Infective EndocarditisInfective Endocarditis

DR MOHAMMAD ALI KHALID, DR MOHAMMAD ALI KHALID,

Assistant professor of medicine,Assistant professor of medicine,

RMC and allied teaching hospitals.RMC and allied teaching hospitals.

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

HIGHLIGHTSHIGHLIGHTS

Fever.Fever.

Murmer.Murmer.

Worsening of valve dysfunction.Worsening of valve dysfunction.

Heart failure?Heart failure?

Vegetations seen on echocardiography.Vegetations seen on echocardiography.

Systemic manifestations.Systemic manifestations.

Positive blood cultures.Positive blood cultures.

Further ClassificationFurther Classification

AcuteAcute– Affects normal heart Affects normal heart

valvesvalves– Rapidly destructiveRapidly destructive– Metastatic fociMetastatic foci– Commonly Staph.Commonly Staph.– If not treated, usually If not treated, usually

fatal within 6 weeksfatal within 6 weeks

SubacuteSubacute– Often affects damaged Often affects damaged

heart valvesheart valves– Indolent natureIndolent nature– If not treated, usually If not treated, usually

fatal by one yearfatal by one year

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

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

Intravenous drug abuseIntravenous drug abuse

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 bacteriaNot so common bacteria– FungiFungi– PseudomonasPseudomonas– HACEKHACEK

HACEKHACEK

Haemophilis parainfluenzaeHaemophilis parainfluenzae

ActinobacillusActinobacillus

CardiobacteriumCardiobacterium

EikenellaEikenella

KingellaKingella

SymptomsSymptoms

AcuteAcute– High grade fever and High grade fever and

chillschills– SOBSOB– Arthralgias/ myalgiasArthralgias/ myalgias– Abdominal painAbdominal pain– Pleuritic chest painPleuritic chest pain– Back painBack pain

SubacuteSubacute– Low grade feverLow grade fever– AnorexiaAnorexia– Weight lossWeight loss– FatigueFatigue– Arthralgias/ myalgiasArthralgias/ myalgias– Abdominal painAbdominal pain– N/VN/V

The onset of symptoms is usually ~2 weeks or less from the initiating bacteremia

HISTORYHISTORY

Rhuematic feverRhuematic fever

Valve surgery or repairValve surgery or repair

FeverFever

SOBSOB

ArthralgiasArthralgias

Embolic phenomenonEmbolic phenomenon

Fatigue,dizziness,palpitations.Fatigue,dizziness,palpitations.

SignsSignsFever .Fever .

Heart murmur.Heart murmur.

Nonspecific signs – petechiae, subungal Nonspecific signs – petechiae, subungal or “splinter” hemorrhages, clubbing, or “splinter” hemorrhages, clubbing, splenomegaly, neurologic changes.splenomegaly, neurologic changes.

More specific signs - Osler’s Nodes, More specific signs - Osler’s Nodes, Janeway lesions, and Roth Spots.Janeway lesions, and Roth Spots.

Features particular to a specific valve.Features particular to a specific valve.

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

TheThe EssentialEssential Blood TestBlood Test

Blood CulturesBlood Cultures– Minimum of three blood culturesMinimum of three blood cultures11

– Three separate venipuncture sitesThree separate venipuncture sites– Obtain 10-20mL in adults and 0.5-5mL in childrenObtain 10-20mL in adults and 0.5-5mL in children22

Positive ResultPositive Result– Typical organisms present in at least Typical organisms present in at least 22 separate samples separate samples– Persistently positive blood culture (atypical organisms)Persistently positive blood culture (atypical organisms)

Two positive blood cultures obtained at least 12 hours apartTwo positive blood cultures obtained at least 12 hours apartThree or a more positive blood cultures in which the first and Three or a more positive blood cultures in which the first and last samples were collected at least one hour apartlast samples were collected at least one hour apart

Additional LabsAdditional Labs

CBCCBC

ESR and CRPESR and CRP

Complement levels (C3, C4,)Complement levels (C3, C4,)

