ENFECTIVE ENDOCARDITISENFECTIVE ENDOCARDITIS

M.RASOOLINEJAD, MDM.RASOOLINEJAD, MDDEPARTMENT OF INFECTIOUS DISEASEDEPARTMENT OF INFECTIOUS DISEASETEHRAN UNIVERSITY OF MEDICAL SCIENCETEHRAN UNIVERSITY OF MEDICAL SCIENCE

INFECTIVE ENDOCARDITISINFECTIVE ENDOCARDITIS

Infection of the endocardial surfaceInfection of the endocardial surface

INFECTIVE ENDOCADITISINFECTIVE ENDOCADITIS

INTRUDUCTIONINTRUDUCTION

•Clinical manifestations are so varied.Clinical manifestations are so varied.

•All of medical subspecialist must encounterAll of medical subspecialist must encounter

•Successful managementSuccessful management Medical & Surgical.Medical & Surgical.

EPIDEMIOLOGYEPIDEMIOLOGY20% of cases are categorized as definite20% of cases are categorized as definite

Mean age of patients are increasedMean age of patients are increased

Underlying heart diseaseUnderlying heart diseaseRheumatic heart diseaseRheumatic heart diseaseDegenerative heart diseaseDegenerative heart diseaseCongenital heart diseaseCongenital heart diseaseNosocomial endocarditisNosocomial endocarditisIntracardiac prosthesesIntracardiac prosthesesInjection Drug Users Injection Drug Users ( IDU )( IDU )

Endothelium Mucus membrane Endothelium Mucus membrane (Trauma, Turbulance, or(Trauma, Turbulance, or metabolic change ) Colonized tissuemetabolic change ) Colonized tissue

Plt - fib deposition TraumaPlt - fib deposition Trauma

NBTE BacteremiaNBTE Bacteremia AdherenceAdherence ColonizationColonization

Mature VegetationMature Vegetation

PATHOGENESISPATHOGENESIS

Local factorBacteriocinsIgA proteaseBacterial adherence

Complement Antibody

PATHOGENESISPATHOGENESIS

Nonbacterial Thrombotic Endocarditis (NBTA)Nonbacterial Thrombotic Endocarditis (NBTA)

Hemodynamic factorHemodynamic factor

Transient BacteremiaTransient Bacteremia

MicroorganismsMicroorganisms

ImmunopathologicImmunopathologic

ETIOLOGIC AGENTSETIOLOGIC AGENTS

Streptococci ( viridance, Fecalis,… ) 60 – 80 %Streptococci ( viridance, Fecalis,… ) 60 – 80 %

Staphylococci ( +ve Or -ve coagolase ) 20 – 30 %Staphylococci ( +ve Or -ve coagolase ) 20 – 30 %

Gram -ve bacteria 1.5 – 13%Gram -ve bacteria 1.5 – 13%

Fungi 2 - 4 %Fungi 2 - 4 %

Culture negative 5 – 25 %Culture negative 5 – 25 %

Others 1 – 2 %Others 1 – 2 %

CULTURE – NEGATIVE ENDOCARDITIS

Subacute right – side infective endocarditis

Chronic course > 3 months

Uremia supervening chronic course

Mural IE as in VSD

Pacemaker wires infection

CULTURE - NEGATIVE ENDOCARDITIS

HACEK*

Brucella spp, Prior administration of antibiotics

Rickettsiae, Chlamydia, Virus

Noninfective endocarditis* Haemophilus spp, Actinobacillus spp, Cardiobacterium spp, Eikenella, Kingella

PATHOLOGYHEART:

•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

PATHOLOGY

RENAL

Renal architecture is abnormal in all cases, Even in the absence of clinical or biochemical

of renal disease

PATHOLOGY

RENALFocal glomerulonephritis

Diffuse glomeruonephritis

Membranoproliferative glomerulonephritis

Renal infarction

Renal abscess

PATHOLOGYPATHOLOGYCNSCNS

Emboli (middle cerebral artery )Emboli (middle cerebral artery )InfarctionInfarctionArteritisArteritisAbscessAbscessMycotic aneurysmsMycotic aneurysmsHemorrhage:Hemorrhage:Intracerebral or SubarachnoidIntracerebral or SubarachnoidEncephalomalaciaEncephalomalaciaMeningitisMeningitis

PATHOLOGYPATHOLOGYMYCOTIC ANEURYSMSMYCOTIC ANEURYSMS

Usually during active IEUsually during active IE

Occasionally mons or years after successful treatmentOccasionally mons or years after successful treatment

Direct bacterial invasionDirect bacterial invasion abscess abscess

Septic embolic to vasa vasorumSeptic embolic to vasa vasorum

Immun complex depositionImmun complex deposition

Cerebral vessels, abdominal aorta, sinus of ValsalvaCerebral vessels, abdominal aorta, sinus of Valsalva

