Infective Endocarditis

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Infective Endocarditis

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Infective Endocarditis

• Definition proliferation of microorganisms on
  the endocardial surface of heart
• Bacteria , chlamydiae , rickettsiae , mycoplasma
  , fungi and virus
• Vegetation mass of plt. , fibrin ,
  microcolonies of microorganism , scant
  inflammatory cell
• Moss common heart valves
• Infective endarteritis

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Classification

• Acute fulminant, high fever, rapidly damages
  cardiac structures, hematogenously seeds
  extracardiac sites, death lt 6 wk
• Staphylococcus aureus ,
• Streptococcus pyogenes ,
• Streptococcus pneumoniae , or
• Neisseria gonorrhoeae
• Subacute indolent course, rarely causes
  metastatic infection, death in 6 wk-3mo
• Chronic death gt 3 mo

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Incidence

• 1.5-6.5 / 100,000 /year
• Half injection drug use
• Notably increased among elderly
• Prosthetic valve Cumulative rate 1.5-3 at 1
  yr
• 3-6 at 5 yrs
  
• greatest 6 mo.

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Etiology

• Many species of bacteria and fungi
• Portals of entry
• - Oral, skin, URI S. viridans, Staphylococci,
  
• HACEK
• - GI S. bovis (ass. Polyps colonic tumors)
• G ve (Enterobacteriacae)
• - GU Enterococci
• - Nosocomial intravascular catheters S.aureus

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• Prosthetic valve
• 2mo , NI
• Intraoperative contamination
• Bacteremic postoperative
• S.coag.-ve, S. aureus, G-ve rod,
  diphtheroids,
• fungi
• gt12mo. Community-acquired native valve
• gt85 S.coag-ve MRSA
• Transvenous pacemaker and/or implanted
  defibrillator
• NI , within weeks, S. aureus, S.coag -ve

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• Injection drug users
• - TV
• - S.aureus strains MRSA
• - Lt side varied etiology abnormal valve
  
• P.aeruginosa, Candida spp.,
• Bacillus, Lactobacillus,
  
• Corynebacterium
• -Polymicrobial

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• H/C negative
• - 5-15
• - 1/3-1/2 prior ATB
• - fastidious Pyridoxal-requiring S.,
• G-ve coccobacillary
  HACEK
• Bartonella
  henselae/quintana
• Tropheryma whipplei

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Pathogenesis
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• Mucous membrane or other
• Valvular endothelium
  colonized tissue
• trauma
• turbulence
• metabolic
• Platelet-fibrin deposition
  Trauma
• Nonbacterial thrombotic
  Bacteremia
• endocarditis (NBTE)
• 
  Complement Ab
• Adherence
• Colonization
• bacterial division
• fibrin
  depositon
• platelet aggregation
• extracellular proteases
• neutrophils protection

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Pathologic changes

• Heart
• - classic vegetation line of closure
• atrial surface of atrioventricular valve
• ventricular surface of semilunar valve
• - singer or multiple
• - few mm. to several cm. in size
• - vary in color, consistency, gross appearance
• - microscopic fibrin, platelet aggregates,
  bacterial mass,
• rare PMNRBC
• - destruction of underlying valve , fibrosis
  after healing

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• - acute larger, softer, friable, may
  suppuration, more necrosis, less healing than
  subacute
• - large valvular stenosis
• - may perforation
• - valve ring abscesses with fistular formation
• - aneurysms
• -CHF, myocarditis, MI, pericarditis

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• Kidney
• 3 processes infarction 56
• glomerulonephritis - focal 48-88
• - diffuse 17-80
• abscesses uncommon
• - normal size, slightly swollen, petechiae
• - all case abnormal renal architecture

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• Mycotic aneurysms
• - 10-15
• - acute IE
• - S. viridans
• - mechanism direct bacterial invasion
• septic embolic
  occlusion
• immune complex deposition
• - bifurcation points, common-cerebral vv (MCA)
• - clinically silent until rupture

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• CNS
• Cerebral emboli
• MCA and its branches
• Cerebral infarction, arteritis, abscesses,
  mycotic aneurysm, ICH, SAH, encephalomalacia,
  cerebritis, meningitis
• Hemorrhagic transformation of ischemic
  infarct-fatal
• Pneumococcal purulent meningitis
• S. aureus multiple microabscesses