RFRF

UrinalysisUrinalysis

Baseline chemistryBaseline chemistry

ImagingImaging

Chest x-ray Chest x-ray – Look for multiple focal infiltrates and Look for multiple focal infiltrates and

calcification of heart valvescalcification of heart valves

EKGEKG– Rarely diagnosticRarely diagnostic– Look for evidence of ischemia, conduction Look for evidence of ischemia, conduction

delay, and arrhythmiasdelay, and arrhythmias

EchocardiographyEchocardiography

Indications for EchocardiographyIndications for Echocardiography

Transthoracic echocardiography (TTE)Transthoracic echocardiography (TTE)– First line if suspected IEFirst line if suspected IE– Native valvesNative valves

Transesophageal echocardiography (TEE)Transesophageal echocardiography (TEE)– Prosthetic valvesProsthetic valves– Intracardiac complicationsIntracardiac complications– Inadequate TTE Inadequate TTE – Fungal or S. aureus or bacteremiaFungal or S. aureus or bacteremia

Making the DiagnosisMaking the Diagnosis

Pelletier and Petersdorf criteriaPelletier and Petersdorf criteria (1977) (1977)– Classification scheme of definite, probable, and possible IEClassification scheme of definite, probable, and possible IE

– Reasonably specific but lacked sensitivityReasonably specific but lacked sensitivity

Von Reyn criteriaVon Reyn criteria (1981) (1981)– Added “rejected” as a categoryAdded “rejected” as a category

– Added more clinical criteriaAdded more clinical criteria

– Improved specificity and clinical utilityImproved specificity and clinical utility

Duke criteriaDuke criteria (1994) (1994)– Included the role of echocardiography in diagnosisIncluded the role of echocardiography in diagnosis

– Added IVDA as a “predisposing heart condition”Added IVDA as a “predisposing heart condition”

DUKE CRITERIADUKE CRITERIA

MAJORMAJOR

Positve culturesPositve cultures

Positive echoPositive echo

New valvular New valvular regurgitationregurgitation

MINORMINOR

IV drug abuserIV drug abuser

Heart diseaseHeart disease

Fever>38 CFever>38 C

Minor echo findings(eg Minor echo findings(eg deformed valve but no deformed valve but no vegetation)vegetation)

MAJORMAJOR MINORMINOR

Vascular embolic events like Vascular embolic events like janeway lesionsjaneway lesions septic septic pul infarctspul infarcts arterial arterial emboli.emboli.

Immunological eventsImmunological eventsosler nodesosler nodes

Roth spots Roth spots GNGN

Enlarged spleenEnlarged spleen

Modified Duke CriteriaModified Duke Criteria

Definite IEDefinite IE– Microorganism (via culture or histology) in a valvular vegetation, Microorganism (via culture or histology) in a valvular vegetation,

embolized vegetation, or intracardiac abscessembolized vegetation, or intracardiac abscess– Histologic evidence of vegetation or intracardiac abscessHistologic evidence of vegetation or intracardiac abscess

Possible IEPossible IE– 2 major2 major– 1 major and 3 minor1 major and 3 minor– 5 minor5 minor

Rejected IERejected IE– Resolution of illness with four days or less of antibioticsResolution of illness with four days or less of antibiotics

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 vegetationsclustered in vegetations

SurgerySurgery– Intracardiac complicationsIntracardiac complications

Surveillance blood culturesSurveillance blood cultures

ANTIBIOTICSANTIBIOTICS

RecommendedRecommended

Benzyl penicillin 2-4 mu Benzyl penicillin 2-4 mu QID for 2-6 wksQID for 2-6 wks

Gentamycin 1-2mg/kg Gentamycin 1-2mg/kg TDS for 2-6 wks.TDS for 2-6 wks.

AlternativelyAlternatively

Ceftriaxone 1 -2 gm BDCeftriaxone 1 -2 gm BD

Vancomycin 15mg/kg BDVancomycin 15mg/kg BD

Piperacillin 2-4 gmQIDPiperacillin 2-4 gmQID

Imepeum 250 mg QIDImepeum 250 mg QID

Cefotaxime 2gm BDCefotaxime 2gm BD

FUNGALFUNGAL

Amphoterecin B Amphoterecin B 1mg/kg QID 2 wks 1mg/kg QID 2 wks max upto 4 wks. max upto 4 wks. Donot exceed Donot exceed 50mg/day50mg/day

Flucytocine 150mg/kg Flucytocine 150mg/kg oral for four daysoral for four days

CautionCaution

Highly toxicHighly toxic

Liver and kidneysLiver and kidneys

Valve replacement mandatory after 2wks Valve replacement mandatory after 2wks therapy with amphoterecin therapy.therapy with amphoterecin therapy.

