Endocarditis and Other Intravascular Infections

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Endocarditis and Other Intravascular Infections

• Wang, Tzong-Luen, MD, PhD, FACC, FESC

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Introduction

• Intravascular Infections in the Absence of Any
  Foreign Device
• Infections of Intravascular Prosthetic Devices

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Intravascular Infections in the Absence of Any
Foreign Device

• Infective Endocarditis on A Native Valve
• Mycotic Aneurysm
• Carvenous Sinus Thrombosis
• Postanginal Sepsis
• Septic Pelvic Vein Thrombophlebitis
• Pylephlebitis

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Infective Endocarditis (Native)
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Infective Endocarditis (Native)
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Infective Endocarditis (Native Valve)

• Pathogenesis
• the species and concentration of microorganisms
• the presence or absence of antimicrobial agents
  in serum
• the characteristics of endocardium
• Staphylococcus, enterococcus, streptococcus are
  most adherent G (-) Pseudomonas aeruginosa
• central venous catheter gt peripheral IV,
  urological instruments

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Infective Endocarditis (Native Valve)

• Clinical and Laboratory Features
• fever (100) murmur (20 in vascular-associated
  IE 75 in urologic procedure)
• positiveness left-sided disease gt right-sided
  disease
• peripheral petechiae (50) Roth spots splinter
  hemorrhage Oslers node Janeway lesions emboli
  (systemic in 40 of left-sided disease pulmonary
  in 50 of right-sided disease)
• Heart failure valve, MI, myocarditis sepsis
• Renal and neurological
• Laboratory findings as presented

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Infective Endocarditis (Native Valve)

• Diagnosis
• Blood culture
• culture-negative IE HACEK
• Echocardiography
• TTE 60-80 sensitivity
• TEE 90-99 sensitivity 90 specificity
• Durack and colleagues diagnostic criteria

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Dukes Criteria

• Major
• Positive blood culture
• Typical microorganism from two separate samples
• Persistent positive blood culture (12 hr apart)
• Evidence of endocardial involvement
• Positive echocardiogram
• New valvular regurgitation
• Minor
• Predisposition Fever Vascular phenomena
  Microbiological evidence Echocardiogram

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Infective Endocarditis (Native Valve)

• Management
• Empiric antibiotics in
• the patient is critically ill
• antimicrobial therapy for some other infectious
  disorders
• early valve replacement because of valve
  malfunction
• IE highly suspected and one or more blood culture
  positive
• Otherwise, withhold antibiotics till diagnosis
  ()
• Valve replacement in severe heart failure,
  valvular obstruction, fungus, ineffective
  antibiotics, unstable prosthetic valve

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Infective Endocarditis (Native Valve)

• Prognosis
• Factors influencing outcome
• relative pathogenicity of the organism (S.
  aureus 50 fatal)
• the location of infected valve (left gt right)
• the presence of complications of the infection
• large vegetations (gt 1cm)
• complications with poor prognosis severe heart
  failure, shock, major arterial embolism,
  myocardial abscess, major organ system failure

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Infective Endocarditis (Native Valve)

• Antimicrobial prophylaxis
• indicated in (VSD, MVD, PDA, CoA, PVD, etc.)
• dental extraction
• periodontal surgery
• lower GI procedures
• GU procedures
• not indicated in (ASD, PM, atherosclerosis)
• bronchoscopy
• endoscopy
• barium enema
• ET, Foley, CVP

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Mycotic Aneurysm
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Mycotic Aneurysm

• Pathogenesis and Microbial Etiology
• with infective endocarditis (most common)
• embolic localization of vessel lumen
• embolization of the vasa vasorum
• ulcerative atheroma
• intravenous drug abusers (intraarterial
  injections femoral artery)
• Microorganisms same as IE (streptococcus,
  staphylocci, G(-) enteric bacilli) S. aureus and
  Salmonella common in abdominal aorta

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Mycotic Aneurysm

• Clinical Features
• Intracranial SAH/ICH, headache, LOC, focal signs
• small bowel colicky pain, small bowel
  obstruction
• hepatic artery ascending cholangitis (fever, RUG
  pain, jaundice)
• external iliac artery lower ant. abdominal pain,
  quadriceps wasting, diminished DTR, ipsilateral
  lower extremety ischemia
• abdominal aorta pain, fever, vertebral
  osteomyelitis, aortoenteric fistula, palpable
  abdominal mass

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Mycotic Aneurysm

• Diagnosis
• CT
• Arteriography
• bone films
• Management
• Intracranial clipping for peripheral lesions
  antimicrobial agents for deeper lesions except
  history of bleeding, large size, persistence of
  aneurysm after antibiotics
• Abdominal surgery

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Cavernous Sinus Thrombosis
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Dural Venous Sinuses
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Cavernous Sinus
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Cavernous Sinus
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Cavernous Sinus Thrombosis

