Infective Endocarditis

1
Infective Endocarditis

• Tintinallis Chap. 145

2
epidemiology

• Incidence ranges from 2.4 to 11.9 cases per
  100,000 patient-years
• Higher in urban vs. rural populations
• 25 of cases in pts lt 30 y.o.
• 50 of cases in pts ages 31-60
• 25 of cases in pts gt 60 y.o.
• Uncommon in kids
• Related primarily to congenital heart dz,
  rheumatic heart dz, or nosocomial
• Aortic valve most commonly affected
• Then mitral, tricuspid, pulmonic valves

3
risk factors

• IVDA
• Indwelling catheters (vascular)
• Poor dental hygiene
• HIV
• Prosthetic heart valves
• Risk greatest in first 6 mos after surgery
• MVP (most common predisposing cardiac lesion)
• Rheumatic heart dz still leading RF in developing
  countries

4
pathophysiology

• Normal endothelium is resistant to infxn
  thrombus formation
• Turbulent blood flow damage to
  endocardium/endothelium
• Endothelial damage promotes deposition of
  platelets fibrin
• Form sterile vegetations called nonbacterial
  thrombotic endocarditis (NBTE)

5
pathophysiology

• Transient bacteremia may result in colonization
  of vegetations conversion of NBTE to IE
• Highly invasive orgs like S. aureus can also
  directly invade the endocardium and stimulate the
  adherence of platelets fibrin

6
(No Transcript)
7
microbiology

• Table 145-1
• Bacteria are most common cause
• S. aureus is most common bacteria
• Fungi, Rickettsia, Chlamydia species

8
native valve endocarditis

• Non-IVDA
• Streptococcus is org in gt 50 of cases
• Then staph enterococci
• Preexisting valvular abnormalities
• Rapid destruction of valves
• Multiple distal abscesses
• Myocardial abscesses
• Conduction defects
• Pericarditis
• May have negative blood cxs

9
IVDA-associated IE

• Contaminants include normal skin flora or
  injection devices
• S. aureus (gt50 of cases)
• Then strep, enterococci, gm-neg bacilli like
  Pseudomonas, fungi (Candida)

10
prosthetic valve endocarditis

• Contamination during perioperative period
• S. epidermidis
• Then strep, aspergillus candida
• Valve dysfunction
• Fulminant clinical course

11
clinical features

• Acute
• Rapid onset
• High fever/rigors
• Hemodynamic deterioration
• Death
• S. aureus

12
clinical features

• Subacute
• Indolent course
• Progressive constitutional sxs
• Gradual deterioration
• S. viridans
• See Table 145-2

13
clinical features

• Bacteremia
• Heat murmurs
• In right-sided IE lt50 of pts have detectable
  murmurs on admission
• CHF (leading cause of death in IE)
• Valvular abscesses
• Pericarditis
• Heart blocks arrhythmias
• Distal embolisms (bland or septic)

14
clinical features

• Stroke (MCA most common)
• SAH
• Retinal artery emboli (monocular blindness)
• Pulmonary infarction
• Pneumonia
• Empyema
• Pleural effusions
• MI
• Myocarditis
• Splenic infarction
• Renal emboli
• Mesenteric emboli
• Acute limb ischemia

15
Janeway lesions
16
Osler nodes
17
Roth spots
18
diagnosis

• Duke criteria
• Major minor
• Sensitivity about 90
• Table 145-3

19
(No Transcript)
20
(No Transcript)
21
differential diagnosis

• Viral illnesses
• HIV-related fevers
• Acute rheumatic fever
• Systemic complications of collagen vascular
  disorders
• Drug reactions

22
evaluation

• Blood cxs (done in ED!)
• Prior to axbx
• 3 separate sites
• 1 hr between 1st last set
• EKG
• CXR
• CBC
• ESR
• U/A
• Echo

23
(No Transcript)
24
treatment prophylaxis

• ABCs
• Empiric axbx
• Native valve IE
• Penicillinase-resistant penicillin or
  cephalosporin aminoglycoside
• Pts w/ complications (IVDA, CHD)
• Add vancomycin to above regimen
• Table 145-5

25
treatment prophylaxis

• Empiric axbx cont.
• PVE
• Vancomycin aminoglycoside rifampin
• Definitive axbx tx as soon as cxs reveal
  causative orgs
• Tx for 4-6 wks
• Surgical tx for sev. valvular dysfxn.
• Acute CHF or hemodynamic instability

26
treatment prophylaxis

• Axbx given to pts with RFs for endocarditis (see
  Table 145-6)
• Pts w/ prosthetic heart valves, congenital
  cardiac malformations, acquired valvular
  dysfunction, hypertrophic cardiomyopathy, MVP w/
  documented regurgitation or hx of endocarditis
• Procedures include dental work, bronchoscopy,
  cystoscopy, urethral instrumentation ERCP