Clinically silent until rupture Clinically silent until rupture

PATHOLOGYPATHOLOGYSPLEEN:SPLEEN:

LUNG:LUNG:

SKIN:SKIN:

EYE:EYE:

Infarction, Abscess, EnlargementInfarction, Abscess, Enlargement

Emboli, Acute Pneumonia, Emboli, Acute Pneumonia, Pleural EffusionPleural Effusion

Ptechiae, Ptechiae, Osler node ( Arteriolar intimal proliferation )Osler node ( Arteriolar intimal proliferation )Janeway lesions Janeway lesions ( Becteria, Necrosis, PMN, Hemorrhage( Becteria, Necrosis, PMN, Hemorrhage)

Roth spotsRoth spots ( Lymphocyte, Edema, Hemorrhage ( Lymphocyte, Edema, Hemorrhage )

IEIE

CNSCNS

KIDNEYKIDNEY LUNGLUNG

HEARTHEARTFEVERFEVER

EYEEYE SKINSKIN

FUOFUO

ICTERICTER SEPTICSEPTICEMBOLIEMBOLI

PAINPAIN

JOINTJOINTCLINICALCLINICAL MANIFESTATIONMANIFESTATION

IE & IDUMore common in cocain usersFebrile IDU = IENo underlying heart diseaseMore common in tricuspid valveAortic > Aortic + Mitral > Mitral valvePumonary septic emboliS aureous, P aueroginosaIDU & HIV / AIDS

IE & ELDERLYIncreased incidence in elderlyProlonged 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.

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

DIAGNOSISDurack DT, Lukes AS, Bright DK, Criteria

Definite ( Pathologic & Clinical Criteria )

Possible

RejectedCLINICAL CRITERIA

2 Major or3 Major & 3 Minor or5 Minor

MAJOR CRITERIAPositive blood cultureEvidence of endocardial involvement

MINOR CRITERIAPredisposing heart disease or IDUFever > 38Vascular phenomenaImmunologic phenomenaECHOMicrobiologic evidence

POSITIVE BLOOD CULTURETypical 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

EVIDENCE OF ENDOCARDIAL INVOLVEMENT

Positive ECHO for IE

New valvular regurgitation

Oscillating intracardiac mass

Abscess

New dehiscence of prosthetic valve

veg

Mitral valve VegetationMitral valve Vegetation

Mitral valve vegetation

TREATMENTTREATMENT Antimicrobial therapyAntimicrobial therapy High dose, prolonged & IV antibioticsHigh dose, prolonged & IV antibiotics Surgical therapySurgical therapy

ANTIMICROBIAL THERAPYANTIMICROBIAL THERAPY

Empirical therapyEmpirical therapy

Organisms based therapyOrganisms based therapy

Duration of treatmentDuration of treatment

MONITORING ANTIMICROBIAL THERAPYMONITORING ANTIMICROBIAL THERAPY

•Serum concentration of antibiotic Serum concentration of antibiotic should be monitoring.should be monitoring.

•Antibiotic toxicities should be considered.Antibiotic toxicities should be considered.

•Blood culture should be repeated daily Blood culture should be repeated daily Sterile Sterile

•Rechecked B/C if there is recrudescent fever.Rechecked B/C if there is recrudescent fever.

•Performed B/C 4 – 6 WKS after therapy Performed B/C 4 – 6 WKS after therapy to document cure.to document cure.

MONITORING ANTIMICROBIAL THERAPYMONITORING ANTIMICROBIAL THERAPY

•B/C became sterile after start antibiotics:B/C became sterile after start antibiotics:

2 days in 2 days in S.Viridance S.Viridance EnterococciEnterococci HACEK organismsHACEK organisms

3 – 5 days in 3 – 5 days in S. Aureus + beta lactam S. Aureus + beta lactam

7 days in 7 days in S. Aureus + Vancomycin S. Aureus + Vancomycin

MONITORING ANTIMICROBIAL THERAPYMONITORING ANTIMICROBIAL THERAPY

If fever persist for 7 days in spiteIf fever persist for 7 days in spite appropriate AB appropriate AB Evaluate patient for: Evaluate patient for: Paravalvular abscessParavalvular abscess Extracardiac abscessExtracardiac abscess Embilic event Embilic event

Vegetation became smaller with effective therapyVegetation became smaller with effective therapy 3 months after cure: 50% unchanged3 months after cure: 50% unchanged 25% are slightly larger 25% are slightly larger

SURGICAL THERAPYSURGICAL THERAPYRefractory CHFRefractory CHF> One serious systemic emboli> One serious systemic emboliUncontrolled infectionUncontrolled infectionValve dysfunction ( ECHO )Valve dysfunction ( ECHO )Fungal & Brucella endocarditisFungal & Brucella endocarditisMycotic aneurysmsMycotic aneurysmsProsthetic valveProsthetic valveLocal suppurative complicationsLocal suppurative complicationsLarge vegetation > 1 cmLarge vegetation > 1 cm Vegetation size after 4 WKSVegetation size after 4 WKSAortic valve endocarditisAortic valve endocarditisAcute valve insufficiencyAcute valve insufficiencyRecurrent endocarditisRecurrent endocarditis

