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Infective Endocarditis. October 11, 2005 Dr. Kanagala. Microbiology: Organisms Responsible. Bacteria are the predominant cause Fungi Rickettsia Chlamydia Microorganisms vary dependent on risk factors predisposing patient to IE Staph Aureus= single most common cause.

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infective endocarditis

Infective Endocarditis

October 11, 2005

Dr. Kanagala

microbiology organisms responsible
Microbiology: Organisms Responsible
  • Bacteria are the predominant cause
  • Fungi
  • Rickettsia
  • Chlamydia
  • Microorganisms vary dependent on risk factors predisposing patient to IE
  • Staph Aureus= single most common cause
native valve endocarditis
Native Valve Endocarditis
  • Streptococcus responsible for more than 50% of cases
  • Staphylococci
  • Enterococci
  • Infection occurs most frequently in those with preexisting valvular abnormality
staphylococci
Staphylococci
  • Causes endocarditis in those with normal and abnormal valves
  • Most are coagulase positive S.Aureus
  • Causes destruction of valves, multiple distal abscesses, myocardial abscesses, conduction defects, and pericarditis
enterococci
Enterococci
  • Patients generally have underlying valvular disease
  • May occur following manipulation of genitourinary or lower gastrointestinal tract
  • Remainder of cases caused by Haemphilus Actinobacillus, Cardiobacterium, Eikenella, Kingella, Bartonella, or Coxiella Burnetti
diagnosis
Diagnosis
  • Negative culture can occur in 5% of patients.
  • 1/3 to ½ are negative due to prior antibiotic use
  • In patients with culture negative IE, advise lab to allow specialized testing to recover the causative organism which is needed to adequately treat
idu associated ie
IDU associated IE
  • Skin flora and contaminated injection devices are the most frequent sources involved in IDU-associated IE
  • S. Aureus – Most common (50% of cases)
  • Streptococcal species
  • Gram negative Bacilli
    • Pseudomonas
    • Serratia species
  • Fungi
    • Candida
prosthetic valve endocarditis
Prosthetic Valve Endocarditis
  • Most commonly occur during the perioperative period
  • S. epidermidis
    • Most frequently isolated organism
  • Early PVE (w/i 60 days of surgery)
    • Assoc. with valve dysfunction and fulminant clinical course
  • Late PVE (beyond 60 days postop)
    • Disease course is less fulminant
  • Mycotic PVE (Aspergillus and Candida)
    • Larger vegetations
clinical features
Clinical Features
  • Acute IE – Rapid onset of high fevers and rigors with hemodynamic deterioration and death within days to weeks if not treated
    • Assoc. with highly virulent organisms such as Staph Aureus
  • Subacute IE – Indolent course with progressive constitutional signs and symptoms and gradual deterioration
    • Assoc. with avirulent organisms such as viridans streptococci
clinical features10
Clinical Features
  • Bacteremia can produce signs and symptoms that are often nonspecific usually within 2 weeks of infection
    • Most common course of disease (fevers, chills, nausea, vomiting, fatigue and malaise)
    • Fever is the most common symptom
    • Fever can be absent in pts with antibiotic use, antipyretic use, severe CHF, or renal failure
  • Prosthetic valve patient with a fever requires IE work up
cardiac clinical features
Cardiac Clinical Features
  • Heart murmurs are present in up to 85% of cases of IE.
    • Most commonly regurgitant lesions secondary to valvular destruction
  • Acute or progressive CHF is the leading cause of death in patients with IE (70% of patients)
    • Distortion or perforation of valvular leaflets
    • Rupture of the chordae tendinae or papillary muscles
    • Perforation of the cardiac chambers (rare)
  • Valvular abscesses and Pericarditis
  • Heart blocks and Arrhythmias
embolic clinical features
Embolic Clinical Features
  • Extracardiac manifestations are the result of arterial embolization of fragments of the friable vegetation
    • CNS complications occur in 20-40% of cases (embolic stroke with MCA affected most frequently)
    • Retinal artery emboli may cause monocular blindness
    • Mycotic aneurysm may cause a SAH
    • IVDU can cause right sided lesions (tricuspid valve) – Pulmonary complications
    • Pulmonary complications ( pulmonary infarction, pneumonia, empyema, or pleural effusion)
    • Coronary artery emboli (Acute MI or myocarditis with arrhythmias)
    • Splenic infarction (LUQ abdominal pain)
    • Renal emboli (flank pain or hematuria)
clinical features13
Clinical Features
  • Persistent bacteremia can stimulate the humoral and cellular immune systems resulting in circulating immune complexes
  • Petechiae – Red, nonblanching lesions that become brown after several days (20-40%)
    • Conjunctivae, buccal mucosa, and extremities
  • Splinter hemorrhages – Linear dark streaks under the fingernails (15%)
  • Osler’s nodes – Small tender subcutaneous nodules that develop on the pads of the fingers or toes (25%)
  • Janeway lesions – Small hemorrhagic painless plaques located on the palms or soles
  • Roth spots – Oval retinal hemorrhages with pale centers located near the optic disc
diagnosis14
Diagnosis
  • Diagnosis of IE requires hospitalization
    • Cultures
    • Echocardiogram
    • Clinical observation
  • Duke Criteria – 90% sensitive
    • Major Criteria
    • Minor Criteria
major criteria
Major Criteria
  • Positive blood culture for:
    • Strep bovis, Strep viridans, or HACEK group
    • Staph aureus or Enterococci
    • Microorganisms c/w IE from persistent positive blood cultures
