2. DEFINITION
īĸ Infective Endocarditis (IE): an infection of the
heartâs endocardial surface and or heart valves
that involves thrombi formation which may
damage endocardial tissues or valves
īĸ Classified based on temporal evolution of
disease, the site of infection, the cause of
infection, or the predisposing risk factor.
2
3. CLASSIFICATION BASED ON TEMPORAL
EVOLUTION OF THE DISEASE
īĸ Acute
ī Affects normal heart valves
ī Hectically febrile illness that rapidly damages cardiac
structures and hematogenously seed extracardiac sites
ī If not treated, usually fatal within 6 weeks
ī Commonly due to S.aureus
3
4. CONTâDâĻ.
īĸ Subacute
ī Often affects damaged heart valves
ī Indolent nature,characterized by prolonged course of LGF,
and nonspecific compliants :fatigue, arthralgia, wt loss,
diaphoresis
ī Rarely metastasize
ī There is risk of immunologic sequelae:GN
ī If not treated, usually fatal by one year
ī Due to less virulent organisms: V.streptococci,CONS
4
5. CLASSIFICATION (BASED ON PREDISPOSING RISK FACTORS)
1. Native valve endocarditis
īŧ Community acquired
īŧ Health care-associated (nosocomial) endocarditis: defined as a
diagnosis of IE made more than 72 hours after admission in
patients with no evidence of IE on admission, or IE developing
within 60 days of a prior admission when there was a risk factor
for bacteremia or any risk factor for IE during the hospitalization
2. Prosthetic valve endocarditis
3. Endocarditis in IVD abusers
5
6. EPIDEMIOLOGY
īĸ Incidence difficult to ascertain and varies according to
location but it is relatively uncommon disease
īĸ Much more common in males than in females(M:F
ratiovaries from 2:1-9:1)
īĸ May occur in persons of any age and increasingly
common in elderly
īĸ Mortality ranges from 20-30% with Rx , up to100% fatal
with out Rx.
6
7. RISK FACTORS
īĸ Intravenous drug abuse
īĸ Artificial heart valves and pacemakers
īĸ Acquired heart defects
ī Rheumatic heart disease
ī Calcific aortic stenosis
īĸ Congenital heart defects(VSD,PDA,COA,TOF,BAV)
īĸ Intravascular catheters
īĸ Prior episode of infective endocarditis: recurrence is
9%
īĸ NB. The higher gradient flow lesions( high pressure
to low pressure) are highly risk for IE. 7
8. ETIOLOGY( MICROBIOLOGY)
īą Common bacteria
ī Viridans group streptococci (S. mutans, S.
sanguis, S. mitis)
ī Staphylococcus aureus
ī Group D streptococcus (enterococcus) (S. bovis,
S. faecalis)
īą Not so common bacteria
ī Pseudomonas
ī H.influenze
ī HACEK (Haemophilus species, Aggregatibacter
aphrophilus, Actinomycetemcomitans,
Cardiobacterium species,Eikenella species, and
Kingella species)
ī Fungi
8
9. PATHOPHYSIOLOGY1. Turbulent blood flow disrupts the endocardium making it
âstickyâ
2. At the site of the damage, fibrin, platelet and occasionally
RBCs are deposited and form- nonbacterial thrombotic
endocarditis (NBTE)ī
3. Transient Bacteremia or fungemia delivers the organisms
to the endocardial surface
4. Adherence of the organisms to the injured endocardial
surface and thrombus
5. Eventual invasion of the valvular leaflets â further
deposition of platelets resulting in vegetation's
9
10. SYMPTOMS
īĸ Acute
ī High grade fever and
chills
ī SOB
ī Arthralgia/ myalgia
ī Abdominal pain
ī Pleuritic chest pain
ī Back pain
īĸ Subacute
ī Low grade fever
ī Anorexia
ī Weight loss
ī Fatigue
ī Arthralgia/ myalgia
ī Abdominal pain
ī N/V
The onset of symptoms is usually ~2 weeks or less
from the initiating bacteremia
10
11. SIGNS
īĸ Fever
īĸ Heart murmur( new or changing murmur)
īĸ Nonspecific signs â petechiae, subungal or âsplinterâ
hemorrhages, clubbing, splenomegaly, neurologic
changes
īĸ More specific signs - Oslerâs Nodes, Janeway lesions,
and Roth Spots
11
13. PERIPHERAL SIGN OF IE
īĸ Janeway lesions: are macular, blanching, nonpainful, erythematous
lesions on the palms and soles
īĸ Osler's nodes: are painful, papulopustular to violaceous nodular
lesions found in the pulp of fingers and toes and are seen more
often in sub acute than acute cases of IE
īĸ Roth spots are exudative, edematous hemorrhagic lesions of the
retina
īĸ Petechiae
īĸ Splinter hemorrhage: are nonblanching, linear reddish-brown
lesions found under the nail bed
13
14. PETECHIAE
Photo credit, Josh Fierer, M.D.