• Pathogenesis and Microbiology
• direct spread of bacteria from a contiguous focus
  (septic thrombophlebitis of the angular and
  ophthalmic veins from facial cellulitis, along
  the lateral sinus and petrosal sinuses from
  middle ear infections, via the pterygoid venous
  plexus from a peritonsillar abscess, dental
  infection from osteomyelitis of the maxilla,
  cervical abscess, along venous plexus near the
  internal carotid artery from middle ear or
  jugular bulb)
• S. aureus (50), streptococci, anaerobes

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Cavernous Sinus Thrombosis

• Clinical Features
• early onset of external ophthalmoplegia
• periorbital chemosis and edema, meningismus,
  altered mental status, N. III, IV, V, VI palsy,
  fundal venous congestion
• D/D orbital cellulitis, rhinocerebral
  phycomycosis (mucormycosis)

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Orbital Cellulitis
Mucormycosis
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Cavernous Sinus Thrombosis

• Diagnosis and Management
• clinical grounds
• enhanced CT
• (carotid angiography and orbital venography)
• lumbar puncture but usually sterile (pleocytosis
  and elevated protein without hypoglycorrhachia)
• Blood cultures often positive (drainage /
  biopsy)
• Early antimicrobial agents and surgery with
  unsatisfactory results (steroid and anticoagulant
  ineffective)

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Postanginal Sepsis
Lemierres Syndrome
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Postanginal Sepsis

• Pathogenesis
• pharyngitis followed by bacteremia due to
  anaerobic microorganisms and suppurative
  thrombophlebitis into the internal jugular vein
• Bacteremic spread is common, with lung, liver,
  joints the most common sites
• Fusobacterium necrophorum, Bacteroides fragilis,
  and other mouth anaerobes

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Postanginal Sepsis

• Clinical Features and Diagnosis
• sore throat, chills, fever, occ. jaundice
• palpable tender thrombosis of the jugular vein,
  septic arthritis, pleuropulmonary disease, or
  jaundice
• enhanced CT internal jugular vein
  thrombophlebitis
• CXR scattered infiltrates due to pulmonary
  septic emboli

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Postanginal Sepsis

• Management
• early recognition and treatment with effective
  antimicrobial therapy
• against anaerobes metronidazole,
  chloramphenicol, imipenem-cilastatin,
  ticarcillin-clavulanic acid
• surgical drainage

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Postanginal Sepsis
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Septic Pelvic Vein Thrombphlebitis
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Septic Pelvic Vein Thrombophlebitis

• Pathogenesis and Microbiology
• pelvic vein thrombosis develops 1 to 2 weeks
  after delivery, gynecologic procedures, or PID /
  septic abortion / post-CS endometritis
• Peptostreptococcus spp., Peptococcus spp.,
  Bateroides fragilis, aerobic G(-) bacilli (E.
  coli, Klebsiella, Enterobacter, group A and B
  beta-hemolytic streptococci, and rarely,
  staphylococci

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Septic Pelvic Vein Thrombophlebitis

• Clinical Features
• fever, chills, anorexia, nausea, vomiting,
  abdominal pain
• tenderness in lower quadrants, palpable tender
  venous structures (1/3)
• 80 pelvic vein thrombosis on the right side, 5
  on the left side, 14 bilateral (spread to
  femoral v. rare)
• complications pulmonary vein thrombosis (30
  bacteremia)

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Septic Pelvic Vein Thrombophlebitis

• Diagnosis and Management
• difficult similar to other pelvic or abdominal
  inflammatory diseases
• contrasted CT
• ultrasound for intravascular thrombosis
• Treatment antimicrobial therapy AND
  heparinization
• failing to respond to appropriate antibiotics
  and responding to heparinization support the
  diagnosis

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Pylephlebitis
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Pylephlebitis

• Septic thrombosis of the portal vein as a
  complication of appendicitis or diverticulitis
• Three phases
• 1) s/s of original intraabdominal disorders
• 2) portal bacteremia with resultant portal
  thrombosis
• 3) liver abscess
• Late s/s fever, abdominal pain, jaundice, and
  RUQ pain 50 hepatomegaly

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Pylephlebitis

• Laboratory studies
• leukocytosis with shift to left
• abnormal liver functions, esp. Alk Pase AST
• CT portal thrombosis, pneumobilia
• Microorganisms large bowel flora
• Escherichia coli, Klebsiella, Enterobacter
• Peptococcus, Peptostreptococcus, B. Fragilis,
  Fusobacterium
• Staphylococci, enterococci

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Pylephlebitis

• Management
• surgical correction of the primary problem AND
• high-dose antibiotics
• pyogenic liver abscess prolonged use of ATB
  percutaneous drainage if few and large
• effectiveness of ATB judged by physical
  examination, resolution of fever and
  leukocytosis, improvement of abnormalities in
  ultrasound or CT

