Infective endocarditis

1. Infective Endocarditis Pratik kumar 080201186

2. Definition Infection of the endocardial surface of heart characterized by - Colonization or invasion of the heart valves (native or prosthetic) or the mural endocardium by a microbe, - leading to formation of bulky, friable vegetation composed of thrombotic debris and organisms - often associated with destruction of underlying cardiac tissue.

3. Sites involved Heart valves Ventricular septum defects Mural endocardium Intracardiac devices INFECTIVE ENDARTERITIS – analogus

4. Acute Endocarditis Destructive and tumultuous infection, frequently of a previously normal heart valve, with a highly virulent organism Hematogenoulsy seeds If untreated, leads to death within weeks SUBACUTE ENDOCARDITIS Organisms of low virulence causing infection in a previously abnormal heart, particularly on deformed valves. Disease appear insidiously and pursue a protracted course of weeks to month Recover after appropriate antibiotic treatment Classification

5. Cardiac and vascular abnormalities RHD Myxomatous mitral valve Degenerative calcific valvular stenosis Bicuspid aortic valves Prosthetic valves Host factors Neutropenia Immunodeficiency Malignancy Therapeutic immunosuppression Diabetes mellitus Alcohol IV drug abuse Predisposing factors

6. Microbiology Staphylococcus aureus (35%) : Either healthy or deformed valves, IV drug abusers ( polymicrobial ), devices Streptococcus viridans (32%) : Native but previously damaged/abnormal valves Enterococci (8 %) CoNS - S. epidermidis (4%) : Prosthetic valve endocarditis, devices G – ve bacilli of HACEK group (4%) Yeast and Fungi(1%) Culture negative endocarditis (5 %)

7. Pathogenesis Portal of entry : Dental / Surgical Procedures Contamination by IV drug use O bvious infections (RS/Skin) Occult source from gut, oral cavity Trivial injuries . Intravascular catheter infection Nosocomial wounds Chronic invasive procedures

8. Morphology Friable, bulky vegetation containing fibrin, inflammatory cells, and microbes Aortic and mitral valves involved most commonly. Right side valve involvement in iv drug users.

9. Constitutional symptoms --- Cytokine release ? Symptoms - Damage to intracardiac structures - Embolization of vegetation fragments - Hematogenous infection - Immune comple x Clinical features

10. Sub-acute Endocarditis Persistent fever Constitutional symptoms New signs of valve dysfunction Heart failure Embolic Stroke Peripheral arterial embolism Other features

11. Definitive Endocarditis if, - Two major or, - One major and three minor or, - five minor Possible Endocarditis if, - One major and one minor or, - Three minor Modified Dukes Criteria for diagnosis of Infective Endocarditis

12. Major Criteria Positive blood culture Typical organism from two cultures Persistent positive blood cultures taken > 12 hours apart Three or more positive cultures taken over more than 1 hour. Endocardial involvement Positive echocardiographic findings of vegetations New valvular regurgitation

13. Minor Criteria Predisposition: Predisposing valvular or cardiac abnormality Intravenous drug misuse Pyrexia ≥38°C (≥100.4°F) Embolic phenomenon Vasculitic / immunologic phenomenon Blood cultures suggestive: -organism grown but not achieving major criteria Suggestive echocardiographic findings

14. INVESTIGATIONS AVINASH BAJJURI

15. . Microbiology Blood cultures: Key diagnostic investigation in infective endocarditis . Isolation of microorganism from culture is important for diagnosis and also for treatment. At least 3 sets of samples should be taken from different venepuncture sites over 24 hours.

16. . Serology Can be sent when the diagnosis is suspected and the cultures are negative. They aid in cases where the organisms will not grow in blood cultures( Coxiella,Legionella,Bartonella ) ECG To detect complications like MI,conduction abnormalities. CHEST X RAY

17. . Echocardiography It can identify the presence and size of vegetations,detect intracardiac complications and assess cardiac function. Transthoracic echocardiography is noninvasive and has high specificity for visualising vegetations. Transoesophageal echocardiography is more sensitive than TTE.It can detect small vegetations,prosthetic endocarditis and intra cardiac complications.

18. . Complete blood counts may show anamia and increased WBC counts. Urea and Creatinine: may be elevated due to glomerulonephritis Liver biochemistry: Serum alkaline phosphatase may be increased Inflammatory markers CRP,ESR are increased in infection .CRP also helps in monotoring response to therapy. Urine proteinuria and hematuria occur frequently.

19. TREATMENT Antimicrobial Therapy Therapy requires identification of specific pathogen and its susceptibility to antimicrobials. Empirical therapy should be started as soon as possible targeting most likely pathogens. Bactericidal drugs should be used.

20. . Resolution of fever occurs in 5 to 7 days.if fever persists patient should be evaluated for complications like paravalvular abscess and extracardiac abscess. Serologic abnormalities resolve slowly and do not reflect response to treatment.

21. . Antibotic regimen for infective endocarditis Streptococci Benzyl penicillin (1.2g 4 hourly) 4-6 weeks Gentamicin (1mg/kg 8-12 hourly) 4-6 weeks Enterococci Ampicillin sensitive Ampicillin (2 g 4 hourly) 4-6 weeks, and Gentamicin (1mg/kg 8-12 hourly) Ampicillin resistant V ancomycin (1g 12hourly) 4-6 weeks, and Gentamicin (1mg/kg 8-12 hourly)

22. . Staphycocci Penicillin sensitive Benzyl penicillin I.V(1.2 g 4 hourly) Penicillin resistant but methicillin sensitive Flucloxacillin I.V (2g 4 hourly ) Both penicillin and methicillin resistant Vancomycin I.V (1g 12 hourly) and Gentamicin

23. . Surgery Indications patients with direct extension of infection to myocardial structuires . Prosthetic valve dysfunction. Congestive heart failure. Badly damaged valves. IE caused by fungi or gram- ve or resistant organisms. Large vegetations on echocardiography Recurrent embolic attacks.

24. . Prophylaxis High risk category prosthetic cardiac valves Previous bacterial endocarditis,even in absense of heart disease. Complex cyanotic congenital heart disease(TGA,TOF) Surgically constructed systemic pulmonary shunts.

25. . Moderate risk category Rheumatic and other valvular dysfunction Congenital cardiac malformations Hypertrophic cardiomyopathy Mitral valve prolapse with valvular regurgitation

26. . Regimen for IE prophylaxis Standard oral regime Amoxicillin 2 g 1hr before procedure I nability to take oral medication Ampicillin 2g IV or IM 1hr before procedure Penicillin allergy Clindamycin 600 mg Clarithromycin 500 mg Cephalexin 2 g.

27. Thank you.