medicine.ucsd.edu/clinicalimg/ Eye-Petechiae.html
Harden Library for the Health Sciences
www.lib.uiowa.edu/ hardin/
md/cdc/3184.html
1.Nonspecific
2.Often located on extremities
or mucous membranes
dermatology.about.com/.../
blpetechiaephoto.htm
14
15. SPLINTER HEMORRHAGES
1. Nonspecific
2. Nonblanching
3. Linear reddish-brown lesions found under the nail bed
4. Usually do NOT extend the entire length of the nail
15
18. OSLERâS NODES
1. More specific
2. Painful and erythematous nodules
3. Located on pulp of fingers and toes
4. More common in subacute IE 18
19. COMPLICATIONS
īĸ Four etiologies
ī Embolic eg stroke
ī Local spread of infection
ī Metastatic spread of infection
ī Formation of immune complexes â
glomerulonephritis and arthritis
19
20. EMBOLIC COMPLICATIONS
īĸ Occur in up to 40% of patients with IE
īĸ Predictors of embolization
ī Size of vegetation(>or= to 10mm)
ī Left-sided vegetations
ī Fungal pathogens, S. aureus, and Strep. Bovis
īĸ Incidence decreases significantly after initiation of
effective antibiotics
20
21. EMBOLIC COMPLICATIONS
īĸ Stroke
īĸ Myocardial Infarction
ī Fragments of valvular vegetation or vegetation-induced
stenosis of coronary ostia
īĸ Ischemic limbs
īĸ Hypoxia from pulmonary emboli
īĸ Abdominal pain (splenic or renal infarction)
21
22. LOCAL SPREAD OF INFECTION
īĸ Heart failure
ī Due to extensive valvular damage or acute MI
ī Commonest Couse of death
īĸ Paravalvular abscess (30-40%)
ī Most common in aortic valve, IVDA, and S. aureus
ī May extend into adjacent conduction tissue causing
arrythmias
ī Higher rates of embolization and mortality
īĸ Pericarditis
īĸ Fistulous intracardiac connections 22
24. INVESTIGATION
īą Blood Cultures
īŧ 3- 5 separate blood collection should be obtained after careful
preparation for phlebotomy site depending on severity of illness
īŧ In most patients 3 BC are obtained with in the 1st 24 hrs
and additional 2 BC in the next 24 hrs if no growth
īŧ In critically ill patients 3 venipuncture site for blood culture
should be obtained as fast as possible
īŧ Obtain 10-20mL in adults and 0.5-5mL in children2
īļ Positive Result:
ī Typical organisms present in at least 2 separate samples
ī Persistently positive blood culture (atypical organisms)
īĸ Two positive blood cultures obtained at least 12 hours apart
īĸ Three or more positive blood cultures in which the first and
last samples were collected at least one hour apart 24
26. IMAGING
īĸ Chest x-ray
ī Look for multiple focal infiltrates and calcification of heart
valves
īĸ EKG
ī Rarely diagnostic
ī Look for evidence of ischemia, conduction delay, and
arrhythmias
īĸ Echocardiography
26
27. INDICATIONS FOR
ECHOCARDIOGRAPHY
īĸ Transthoracic echocardiography (TTE)
ī First line if suspected IE
ī Native valves
īĸ Transesophageal echocardiography (TEE)
ī Prosthetic valves
ī Intracardiac complications
ī Inadequate TTE
ī Fungal or S. aureus or bacteremia
27
28. DIAGNOSIS
Modified Duke Criteria
īĸ Definite IE
ī Clinical criteria
īĸ Two major criteria, or
īĸ One major and three minor criteria, or
īĸ Five minor criteria
ī Pathologic criteria
īĸ Microorganism: (via culture or histology) in a valvular
vegetation, embolized vegetation, or intracardiac
abscess
īĸ Pathological lesions: vegetation or intracardiac
abscess present, confirmed by histology showing
active endocarditis 28
29. CONâD
īĸ Possible IE
ī One major criterion and one minor criterion
or three minor criteria
īĸ Rejected IE
ī Firm alternative diagnosis for manifestations
of endocarditis, or