INDICATION FOR SURGICAL INTERVENTIONINDICATION FOR SURGICAL INTERVENTION

Surgery required for optimal outcomeSurgery required for optimal outcome

Surgery to be strongly considered Surgery to be strongly considered for improved outcomefor improved outcome

INDICATION FOR SURGICAL INTERVENTIONINDICATION FOR SURGICAL INTERVENTION

Surgery required for optimal outcome:Surgery required for optimal outcome: **Moderate to severe CHE due to valvular dysfunction.Moderate to severe CHE due to valvular dysfunction.

*Partially dehisced unstable prosthetic valve.*Partially dehisced unstable prosthetic valve.

**Persistent bacteremia despite optimal AB therapy.Persistent bacteremia despite optimal AB therapy.

*Lake of effective microbial therapy ( fungal, Brucella…)*Lake of effective microbial therapy ( fungal, Brucella…)

*S. Aureus PVIE + intra cardiac complication.*S. Aureus PVIE + intra cardiac complication.

*Relapse of PVIE after optimal therapy*Relapse of PVIE after optimal therapy

INDICATION FOR SURGICAL INTERVENTIONINDICATION FOR SURGICAL INTERVENTION

Surgery to be strongly considered for improved outcome:Surgery to be strongly considered for improved outcome:

**Peivalvular extension of infectionPeivalvular extension of infection

*Poorly responsive S. aureus in aortic or mitral valve.*Poorly responsive S. aureus in aortic or mitral valve.

*Large > 10 Cm hypermobile vegetation*Large > 10 Cm hypermobile vegetation

*Persistent unexplained fever >10 days in culture -ve IE.*Persistent unexplained fever >10 days in culture -ve IE.

*Poorly responsive or relapse ( Entrococci & Gram-ve ) *Poorly responsive or relapse ( Entrococci & Gram-ve )

Valve Ring abscess

Intra operationIntra operation

After repairAfter repair

Intraoperative TEEIntraoperative TEE

PROPHYLAXIS OF ENDOCADITISPROPHYLAXIS OF ENDOCADITIS

Potential InterventionsPotential InterventionsAlleviation of predisposing conditionAlleviation of predisposing condition

Immunization against bacteriaImmunization against bacteria

Inhibition of bacterial adherenceInhibition of bacterial adherence

Application of antiseptic in the mouthApplication of antiseptic in the mouth

Administration of antibioticsAdministration of antibiotics

Procedure Causing Bacteremia:Procedure Causing Bacteremia:

Oral cavity Oral cavity

Respiratory tractRespiratory tract

Genitourinary tractGenitourinary tract

Gastrointestinal tractGastrointestinal tract

Vascular systemVascular system

RISK OF IE WITH CARDIAC DISORDERSRISK OF IE WITH CARDIAC DISORDERS

HIGH RISK:HIGH RISK:PHV, PID, Cyanotic CHD, PDA, AS, MR, VSD,PHV, PID, Cyanotic CHD, PDA, AS, MR, VSD, Coarctation of aortaCoarctation of aorta

INTERMEDIATE RISKINTERMEDIATE RISKProlapse +MR, MS, TS, TRProlapse +MR, MS, TS, TR

Bicaspid Aorta, Degenerative Heart DiseaseBicaspid Aorta, Degenerative Heart Disease

LOW / NO RISKLOW / NO RISKProlapse Mitral, ASD, Aterosclerosic Plaques,Prolapse Mitral, ASD, Aterosclerosic Plaques,

CAD, Pacemaker.CAD, Pacemaker.

ANTIBIOTIC PROPHYLAXISANTIBIOTIC PROPHYLAXIS

High risk proceduresHigh risk procedures &&High risk of cardiac diseaseHigh risk of cardiac disease

RecommendedRecommended

High risk proceduresHigh risk procedures &&Intermediate risk of cardiac diseaseIntermediate risk of cardiac disease

RecommendedRecommended

Low risk proceduresLow risk procedures &&High risk of cardiac diseaseHigh risk of cardiac disease

OptionalOptional

RECOMMENDED REGIMENSRECOMMENDED REGIMENSProcedures:Procedures: Dental, upper Res, GI, GU, Dental, upper Res, GI, GU,

Implantation of Implantation of Prosthetic ValveProsthetic Valve

Amoxicillin POAmoxicillin PO Clindamycin PoClindamycin Po

Ampicillin + GentamycinAmpicillin + Gentamycin

CefazolinCefazolin

Vancomycin + GentamycinVancomycin + Gentamycin

BeforeBefore& &

AfterAfter