Infective EndocarditisInfective Endocarditis

Dr.Khalid Hama salih, MDDr.Khalid Hama salih, MDPediatrics specialistPediatrics specialist

M.B.Ch. D. C.H B.F.I.B.M.S.pedM.B.Ch. D. C.H B.F.I.B.M.S.ped

DefinitionDefinition

Infectious Endocarditis (IE):Infectious Endocarditis (IE): an infection of an infection of the heart’s endocardial surfacethe heart’s endocardial surface

Classified into Classified into fourfour groups: groups: – Native Valve IENative Valve IE– Prosthetic Valve IEProsthetic Valve IE– Intravenous drug abuse (IVDA) IEIntravenous drug abuse (IVDA) IE– Nosocomial IENosocomial IE

EpidemiologyEpidemiology

Incidence difficult to ascertain and varies Incidence difficult to ascertain and varies according to locationaccording to location

Much more common in males than in Much more common in males than in femalesfemales

May occur in persons of any age and May occur in persons of any age and increasingly common in elderlyincreasingly common in elderly

Mortality ranges from 20-30%Mortality ranges from 20-30%

Risk FactorsRisk Factors

Artificial heart valves and pacemakers Artificial heart valves and pacemakers

Acquired heart defectsAcquired heart defects– Calcific aortic stenosisCalcific aortic stenosis– Mitral valve prolapse with regurgitationMitral valve prolapse with regurgitation

Congenital heart defectsCongenital heart defects

Intravascular cathetersIntravascular catheters

Infecting OrganismsInfecting Organisms

Common bacteriaCommon bacteria– S. aureusS. aureus– Streptococci Streptococci – EnterococciEnterococci

Not so common: Not so common: – FungiFungi– PseudomonasPseudomonas– HACEK group - HACEK group - Haemophilus spp,. Actinobacillus actinomycete comitants, Haemophilus spp,. Actinobacillus actinomycete comitants,

Cardiobacterium hominis, Eikenella spp, and Kingella kingae.Cardiobacterium hominis, Eikenella spp, and Kingella kingae.

PathophysiologyPathophysiology

1.1. Turbulent blood flow Turbulent blood flow disrupts the disrupts the endocardium making it “sticky”endocardium making it “sticky”

2.2. Bacteremia Bacteremia delivers the organisms to delivers the organisms to the endocardial surface the endocardial surface

3.3. AdherenceAdherence of the organisms to the of the organisms to the endocardial surfaceendocardial surface

4.4. Eventual invasionEventual invasion of the valvular of the valvular leafletsleaflets

SYMPTOMS:SYMPTOMS:

Fever, Chills Fever, Chills Night Night sweats  sweats  

Weight loss, MalaiseWeight loss, Malaise

CNS:manifestations(strokCNS:manifestations(stroke,seizures,headache)  e,seizures,headache)  

DyspneaDyspnea

Chest and abdominal Chest and abdominal pain  pain  

Arthralgia, myalgia      Arthralgia, myalgia      

SIGNS:SIGNS:

Elevated temperature  Elevated temperature  Tachycardia Tachycardia Embolic phenomena (Roth Embolic phenomena (Roth spots, petechiae, splinter spots, petechiae, splinter hemorrhages, Osler nodes, hemorrhages, Osler nodes, CNS or ocular lesions) CNS or ocular lesions) Janeway lesions    Janeway lesions    Splenomegaly  Splenomegaly  Arthritis  Arthritis  Heart failure  Heart failure  Arrhythmias  Arrhythmias  Metastatic infection Metastatic infection (arthritis, meningitis, (arthritis, meningitis, mycotic arterial aneurysm, mycotic arterial aneurysm, pericarditis, abscesses)  pericarditis, abscesses)  ClubbingClubbing

PetechiaePetechiae

Photo credit, Josh Fierer, M.D. medicine.ucsd.edu/clinicalimg/ Eye-Petechiae.html