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• Spleen
• - splenic infarction 44 silent
• - splenic abscess uncommon
• Lung
• - Rt side IE PE - infarct, pneumia, effusion,
  empyema
• Skin
• - petechiae 20-40
• - Osler nodes immune complex in dermal
  vessels, arteriolar intimal proliferation
  
• - Janeway lesions septic emboli
• consist of
  bacteria, neutrophile
• necrosis,
  subcutaneous hemorrhage
• Eye
• - Roth spots lymphocytes surrounded by edema
  and hemorrhage in nerve fiber of retina

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Clinical manifestation

• SS protean, and any organ system may be
• involved
• 4 processes
• 1.infectious process on the valve
  complication
• 2.septic embolization
• 3.constant bacteremia
• 4.circulating immune complex

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• Fever remittent, rarely exceeds 40 c
• Half afebile within 3 d. of the initiation of
  ATB , 75 after 1 wk , 90 after
  2 wk
• Prolonged fever specific etiologic agents
• - S. aureus, G-ve bacilli, fungi, H/C ve IE
• - microvascular phenomena
• - embolizaton of major vessels
• - intracardiac peripheral complication
• - tissue infarction
• - PE
• - drug reaction
• - NI

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• Nonspecific symptom
• - anorexia, N/V, wt.loss, malaise,fatigue,chill,
  weakness, night sweats
• Heart murmur
• -gt85
• -may absent Rt sided or mural infection
• -classic but uncommon 5-10
• changing murmur and development of a new
  regurgitant murmur

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• Heart
• -CHF
• - Pericarditis is rare myocardial abscess
• - valvular stenosis/obstructionSx
• - myocarditis
• - MI

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• Classic peripheral manifestation
• Clubbing finger 10-20
• Splinter hemorrhages proximal nail

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• Petchiae 20-40 local vasculitis or emboli
• conjunctivae
• buccal mucosa, palate
• extrenities

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• Osler nodes 10-15
• small, painful, nodular 2-15 mm, multiple

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• Janeway lesions embolic
• Hemorrhagic, macular, painless plaques

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Roth spots 5 near optic disk
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• Splenomegaly 25-60
• -splenic septic emboli may abscent SS
• Musculoskeletal 44
• - proximal oligo/mono arthalgia
• - LBP
• -myalgia
• Major embolic episodes
• - splenic a. emboi LUQ pain or Lt pleural
  effusion
• - renal infarction hematuria
• -retinal a. emboli sudden loss VA
• -PE Rt sided narcotic addicts
• -coronary a. emboli (AV) myocarditis,
  arrhythmias,MI
• -major vv. Emboli femoral, brachial,
  popliteal, radial a.
• fungus

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• Neuro. 20-40
• - embolic Staphylococcal
• - mycotic aneurysms
• - seizure, severe headache, visual loss,
  CN palsy, toxic encephalopathy, psychosis
• Renal
• - renal failure uremia
• - AGN

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IE in drug addicts

• Acute infection
• 2/3 no underlying heart
• Most TV alone or combine 52.2 (Rt side)
• AV 18.5
• MV 10.8
• AVMV 12.5
• TV pleuritic chest pain, blood born pneumonia
• sign of tricuspid insufficiency
• Men 4-6 1 women

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Etiology in narcotic addicts

• S. aureus 38 less severe than nonaddicts
• P. aeruginosa 14.2
• Candida spp. 13.8
• Enterococci 8.2
• S. viridans 6
• S. epidermidis 1.7
• G-ve aerobic baciili 1.7-15
• Other bacteria 2.2
• Mixed infectious 1.3
• Culture negative 12.9

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Etiologic agents

• Streptococci
• -most common community , hospital
• -common organism S. viridans
• - subacute
• - multiple non specific symptom
• -gt80 underlying heart dz.
• -cure rate gt90 (nonenterococcus)
• -GI S.bovis, enterococci