ī Sustained resolution of manifestations of
endocarditis, with antibiotic therapy for 4
days or less, or
ī No pathological evidence of infective
endocarditis at surgery or autopsy, after
antibiotic therapy for 4 days or less 29
30. CONâD
īĸ Major Criteria
ī Positive blood culture
ī Typical microorganism for infective endocarditis from two
separate blood cultures
ī Persistently positive blood culture, defined as recovery of
a microorganism consistent with infective endocarditis
from:
īĸ Blood cultures (âĨ2) drawn more than 12 hr apart, or
īĸ All of three or a majority of four or more separate blood
cultures, with first and last drawn at least 1 hr apart
ī Single positive blood culture for Coxiella burnetii or
antiphase I IgG antibody titer >1:800
30
31. CONâD
ī Evidence of endocardial involvement
ī Positive echocardiogram
īĸ Oscillating intracardiac mass, on valve or supporting structures, or in
the path of regurgitant jets, or on implanted material, in the absence
of an alternative anatomical explanation, or
īĸ Abscess, or
īĸ New partial dehiscence of prosthetic valve, or
īĸNew valvular regurgitation (increase or change in
preexisting murmur not sufficient)
31
32. CONâD
ī Minor Criteria
īŧ Predisposition: predisposing heart condition or
intravenous drug use
īŧ Fever âĨ38.0°C (100.4°F)
īŧ Vascular phenomena: major arterial emboli, septic
pulmonary infarcts, mycotic aneurysm, intracranial
hemorrhage, conjunctival hemorrhages, Janeway
lesions
īŧ Immunological phenomena: glomerulonephritis,
Osler nodes, Roth spots, rheumatoid factor
īŧ Microbiological evidence: positive blood culture but
not meeting major criterion as noted previously[*] or
serologic evidence of active infection with organism
consistent with infective endocarditis
32
33. CONâD
īĸ The following minor criteria are added to those
already listed:
īŧ splenomegaly
īŧ splinter hemorrhages, and petechiae
īŧ a high erythrocyte sedimentation rate
īŧ a high C-reactive protein level
īŧ the presence of central non feeding lines
īŧ peripheral lines
īŧ microscopic hematuria
33
34. TREATMENT
īĸ Parenteral antibiotics
ī High serum concentrations to penetrate vegetations
ī Prolonged treatment to kill dormant bacteria clustered in
vegetations
īĸ Surgery
ī Intracardiac complications
ī intractable heart failure
ī failure to sterilize the blood despite adequate antibiotic
levels
ī increasing size of vegetations while receiving therapy
īĸ Surveillance blood cultures
34
35. īĸ Acute endocarditis or prosthetic valvae endocarditis
vancomycin 30mg/kg/day(ceftriaxone 2gm/day) plus gentamycin
3mg/kg/day once daily or in 2-3 divided doses immedietly after blood
culture.
īĸ Subacute endocarditis âif patient hemodynamically stable wait
for 2- 3 days till blood culture result.
īĸ Culture positive treat based on the isolated organisms
īĸ Culture is negative endocarditis
īĸ SBE-ceftriaxone 2gm /day+gentamycin 3gm/kg for the 1st 2wks and
continue with ceftriaxone only for the remaining weeks of therapy
īĸ Acute endocarditis âcontinue vancomycin +gentamycin for 2wks and
then vancomycin for the remaining wks of therapy
īĸ patients with proven or suspected enterococcal endocarditis should
receive combination of vancomycin and gentamycin for the whole
duration of therapy.
īĸ Duration of therapy- 4wks for most patients 35
36. PREVENTION
īĸ Antimicrobial prophylaxis before various
procedures and other forms of dental
manipulation may reduce the incidence of
infective endocarditis in susceptible patients
36