Infective endocarditis

Dr. Md.Toufiqur Rahman

MBBS, FCPS, MD, FACC, FESC, FRCPE, FSCAI, FAPSC, FAPSIC, FAHA, FCCP, FRCPG

Associate Professor of CardiologyNational Institute of Cardiovascular Diseases(NICVD),

Sher-e-Bangla Nagar, Dhaka-1207

Consultant, Medinova, Malibagh branchHonorary Consultant, Apollo Hospitals, Dhaka and

STS Life Care Centre, Dhanmondi drtoufiq19711@yahoo.com

CRT 2014Washington DC, USA

Outline 1.1. DefinitionsDefinitions, general information, general information2. Clinical symptoms3. Diagnosis

1. Duke criteria2. Blood cultures3. Echocardiography

4. Treatment basics5. Complications6. Prophylaxis7. Summary

Definitions, general information

• Infective endocarditis Infective endocarditis – inflammatory process on-going inside

endocardium – due to infection after endothelium damage– most often involving aortic and mitral valves

Definitions, general information- continued

Acording to localisation Acording to localisation • Left sided IE– Native valve IE (NVE)– Prosthetic valve IE(PVE) • Early < 1 year after surgery• Late >1 year after surgery

• Right sided IE• Device- related IE (ICD)

AAcording to the mode of acquisitioncording to the mode of acquisition• Health-care associated IE– Nosocomial– Non-nosocomial

• Community acquired IE• Intravenous drug abuse-associated IE

Definitions, general information- continued

Definitions, general information- continued

• Active IE• Recurrence– Relpse– Reinfection

Definitions, general information- continued

• 3-10/100 000/year• Maximum at the age of 70-80• More common in women• Staphylococcus aureus is the most common

pathogen • Streptococcal IE is still the most common

in developing countries

Clinical symptoms

• Fever – over 90% of patients• New intra-cardiac murmur - about 85% of

patients• Roth spots, petechiae, glomerulonephritis –

up to 30% of patients

Clinical symptoms – when to suspect?

• Sepsis of unknown origin• Fever coexisting with:– Intracardiac implantable material– IE history– Congenital heart disease or valve disease – IE risk factors– Congestive heart failure symptoms– New heart block– Positive blood cultures– Focal neurological signs without known etiology– Peripheral abscesses (kidney, spleen, brain, vertebral

column)

Duke criteria

Major criteria1. Blood culture positive for

typical IE-causing microorganism

2. Evidence of endocardial involvement

Minor criteria1. Predisposition – heart

condition or i.v. drug abuse2. Fever – temp. >38 °C3. Vascular phenomena –

arterial emboli etc.4. Immunologic phenomena –

glomerulonephritis, Osler’s nodes, Roth’s spots

5. Microbiological evidence – positive blood cultures but do not meet major criteria

Diagnosis• 2 major criteria• 1 major and 3 minor• 5 minor criteria

Blood cultures

• Always before starting antibiotics• Always triple samples – aerobe, anaerobe and

mycotic , 10 ml each• Three sets of samples required

Echocardiography

• Transthoracic (TTE) and transoesophageal (TEE)

• fundamental importance in diagnosis, management, and follow-up

• Should be performed as soon as the IE is suspected

• Sensitivity of TEE is bigger than TTE (vs 90-100% vs. 40-63% )

• TEE is first choice to find IE complications

Echocardiography

Echocardiographic findings in IEEchocardiographic findings in IE• Vegetation• Abscess• Pseudoaneurysm• Perforation• Fistula• Valve aneurysm• Dishence of prosthetic valve

Treatment basics

• Sucess relies on eradication of pathogen• Bactericidal regiment should be used• Drug choice due to pathogen• Surgery is used mainly to cope with structural

complications

Treatment basics - continued

• NVE standard therapy - it takes 2-6 weeks to eradicate the pathogen

• PVE – longer regime is necessery – over 6 weeks• In Streptococcal IE shorter, 2 week course, can

be used when combining β-laktams with aminoglycosides

• Most widely used drugs – amoxycylin, gentamycin

• In case of β-laktams alergy - vancomycin

Complications1.1. Congestive heart failureCongestive heart failure• Most common complication• Main indication to surgical treatment• ~60% of IE patients

2.2. Uncontrolled infectionUncontrolled infection• Persisting infection • Perivalvular extension in infective endocarditis

3.3. Systemic embolismSystemic embolism• Brain, spleen and lungs• 30% of IE patients• May be the first symptom

Complications - continued

5.5. Neurologic eventsNeurologic events6.6. Acute renal failureAcute renal failure7.7. Rheumatic problemsRheumatic problems8.8. MyocarditisMyocarditis

Prophylaxis • First and most important – proper oral hygieneproper oral hygiene• Regular Regular dental reviewdental review• Antibiotics only in high-risk group patients– Prosthetic valve or foreign material used for heart

repair– History of IE– Congenital heart disease

• Cyanotic without correction or with residual lickeage• CHD without lickeage but up to 6 months after surgery

– Use amoxycilin or ampicylin 30-60 min prior to intervention

Prophylaxis

The ‘Endocarditis Team’

No single practitioner will be able to manage full spectrum of IE.

