heart failure

Neurological complication

s

Embolisms

septic shock

GND with kidney failure

IE, complications

Embolic cerebral infarct

Transient ischemic attack

Meningitis

Others

Brain abscess

mycotic aneurysms

Intracranial Haemorrahage

IE , neurological complications

Renal touch with triggering IR indicate a prognosis reserved especially for the streptococci IE ,which in its evolution, it becomes more malignant than the staphylococci one

Diffused NGThe first manifestation of the

IE

IE, diffuse Glomerulonephritis

Causes: High share of IE of streptococci, which frequently

evaluates with the immunological complications The late diagnosis when IE is already complicated with

immunological manifestations, GN being the most important from them.

The treatment of patients with IE

The treatment’s initiation as earlier (delay of 2 to 8 weeks increase mortality of 2 times )

Combined Antibioticoterapia (2 – 3 antibiotics) in maximum doses Administered intravenous

Antibiotics are administerred according to the susceptibility to pathogens and CIM

Correction dose of antibiotics according to the degree of kidney damage

In the event of inefficiency of the antibiotic replacing it after 3-4 days

The treatment of patients with IE

Prolonged Treatment with average of antibioticoterapa: in IE of streptococci etiology– 4 weeks in staphylococci IE and in IE negative gram bacteria – 6 – 8 weeks

Until the clinical effect.Antibacterial therapeutic regimes in IE is given

according to National Clinical Protocol ”Infectious Endocarditis in adults”,

Updated in 2011 (www. ms.md)

Other causes7,7%

Kidney failure

12,8% TromboembolicSyndrome

20,5%

IE, causes of deaths, n=78

Progressive heart failure

30,8%Septic shock with poliorganica sauce

33,3%

Died 78 patients

Mortality - 19,1%

Știrbul A., Grejdieru A, Mazur M.,.”Infectious Endocarditis : clinic profile, prezentation and evolution (effectuated on a lot of 408 patients by 16 years – 1992-2007)” Bulletin of Academy of Sciences of Moldovei, 4 (18), Chişinău 2008.

Antibioticoprofilaxia Peroral administration of Amoxicillin 2 - 3 gr in allergy to penicilins:

Azithromycin 500 mg Clarithromycin 500 mg

with 30min before the dental procedure

Periajul zilnic Tratamentul dinţilor cariaţi Adresarea imediată la

apariţia semnelor suspecte

immediate addressing to the doctor,

In case of suspicious signs

Dental hygiene has a major importance in the prevention of IE!

cleaning The Caria teeth

Daily teeth brushing

Famous people died of IE

AlexanderBlok1880-1921Russian poet

GustavMahler1860-1911Austrian, jewish composer

Savely Cramarov1934-1995Russian actor

RobertsBurns1759-1796Scottish poetAloisAlzheimer1864-1915German neurologist

OttorinoRespighi1879-1936Italiancomposer

God bless you!