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Update on Infective Endocarditis

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Bacterium-endothelium interaction with bacterial attachment and invasion of endothelial cells ... 'innocent' heart murmur by auscultation in the pediatric population ' ... – PowerPoint PPT presentation

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Title: Update on Infective Endocarditis


1
Update on Infective Endocarditis
2
Pathogenesis
  • Disruption of the endocardial layer as a
    complication of abnormal blood flow associated
    with underlying cardiac defect
  • Bacterium-endothelium interaction with bacterial
    attachment and invasion of endothelial cells

3
Epidemiology
  • Underlying valvular abnormality predisposing to
    infective endocarditis
  • rheumatic fever a common cause in the past
  • mitral valve prolapse currently represents the
    most common underlying cardiac abnormality

4
mitral valve prolapse
  • risk for infective ednocarditis is ?5x-8x
  • mitral regurgitation increases the risk
  • leaflet redundancy with myxomatous degeneration
    is a frequent finding
  • age lt20 , female predominate age gt20 , male
    accounts for 60 age gt50 , male accounts for 68

5
Mitral Valve Prolapse and Infective Endocarditis
Male
Female
Number of cases
Rev Infect Dis 19868117-137
6
Coagulase-negative Staphylococci
  • can produce native-valve endocarditis in mitral
    valve prolapse
  • usually subacute, difficult to diagnose, and
    disregarded as a contaminant
  • delay in diagnosis and treatment may account for
    the severe complications
  • myocardial abscess formation
  • valvular insufficiency requiring valve surgery
  • death

7
Prosthetic Heart Valve
  • positive blood culture in hospitalized patients
    with underlying prosthetic valves can be a
    harbinger of endocarditis
  • 43 patients with nosocomial bacteremia or
    fungemia had prosthetic valve infection
  • a serious complication

8
IV Drug Use
  • Recurrent
  • Polymicrobial
  • Staph aureus accounts for the majority of cases
    of endocarditis
  • tricuspid valve, either alone or in combination,
    us most often infected

9
Predisposing Factors Polymicrobial Infective
Endocarditis
10
Polymicrobial Infective Endocarditis clinical
features
  • IV drug use is the predominant risk factor
  • younger age (mean 36.5 years)
  • 2/3 were male
  • right-sided cardiac involvement in gt 60
  • streptococci more frequent than S. aureus
  • 1/3 of patients died
  • mortality rate is 4x higher for pure left-sides
    vs pure right-sided endocarditis

11
Diagnostic (Duke) Criteria
  • Definitive infective endocarditis
  • pathologic criteria
  • microorganisms or pathologic lesions
    demonstrated by culture or histology in a
    vegetation, or in a vegetation that has
    embolized, or in an intracardiac abscess
  • clinical criteria (see below)
  • two major criteria, or one major and three minor
    criteria, or five minor criteria

12
Diagnostic (Duke) Criteria
  • Possible infective endocarditis
  • findings consistent of IE that fall short of
    definite, but not rejected
  • Rejected
  • firm alternate Dx for manifestation of IE
  • resolution ofmanifestations of IE, with
    antibiotic therapy for ? 4 days
  • no pathologic evidence of IE at surgery or
    autopsy, after antibiotic therapy for ? 4 days

13
Diagnostic (Duke) Criteria
  • Major criteria
  • positive blood culture for IE
  • evidence of endocardial involvement
  • Minor criteria
  • predisposition (heart condition or IV drug use)
  • fever of 100.40F or higher
  • vascular or immunologic phenomena
  • microbiologic or echocardiographic evidence not
    meeting major criteria

14
Dukes Major Criteria
  • positive blood culture for IE
  • typical microorganism (strep viridans, strep
    bovis, HACEK group, staph aureus or enterococci
    in the absence of a primary locus) for
    endocarditis from two separate blood cultures
  • persistently positive blood culture from
  • blood cultures drawn more than 12 hr apart, or
  • all of 3 or a majority of 4 or more separate
    blood cultures, with first and last drqwn at
    least 1 hr apart