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• Staphylococci
• -20-30 of IE
• -S. aureus coagve 80-90
• -acute IE
• -normal heart valve 1/3
• -fulminant MV, AV
• -40 death myocardial abscess, purulent
  pericarditis, valve ring abscess
• -narcotic addicts S. aureus less severe
• -S.epidermidis prosthetic valve IE

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• Enterococcus
• -GI tract , ant. Urethra
• -Lancefield group D
• -5-18
• -subacute
• -older men 59 yr after GU manipulation
• -younger women 37 yr after obstetric
  procedures
• -40 no underlying heart 95 develop murmur
• -high mortality

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• Gram negative bacilli
• -10 of IE
• -2/3 coexisted/followed serious Gve infection
• -most case fastidious
• -common Enterobacteriaceae , Salmonela spp.
• -increase risk narcotic addicts
• prosthetic valve
  recipients
• cirrhosis
• -40-50 yr., duration 6 wk, Lt side, poor
  prognosis
• -persistent bacteremia vs g-ve septicemia
• -High levels ATB activity
• -2/3 normal heart valve AV MV
• -large vegatations near total occlusion

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• Pseudomonas
• -abused intravenous drugs
• -malefemale 2.51
• -mean age 30
• -major embolic phenomena complications
• Unusual G-ve
• -N. gonorrhoeae
• -HACEK group Haemophilus spp.
• Actinobacillus
• Cardiobacterium
• Eikenella
  corrodens
• Kingella
• Gve bacilli
• -Corynebacterium
• -Listeria monocytogenes
• Anaerobic bacteria

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HACEK

• -Fastidious
• Clinical syndrome
• - subacute IE, large friable, freq.emboli, CHF,
  need
  for valve replace
• -2-3 wk primary isolation
• -subculturing all culture-negative
• Haemophilus spp.
• -H. paraphrophilus, H. parainfluenzae, H.
  aphrophilus, H. seguis, H. aegyptius
• -0.8-1.3
• -subacute, vulvulae dz.

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• Actinobacillus actinomycetemcomitans
• -rare, subacute, mortality 34
• Cardiobacterium hominis
• - resembles Haemophilus
• Eikenella corrodens
• -IVDU
• -usual habitant of oropharynx
• -indolent
• Kingella endocarditis
• -50 complication eg. stroke

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Fungi

• 3 pt group
• -narcotic addicts
• -reconstructive cardiovascular suegery
• -prolonged intravenous ATB
• Underlying heart 2/3 major systemic emboli
• Addicts C. parapsilosis
• C. tropicalis
• Non addicts C. albicans
• Aspergillus spp.

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• Acute
• -B-hemolytic streptococci
• -S. aureus (occasionalsubacute)
• -Pneumococci
• Subacute
• -S. viridans
• -Enterococci (may acute)
• -S. coag ve (may acute)
• -HACEK group

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LAb

• Echocardiography
• - identified vegetations
• confirm IE
• intracardiac complication
• size
• cardiac function
• - sensitivity specificity uncertain
• TTE sens. 65 - Rt side, not seen
  lt2mm
• TEE sens. gt90 - prosthetic, intracardiac
  complication
• - vegetation gt 1 cm stroke

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Diagnosis
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• Clinical definite diagnosis
• -2 major
• -1 major 3 minor
• -5 minor
• Possible
• -1 major 1 minor
• -3 minor
• Reject
• -resolve/not recur lt4 d.ATB
• -no histologic of endocarditis

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Treatment
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indication

• Empirically immediately ATB take H/C 3 spp.
• - acute IE
• - deterioration hemodynamics
• - may require urgent surgery
• Acute IVDU Vancomycin Gentemicin
• Subacute Ceftriazone Gentamicin
• Prosthertic Vancomicin

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IE prophylaxis

• Single dose before procedure
• Dental procedure
• -S. viridans
• Respiratory tract procedure
• -S. viridans
• -S. aureus
• Skin musculoskeletal
• -Staphylococci
• -B-hemolytic streptococci
• GI GU procedure not prophylaxis
• -Enterococci

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summary

• 1. Bacteremia from daily activity gt procedure
• 2. prevent small number of case
• 3. limit in table 3
• 4. dental, RS, skin, musculoskelatal procedure in
  underlying cardiac condition
• 5. not recommen in GI GU

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Thank you