      • 2 positive blood cultures drawn >12 hrs apart
      • All of 3 or a majority of 4 or more positive blood cultures
major criteria16
Major Criteria
  • Echocardiographic involvement:
    • Mass on valve
    • Abscess
    • Dehiscence of prosthetic valve
    • New valvular regurgitation
minor criteria
Minor Criteria
  • Predisposition: Heart condition or injection drug use
  • Fever > 38 degrees C
  • Vascular: Emboli, conjunctival hemorrhages, janeway lesions
  • Immunological: Glomerulonephritis, osler’s nodes, roth spots, and rheumatoid fever
  • Positive blood cultures
  • Echocardiographic findings c/w IE
duke criteria
Duke Criteria
  • Definite infective endocarditis
    • Microorganisms demonstrated by culture or histologic examination of vegetation or emboli
    • Abscess with active endocarditis
    • Two major criteria
    • One major and three minor criteria
    • Five minor criteria
  • Possible endocarditis
    • Findings c/w IE that fall short of definite, but not rejected
  • Rejected
    • Firm alternate diagnosis
    • Resolution of manifestations of IE with abx for < 4 days
    • No pathologic evidence of IE at surgery or autopsy after 4 days of abx
ddx and consideration of ie
DDx and Consideration of IE
  • IE should be considered in:
    • All febrile IDUs
    • Pts with a cardiac prosthesis and fever (or malaise, vasculitis or new murmur)
    • Pts with new murmur or change in murmur with evidence of vasculitis or embolization
    • Any cardiac risk factor with unexplained fever
    • Any patient with a prolonged fever (>2 weeks)
evaluation of bacteremia
Evaluation of Bacteremia
  • All patients with suspected bacteremia should have blood cultures drawn in the ED prior to abx
  • Blood cultures should be drawn in 3 different sites
  • Minimum of 10 ml blood in each bottle
  • Minimum of one hour between first and last bottle
diagnostic tests
Diagnostic Tests
  • ECG should be done in all pts with suspected IE
    • Nonspecific usually
    • Conduction abnormalities ( new LBBB, Prolonged PR interval, new RBBB, complete heart block)
    • Junctional tachycardia
  • Chest Xray
    • Pulmonic emboli or CHF
  • Nonspecific lab tests
    • Anemia (70-90% of cases)
    • Elevated ESR (>90% of cases)
    • Hematuria
echocardiography
Echocardiography
  • Mandatory in all pts with possible IE
  • Transthoracic Echo(TTE) should be done first.
    • Specificity for vegetations is 98%
    • Sensitivity varies but it is the highest with IDUs because they more often have larger vegetations, right sided valvular lesions and favorable precordial windows.
  • Transesophageal Echo(TEE) has a higher sensitivity and specificity than TTE
    • Recommended for the following:
      • Prosthetic valves
      • Pts with obesity, chest wall deformities, COPD
      • Intermediate or high probability of IE
treatment
Treatment
  • Initial Stabilization
    • Rapid airway stabilization secondary to possible respiratory or hemodynamic compromise( acidosis, altered mental status, sepsis)
    • Cardiac decompensation may occur secondary to left sided valvular rupture
      • Intraaortic balloon counterpulsation may be indicated
    • Neurologic complications such as stroke
      • Standard stroke protocol
empiric treatment
Empiric Treatment
  • Therapy of suspected Bacterial Endocarditis
    • Uncomplicated history
      • Ceftriaxone or nafcillin plus gentamycin
    • IVDU, Congenital heart disease, MRSA, current abx use
      • Nafcillin plus gentamycin plus vancomycin
    • Prosthetic heart valve
      • Vancomycin plus gentamycin plus rifampin
  • Most patients will require 4 to 6 weeks of antibiotic therapy
surgical treatment
Surgical Treatment
  • Indications for surgical management:
    • Severe valvular dysfunction: Acute CHF or impaired hemodynamic status
    • Relapsing prosthetic valve endocarditis
    • Major embolic complications
    • Fungal endocarditis
    • New conduction defects or arrhythmias
    • Persistent bacteremia
anticoagulation
Anticoagulation
  • Anticoagulation for native valve endocarditis has not been shown to be beneficial
    • Increase the risk of intracranial hemorrhage
  • Pts with prosthetic valves who are treated with anticoagulation can be maintained on their regimen with proper caution for CNS complications
ie prophylaxis
IE Prophylaxis
  • Prophylaxis is indicated for:
    • Prosthetic heart valves
    • Congenital cardiac manifestations
    • Acquired valvular dysfunction
    • Hypertrophic cardiomyopathy
    • Mitral valve prolapse with documented regurgitation
    • History of endocarditis
  • Not indicated for the following:
    • MVP without regurgitation
    • Pacemakers
    • Physiologic murmurs
    • Prior CABG, angioplasty, ASD repair, VSD, or PDA
ie prophylaxis28
IE Prophylaxis
  • Dental, oral, respiratory or esophageal procedures
    • Amoxicillin or Ampicillin or Clindamycin
  • Genitourinary, gastrointestinal procedures
    • Ampicillin plus Gentamycin plus Ampicillin (post) or Amoxicillin
    • Alternate regimen: Vancomycin plus Gentamycin
question 1
Question 1:
  • T/F Streptococcus is responsible for more than 50% of Native Valve Endocarditis.
question 2
Question 2:
  • Embolic clinical features of infective endocarditis include:

A) CNS complications

B) Pulmonary complications

C) Coronary Artery Emboli

D) All of the above

question 3
Question 3:
  • Small hemorrhagic painless plaques located on palms or soles are called?

A) Janeway lesions

B) Osler’s nodes

C) Roth Spots

D) Splinter hemorrhages

answers
Answers
  • 1) T
  • 2) D
  • 3) A