Infective Endocarditis Case Studies

MBBS, FCPS, MD, FACC, FESC, FRCP, FSCAI,
FCCP,FAPSC, FAPSIC, FAHA,FACP,FASE
Professor and Head of Cardiology
Colonel Malek Medical College , Manikganj.
For post-graduates
drtoufiq19711@yahoo.com13/09/2019
Post graduate version 2019

Infective Endocarditis12.09.2019
drtoufiq19711@yahoo.comProf. Dr Md Toufiqur Rahman

A 16 years old lady presented
with low grade fever for 24
days . She had a history of
PTMC 37 days back.
How will you evaluate and
manage the case?
Case study 01

An 18 years old lady presented with
low grade fever for 29 days. She had
a history of tooth extraction 35 days
back. She is a diagnosed case of
valvular heart disease.
manage the case?
Case study 02

A 42 years old lady presented with
low grade fever for 20 days. She had a
history of urinary tract
catheterization 30 days back for a
major surgery. She is a diagnosed
case of Atrial septal defect .
manage the case?
Case study 03

A 24 years old man presented with
fever with chills and rigor for 10
days. He is an intravenous drug
abuser. On examination a pansystolic
murmur found in precordium.
manage the case?
Case study 04

A 32 years old man presented with
fever with chills and rigor for 11 days
. On examination a murmur found in
precordium. Echocardiography
showed aortic root abscess .
manage the case?
Case study 05

A 42 years old lady presented with low
grade fever for 21 days . She had a
history of colonoscopy 31 days back
and diagnosed as ulcerative colitis.
She is a diagnosed case of Aortic
valvular disease .
manage the case?
Case study 06

A 32 years old lady presented with low
grade fever for 21 days and sudden left
sided hemiparesis. She had a history of
major abdominal surgery 33 days back.
She is a diagnosed case of VSD with
Eisenmengers syndrome.
manage the case?
Case study 07

1. Definitions, general information
2. Clinical symptoms
3. Diagnosis
• Duke criteria
• Blood cultures
• Echocardiography
4. Treatment basics
5. Complications
6. Prophylaxis
7. Summary
Outline of lecture

Infective endocarditis is
• inflammatoryprocess on-goinginside
endocardium
• duetoinfectionafterendothelium
damage
• mostofteninvolvingaorticandmitral
valves
Definitions, general information

Acordingtolocalisation
• LeftsidedIE
• NativevalveIE(NVE)
• ProstheticvalveIE(PVE)
Early<1year aftersurgery
Late >1yearaftersurgery
• RightsidedIE
• Device-relatedIE(ICD)
Definitions, general information- continued

According to the mode of acquisition
• Health-care associated IE
• Nosocomial
• Non-nosocomial
• Community acquired IE
• Intravenous drug abuse-associated IE

• Active IE
• Recurrence
Relapse
Reinfection

• 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

• Fever – over 90% of patients
• New intra-cardiac murmur - about
85% of patients
• Roth spots, petechiae,
glomerulonephritis – up to 30% of
patients
Clinical symptoms

• 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)
Clinical symptoms – when to suspect?

Duke criteria
Major criteria
1. Blood culture positive for
typical IE-causing
microorganism
2. Evidence of endocardial
involvement
Minor criteria
1. Predisposition – heart
condition or i.v. drug
abuse
2. Fever – temp. >38 °C
3. 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

Duke 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

Classes of recommendations
drtoufiq19711@yahoo.cProf. Dr Md Toufiqur

Echocardiography

Echocardiography
Echocardiographic findings
in IE
• Vegetation
• Abscess
• Pseudoaneurysm
• Perforation
• Fistula
• Valve aneurysm
• Dehiscence of
prosthetic valve
12.09.2019 Infective Endocarditis
Prof. Dr Md Toufiqur Rahman drtoufiq19711@yahoo.com

Treatment basics
• Success relies on eradication of pathogen
• Bactericidal regiment should be used
• Drug choice due to pathogen
• Surgery is used mainly to cope with structural
complications
• NVE standard therapy - it takes 2-6 weeks to
eradicate the pathogen
• PVE – longer regime is necessery – over 6
weeks

Treatment basics_continued
•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

Complications
1. Congestive heart failure
• Most common complication
• Main indication to surgical treatment
• ~60% of IE patients
2. Uncontrolled infection
• Persisting infection
• Perivalvular extension in infective endocarditis
3. Systemic embolism
• Brain, spleen and lungs
• 30% of IE patients
• May be the first symptom

Complications - continued
5.Neurologic events
6.Acute renal failure
7.Rheumatic problems
8.Myocarditis

Prophylaxis
•First and most important – proper oral hygiene
•Regular dental 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 leakage
•CHD without leakage but up to 6 months after surgery
–Use amoxycilin or ampicylin 30-60 min prior to
intervention

Prophylaxis

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 ‘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 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.

Infective endocarditis 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.

Infective endocarditis 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.

Non-bacterial thrombotic endocarditis contd
 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 contd
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.

Infective Endocarditis Case Studies

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