15
Dukes Major Criteria
  • Evidence of endocardial involvement
  • positive echocardiogram for endocarditis
  • oscillating intracardiac mass on valve or
    supporting structure, or in the path of
    regurgitant jets, or on implanted material, in
    the absence of an alternate anatomic explanation
  • abscess
  • new partial dehiscence of prosthetic valve
  • new valvular regurgitation (increase or change in
    pre-existing murmur not sufficient)

16
Dukes Minor Criteria
  • predisposition (predisposing heart condition or
    iv drug use)
  • fever of 100.40F or higher
  • vascular phenomena (major arterial emboli, septic
    pulmonary infarcts, mycotic aneurysm,
    intracranial hemorrhage, conjunctive hemorrhages,
    Janeway lesions)

17
Dukes Minor Criteria
  • immunologic phenomena (glomerulonephritis,
    Oslers nodes, Roth spots, rheumatoid factor)
  • microbiologic evidence (positive blood culture
    not meeting major criteria or serologic evidence
    of active infection with organism consistent with
    IE)
  • echocardiogram (consistent with IE but not
    meeting major criteria)

18
Risk for Endocarditis
  • High risk
  • prosthetic cardiac valve
  • prior episodes of endocarditis
  • complex congenital cardiac defect
  • surgically constructed systemic-pulmonary shunts
    or conduits

19
Risk for Endocarditis
  • Moderate risk
  • patent ductus arteriosus
  • VSD, primum ASD
  • coarctation of the aorta
  • bicuspid aortic valve
  • hypertrophic cardiomyopathy
  • acquired valvular dysfunction
  • MVP with mitral regurgitation

20
Risk for Endocarditis
  • Low risk
  • isolated secundum atrial septal defect
  • ASD, VSD, or PDA gt6 months past repair
  • innocent heart murmur by auscultation in the
    pediatric population
  • innocent heart murmur by echocardiography in
    adult patients

21
Treatment
  • Pre-antibiotic era - a death sentence
  • Antibiotic era
  • microbiologic cure in majority of patients

22
New Treatments
  • Right-sided infective endocarditis due to
    methicillin-susceptible S aureus (MSSA) in IV
    drug users
  • 2-wk therapy with a penicillinase-resistant
    penicillin and an aminoglycoside
  • 2-wk monotherapy with IV cloxacillin
  • short-term therapy is inappropriate if
    complicated by ostomyelitis, meningitis,
    myocardial abscess, or concomitant left-sided
    involvement

23
New Treatments
  • Highly penicillin-susceptible Streptococcus
    viridans or bovis
  • Once-daily ceftriaxone for 4 wks
  • cure rate gt 98
  • easily administered as outpatient, avoid
    hospitalization, offers significant cost savings
  • Once-daily ceftriaxone 2 g for 2wks followed by
    oral amoxicillin qid for 2 wks
  • Once-daily ceftriazone and netilmicin for 2 wks

24
New Treatments
  • Prosthetic valve endocarditis due to
    fluconazole-susceptible Candida species
  • many are due to bloodstream invasion
  • chronic oral suppressive therapy with fluconazole
    for inoperable disease

25
SBE Prophylaxis
  • Standard general prophylaxis amoxicillin
  • Unable to take oral meds ampicillin
  • Allergic to penicilin clindamycin
  • cephalexin
  • azithromycin
  • clarithromycin
  • Allergic to penicillin and unable clindamycin
  • to take oral medications cefazolin

26
References
  • Prevention of bacterial endocarditis.
    Recommended by the American Heart Association.
    Dajani AS, Taubert KA, Wilson W, et al.
    Circulation 199796358-366
  • New Criteria for diagnosis of infective
    endocarditis Utilization of specific
    echocardiographic findings. Durack DT, Lukes AS,
    Bright DK, et al. Am J Med 199496200-209
  • Antibiotic treatment of adults with infective
    endocarditis due to strptococci, enterococci,
    staphlococci, and HACEK microorganisms. Wilson
    WR, Karchmer AW, Dajani AS. JAMA
    19952741706-1713
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