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Infections of Intravascular Prosthetic Devices

• Prosthetic Valve Endocarditis
• Cardiac Pacemaker Infections
• Arterial Graft Infections

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Prosthetic Valve Endocarditis
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Prosthetic Valve Endocarditis

• Pathogenesis and Microbiology
• 2 (1/3 the first few months)
• Early inoculation at op or transient bacteremia
• increased risk of PVE IE of native valve before
  op, mechanical valve, IV drug abuse, male, longer
  CPB
• Late resemble native IE
• Early S. epidermidis gt S. aureus gt G(-) bacilli
• Late viridans streptocoous, S. sureus
• Nosocomial S. epidermidis gt S. aureus
  gtenterococcis, G(-) bacilli, candida, viridans
  streptococcus

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Prosthetic Valve Endocarditis

• Clinical Features
• similar to native IE
• higher prevalence of cardiac complications
• paravalvular leak from dehiscence of the valve
  ring
• intraventricular and atrioverntricular conduction
  defects resulting from extension of a
  paravalvular abscess into the intraventricular
  septum
• malfunction of the valve caused by a vegetation
• Nosocomial PVE peripheral stigmata 20
  spleno-megaly 5 stroke 3 new/changing murmur
  31

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Prosthetic Valve Endocarditis

• Diagnosis
• diphtheroids, staphylococcus and yeast rather
  than G(-) bacilla bacteremia consider true
  post-op PVE
• Blood cultures esp. () for late PVE
• TTE and TEE (specificity 86 to 88)
• cinefluoroscopic examination
• CT of head embolic hemorrhagic infarcts and
  abscess

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Prosthetic Valve Endocarditis

• Management
• similar principles as native IE
• antibiotics empiric vancomycin and gentamicin
  (S. epidermidis, S. aureus, streptococcus cover
  most nosocomial PVE as well)
• immediate therapy for ill, bacteremic patients
  and/or surgery is scheduled
• Relative indications for valve replacement early
  PVE, nonstreptococcal late PVE, periprosthetic
  leak
• antibiotics for 6 to 8 weeks (c/s op) best
  beginning from the culture at the time of valve
  replacement

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Cardiac Pacemaker Infections
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Cardiac Pacemaker Infections

• Pathogenesis and Microbiology
• 4 of permanent pacemakers
• generator, subcutaneous course of the electrode,
  intravascular portion c/s IE (1/3 each)
• predisposing factors DM, cancer, corticosteroid,
  skin erosion near generator
• Early wound infection Late transient
  bacteremia
• S. epidermidis 44 S. aureus 29
  Corynebacterium spp., G(-) aerobic bacilli occ.
  fungi

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Cardiac Pacemaker Infections

• Clinical Features
• fever, chills, other constitutional s/s
• blood culture AND inspecting generator/electrode
• generator pocket/subcutaneous course local
• associated with IE always right-sided without
  systemic emboli with pulmonary septic emboli,
  multifocal pneumonia, right-sided IE

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Cardiac Pacemaker Infections
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Cardiac Pacemaker Infections

• Management
• identity of the suspected or proved infecting
  microorganisms
• the particular components involved
• the presence of bacterial infection other than PM
• removal generator infection, persistent
  bacteremia, evidence of IE (new generator in
  deeper pocket)
• antibiotics 4 to 6 weeks for those did not
  perform removal (fungi or mycobateria longer) 2
  weeks for those after removal (unless native IE
  metastatic dz longer)

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Arterial Graft Infections
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Arterial Graft Infections

• Pathogenesis and Microbiology
• 2-6 of arterial graft
• analogous to that of prosthetic valve disease
• slow process of pseudoaneurysm formation
• mean 8 months (as long as 7 to 10 years)
• Knitted Dacron gt woven Dacron gt Autogenous
• Graft across the femoral area more infective
• G() S. aureus most common G(-) E. coli,
  proteus or pseudomonas

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Arterial Graft Infections

• Clinical Features
• variable constitutional s/s and non-specific
  laboratory findings (leukocytosis, elevated ESR)
• Early (lt4 months) with sepsis or wound infection
• Late graft malfunction or cutaneous sinus
  formation
• Intraluminal fever Extraluminal local
  findings obst.
• Abdominal mass, obstr. uropathy, lower extremity
  ischemia, aortoduodenal fistula UGIB, CV
  collapse
• Blood culture always negative
• indium/technetium WBC scan, CT, MRI, aspiration

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Arterial Graft Infections
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Arterial Graft Infections
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Arterial Graft Infections
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Arterial Graft Infections

• Management
• specific antimicrobial therapy chosen on the
  basis of the presumed or demonstrated infecting
  organisms AND
• graft removal
• alternative revascularization to avoid distal
  organ or extremity ischemia
• e.g. axillofemoral graft to bypass an infected
  aortic bifurcation prosthesis

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Arterial Graft Infections
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