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Infective Endocarditis. Dr. Hussein Amrat Cardiologist PHH-MOH. 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

Dr. Hussein Amrat

Cardiologist PHH-MOH

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


  • 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


  • 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


  • 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 features1
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 features2
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


  • 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 criteria1
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


  • 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


  • 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 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 prophylaxis1
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


  • 1) T

  • 2) D

  • 3) A