A very high level of expertise is needed from several specialties, including cardiologists, cardiac surgeons, ID specialists, microbiologists, neurologists, neurosurgeons, experts in CHD and others.

About 50% patients with IE undergo surgery during the hospital course. Early discussion with the surgical team is important and is considered mandatory in all cases of complicated IE.

Characteristics of the ‘Endocarditis Team’ When to refer a patient with IE to an ‘Endocarditis

Team’ in a reference centre:

1. Patients with complicated IE should be referred early.

2. Patients with non-complicated IE can be initially managed in a nonreference centre, but with regular communication with the reference centre, consultations with the multidisciplinary ‘Endocarditis Team’, and, when needed, with external visit to the reference centre.

Characteristics of the reference centre

1. Immediate access to diagnostic procedures, including TTE, TOE, multislice CT, MRI, and nuclear imaging.

2. Immediate access to cardiac surgery.

3. Several specialists should be present on site (the ‘Endocarditis Team’), including cardiac surgeons, cardiologists, anaesthesiologists, ID specialists, microbiologists and, when available, specialists in valve diseases, CHD, pacemaker extraction, echocardiography and other cardiac imaging techniques, neurologists, and facilities for neurosurgery and interventional neuroradiology .

Role of the ‘Endocarditis Team’ 1. It should have meetings on a regular basis in order to discuss cases, take

surgical decisions, and define the type of follow-up.

2. They chooses the type, duration, and mode of follow up of antibiotic therapy, according to a standardized protocol, following the current guidelines.

3. They should participate in national or international registries, publicly report the mortality and morbidity of their centre,

and be involved in a quality improvement programme, as well as in a patient education programme.

4. The follow-up should be organized on an outpatient visit basis at a frequency depending on the patient’s clinical status (ideally at 1, 3, 6, and 12 months after hospital discharge, since the majority of events occur during this period).

Indication for surgical treatment of right sided infective endocarditis

Infective endocarditis in the ICU The incidence of nosocomial infection is increasing and patients

may develop IE

Admitted to the ICU due to haemodynamic instability related to severe sepsis, overt HF and/or severe valvular pathology or organ failure from IE-related complications

Staph is M.C. f/b streptococcus f/b fungal

There should be a relatively low threshold for TOE in critically ill patients with S. Aureus

multidisciplinary Endocarditis Team environment should be created.

I.E. during pregnancy• Incidence – 0.006%.• Higher inpatients with cardiac disease and further

more in pt with prosthetic valves.• Maternal mortality ~33%.• Foetal mortality ~29%.• Rapid detection and appropriate treatment is

important.• Despite the high foetal mortality , urgent surgery

should be performed in pt who present with HF due to acute regurgitation.

I.E. In congenital heart diseases Fewer systematic studies.

Incidence is lower in children(o.o4% per year ) than in adult(0.1%)

CHD with multiple lesion is at higher risk than simple lesion.

Mortality of 4-10 %. Prognosis is better than other forms.

Surgical repair of CHD reduces the risk, provided there is no residual shunt.

Artificial valve substrate may increase the risk.

Non-bacterial thrombotic endocarditis Sterile vegetations consisting of fibrin and platelet

aggregates on cardiac valves Neither bacteraemia nor with destructive changes

of the underlying valve Associated with CTD, autoimmune disorders,

hypercoagulable states, septicaemia, severe burns, tuberculosis, uraemia or AIDS

A potentially life-threatening source of thromboembolism,

Cont… Initial diagnostic workup- same

Strong suspicion if- presence of a heart murmur, the presence of vegetations not responding to antibiotic and evidence of multiple systemic emboli

Small, broad based and irregularly shaped.

TOE should be ordered when there is a high suspicion

Immunological assays for APLA syndrome (i.E. Lupus anticoagulant, anticardiolipin antibodies, and anti-b2- glycoprotein 1 antibodies; at least one must be positive for the diagnosis of APLA on at least two occasions 12 weeks apart)

Non-bacterial thrombotic endocarditis

Anticoagulated with UFH or LMWH or warfarin, although there is little evidence to support this strategy

Surgery, valve debridement and/or reconstruction are often not recommended unless the patient presents with recurrent thromboembolism despite well-controlled anticoagulation.

Other indications for valve surgery are the same as for IE

Infective endocarditis associated with cancer IE may be a potential marker of occult cancers.

In a large, Danish,nationwide, population-based cohort study, 997 cancers were identified among 8445 IE patients with a median follow-up of 3.5 years.

Risk of abdominal and haematological cancers was high (within the first 3 months)

S. bovis infection, specifically S. gallolyticus subspecies-- colonic adenoma or carcinoma.

it is recommended to rule out occult colon cancer during hospitalization and annual colonoscopy.

Summary• IE is rare but serious disease, with high mortality

rate• Every case of fever of unknown origin should be

suspected for IE• Blood cultures are essential for diagnosis• TTE/TEE is the best method to monitor and follow-

up of IE• Antibiotics are main treatment• CHF is the most common complication• Pharmacological prophylaxis is reserved for a

narrow group of high risk patients