Monitor drug levels according to Monitor drug levels according to manufacturers guidelines.manufacturers guidelines.

ComplicationsComplications

Four etiologiesFour etiologies– EmbolicEmbolic– Local spread of infectionLocal spread of infection– Metastatic spread of infectionMetastatic spread of infection– Formation of immune complexes – Formation of immune complexes –

glomerulonephritis and arthritisglomerulonephritis and arthritis

Embolic ComplicationsEmbolic Complications

Occur in up to 40% of patients with IEOccur in up to 40% of patients with IE

Predictors of embolizationPredictors of embolization– Size of vegetationSize of vegetation– Left-sided vegetationsLeft-sided vegetations– Fungal pathogens, S. aureus, and Strep. Fungal pathogens, S. aureus, and Strep.

BovisBovis

Incidence decreases significantly after Incidence decreases significantly after initiation of effective antibioticsinitiation of effective antibiotics

Embolic ComplicationsEmbolic Complications

StrokeStroke

Myocardial InfarctionMyocardial Infarction– Fragments of valvular vegetation or Fragments of valvular vegetation or

vegetation-induced stenosis of coronary ostiavegetation-induced stenosis of coronary ostia

Ischemic limbsIschemic limbs

Hypoxia from pulmonary emboliHypoxia from pulmonary emboli

Abdominal pain (splenic or renal infarction) Abdominal pain (splenic or renal infarction)

Septic Pulmonary EmboliSeptic Pulmonary Emboli

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

Septic Retinal EmbolusSeptic Retinal Embolus

Local Spread of InfectionLocal Spread of Infection

Heart failureHeart failure– Extensive valvular damageExtensive valvular damage

Paravalvular abscessParavalvular abscess (30-40%) (30-40%)– Most common in aortic valve, IVDA, and S. aureusMost common in aortic valve, IVDA, and S. aureus– May extend into adjacent conduction tissue causing May extend into adjacent conduction tissue causing

arrythmiasarrythmias– Higher rates of embolization and mortalityHigher rates of embolization and mortality

PericarditisPericarditis

Fistulous intracardiac connectionsFistulous intracardiac connections

Local Spread of InfectionLocal Spread of Infection

Acute S. aureus IE with perforation of the aortic valve and aortic valve vegetations.

Acute S. aureus IE with mitral valve ring abscess extending into myocardium.

Metastatic Spread of InfectionMetastatic Spread of Infection

Metastatic abscess Metastatic abscess – Kidneys, spleen, brain, soft tissuesKidneys, spleen, brain, soft tissues

Meningitis and/or encephalitisMeningitis and/or encephalitis

Vertebral osteomyelitisVertebral osteomyelitis

Septic arthritisSeptic arthritis

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

Apache II scoreApache II score

Heart failureHeart failure

Paravalvular abscessParavalvular abscess

Embolic eventsEmbolic events

PROPHYLAXISPROPHYLAXIS

Dental/oral/Dental/oral/Respiratory/Respiratory/esophageal esophageal procedures.procedures.

Genitourinary/GE Genitourinary/GE proceduresprocedures

Amoxicillin 2gm oral 1 hr Amoxicillin 2gm oral 1 hr before.Clindamycin 600mg or before.Clindamycin 600mg or clarithromycin500mg if allergic to penicillin.clarithromycin500mg if allergic to penicillin.

– ..

Ampicillin 2gm +Gentamycin Ampicillin 2gm +Gentamycin 1mg/kg within ½ hr of starting IV 1mg/kg within ½ hr of starting IV followed byAmpicillin 1gm IV 6 hrs followed byAmpicillin 1gm IV 6 hrs later.later.

WHO NEEDS PROPHYLAXIS?WHO NEEDS PROPHYLAXIS?

REQUIREDREQUIRED

Prosthetic valvesProsthetic valves

Previous IEPrevious IE

CCHDCCHD

MVP with regurgitationMVP with regurgitation

HOCM/IHSSHOCM/IHSS

NOT REQUIREDNOT REQUIRED

MVPMVP

Isolated ASDIsolated ASD

CAD or CABGCAD or CABG

PPM’S or ICD’SPPM’S or ICD’S

THANK YOU.THANK YOU.