infective endocarditis-1
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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.