Harden Library for the Health Scienceswww.lib.uiowa.edu/ hardin/md/cdc/3184.html

1.Nonspecific2.Often located on extremities

or mucous membranesdermatology.about.com/.../ blpetechiaephoto.htm

Splinter HemorrhagesSplinter Hemorrhages

1. Nonspecific2. Nonblanching3. Linear reddish-brown lesions found under the nail bed4. Usually do NOT extend the entire length of the nail

Osler’s NodesOsler’s Nodes

1. More specific2. Painful and erythematous nodules3. Located on pulp of fingers and toes4. More common in subacute IE

American College of Rheumatologywebrheum.bham.ac.uk/.../ default/pages/3b5.htm www.meddean.luc.edu/.../

Hand10/Hand10dx.html

Janeway LesionsJaneway Lesions

1. More specific2. Erythematous, blanching macules 3. Nonpainful4. Located on palms and soles

Investigation:Investigation:

    

Positive blood culture  Positive blood culture  

Elevated erythrocyte Elevated erythrocyte sedimentation rate.  sedimentation rate.  

Elevated C-reactive proteinElevated C-reactive protein

Anemia  Anemia  

Leukocytosis    Leukocytosis    

HypergammaglobulinemiaHypergammaglobulinemia

Hypocomplementemia     Hypocomplementemia     

HematuriaHematuria

Renal failure: azotemia, Renal failure: azotemia, highcreatinine(glomerulonhighcreatinine(glomerulonephritis)ephritis)

Chest radiograph: Chest radiograph: bilateral infiltrates,,pleural bilateral infiltrates,,pleural effusions.effusions.

Echocardiographic Echocardiographic evidence of valve evidence of valve vegetations, prosthetic vegetations, prosthetic valve dysfunction or leak, valve dysfunction or leak, myocardial abscess, new-myocardial abscess, new-onset valve insufficiencyonset valve insufficiency

Duke criteriaDuke criteria :- :-Major criteriaMajor criteria include include (1) positive blood cultures (two (1) positive blood cultures (two separate cultures for a usual pathogen) andseparate cultures for a usual pathogen) and (2) evidence of endocarditis on echocardiography(2) evidence of endocarditis on echocardiographyMinor criteriaMinor criteria include: include: predisposing conditionspredisposing conditions feverfever embolic-vascular signsembolic-vascular signs immune complex phenomenaimmune complex phenomena a single positive blood culture or serologic evidence of a single positive blood culture or serologic evidence of infection, and echocardiographic signs not meeting the infection, and echocardiographic signs not meeting the major criteria.major criteria.NB/ Two major criteria, one major and three minor, or NB/ Two major criteria, one major and three minor, or five minor criteria suggest definite endocarditisfive minor criteria suggest definite endocarditis

TreatmentTreatment

Parenteral antibioticsParenteral antibiotics– High serum concentrations to penetrate High serum concentrations to penetrate

vegetationsvegetations– Prolonged treatment to kill dormant bacteria Prolonged treatment to kill dormant bacteria

clustered in vegetations 4–6 wk .clustered in vegetations 4–6 wk .

SurgerySurgery– Intracardiac complicationsIntracardiac complications

Surveillance blood culturesSurveillance blood cultures

Poor Prognostic FactorsPoor Prognostic Factors

FemaleFemale

S. aureusS. aureus

Vegetation sizeVegetation size

Aortic valve Aortic valve

Prosthetic valveProsthetic valve

Older ageOlder age

Diabetes mellitusDiabetes mellitus

Low serum albumen Low serum albumen

Heart failureHeart failure

Paravalvular abscessParavalvular abscess

Embolic eventsEmbolic events

PREVENTIONPREVENTION

Antimicrobial prophylaxis before various Antimicrobial prophylaxis before various procedures and other forms of dental procedures and other forms of dental manipulation may reduce the incidence of manipulation may reduce the incidence of infective endocarditis in susceptible infective endocarditis in susceptible patientspatients