ENFECTIVE ENDOCARDITIS

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ENFECTIVE ENDOCARDITIS M.RASOOLINEJAD,
MD DEPARTMENT OF INFECTIOUS DISEASE TEHRAN
UNIVERSITY OF MEDICAL SCIENCE
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INFECTIVE ENDOCARDITIS
Infection of the endocardial surface
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INFECTIVE ENDOCADITIS
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INTRUDUCTION

• Clinical manifestations are so varied.
• All of medical subspecialist must encounter
• Successful management? Medical Surgical.

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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 )

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PATHOGENESIS
Endothelium
Mucus membrane (Trauma,
Turbulance,
or metabolic change )
Colonized tissue Plt -
fib deposition
Trauma NBTE
Bacteremia

Adherence
Colonization
Mature Vegetation

Local factor Bacteriocins IgA
protease Bacterial adherence
Complement Antibody
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PATHOGENESIS

• Nonbacterial Thrombotic Endocarditis (NBTA)
• Hemodynamic factor
• Transient Bacteremia
• Microorganisms
• Immunopathologic

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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
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CULTURE NEGATIVE ENDOCARDITIS

• Subacute right side infective endocarditis
• Chronic course gt 3 months
• Uremia supervening chronic course
• Mural IE as in VSD
• Pacemaker wires infection

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CULTURE - NEGATIVE ENDOCARDITIS

• HACEK
• Brucella spp,
• Prior administration of antibiotics
• Rickettsiae, Chlamydia, Virus
• Noninfective endocarditis

Haemophilus spp, Actinobacillus spp,
Cardiobacterium spp, Eikenella, Kingella
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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

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PATHOLOGY
RENAL
Renal architecture is abnormal in all
cases, Even in the absence of clinical
or biochemical of renal disease
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PATHOLOGY
RENAL

• Focal glomerulonephritis
• Diffuse glomeruonephritis
• Membranoproliferative glomerulonephritis
• Renal infarction
• Renal abscess

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PATHOLOGY
CNS

• Emboli (middle cerebral artery )
• Infarction
• Arteritis
• Abscess
• Mycotic aneurysms
• HemorrhageIntracerebral or Subarachnoid
• Encephalomalacia
• Meningitis

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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

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PATHOLOGY

• SPLEEN
• LUNG
• SKIN
• EYE

Infarction, Abscess, Enlargement
Emboli, Acute Pneumonia, Pleural Effusion
Ptechiae, Osler node ( Arteriolar intimal
proliferation ) Janeway lesions ( Becteria,
Necrosis, PMN, Hemorrhage)
Roth spots ( Lymphocyte, Edema, Hemorrhage )
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JOINT
CLINICAL
MANIFESTATION
CNS
HEART
FUO
FEVER
ICTER
SEPTIC EMBOLI
IE
EYE
SKIN
PAIN
KIDNEY
LUNG
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IE IDU

• More common in cocain users
• Febrile IDU IE
• No underlying heart disease
• More common in tricuspid valve
• Aortic gt Aortic Mitral gt Mitral valve
• Pumonary septic emboli
• S aureous, P aueroginosa
• IDU HIV / AIDS

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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.

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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

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DIAGNOSIS
Durack DT, Lukes AS, Bright DK, Criteria

• Definite ( Pathologic Clinical Criteria )
• Possible
• Rejected

CLINICAL CRITERIA

• Major or
• Major 3 Minor or
• 5 Minor

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MAJOR CRITERIA

• Positive blood culture
• Evidence of endocardial involvement

MINOR CRITERIA

• Predisposing heart disease or IDU
• Fever gt 38
• Vascular phenomena
• Immunologic phenomena
• ECHO
• Microbiologic evidence

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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
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EVIDENCE OF ENDOCARDIAL
INVOLVEMENT

• Positive ECHO for IE
• New valvular regurgitation

• Oscillating intracardiac mass
• Abscess
• New dehiscence of prosthetic valve

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veg
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Mitral valve Vegetation
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Mitral valve vegetation
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TREATMENT

• Antimicrobial therapy
• High dose, prolonged IV antibiotics
• Surgical therapy

ANTIMICROBIAL THERAPY

• Empirical therapy
• Organisms based therapy
• Duration of treatment

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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.

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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

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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

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SURGICAL THERAPY

• Refractory CHF
• gt One serious systemic emboli
• Uncontrolled infection
• Valve dysfunction ( ECHO )
• Fungal Brucella endocarditis
• Mycotic aneurysms
• Prosthetic valve
• Local suppurative complications
• Large vegetation gt 1 cm
• Vegetation size after 4 WKS
• Aortic valve endocarditis
• Acute valve insufficiency
• Recurrent endocarditis

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INDICATION FOR SURGICAL INTERVENTION

• Surgery required for optimal outcome
• Surgery to be strongly considered
• for improved outcome

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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

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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 gt 10 Cm hypermobile vegetation
• Persistent unexplained fever gt10 days in
  culture -ve IE.
• Poorly responsive or relapse (
  Entrococci Gram-ve )

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Valve Ring abscess
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Intra operation
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After repair
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Intraoperative TEE
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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

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Procedure Causing Bacteremia

• Oral cavity
• Respiratory tract
• Genitourinary tract
• Gastrointestinal tract
• Vascular system

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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.

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ANTIBIOTIC PROPHYLAXIS

• High risk procedures
• High risk of cardiac disease

? Recommended

• High risk procedures
• Intermediate risk of cardiac disease

? Recommended

• Low risk procedures
• High risk of cardiac disease

? Optional
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RECOMMENDED REGIMENS
Procedures
Dental, upper Res, GI, GU, Implantation of
Prosthetic Valve
Amoxicillin PO Clindamycin Po Ampicillin
Gentamycin Cefazolin Vancomycin Gentamycin
Before After
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