Infective endocarditis.ppt infective endocarditis

This book contains alot of information regarding infective endocarditis

2. This is an infection, usually bacterial, of the
endocardial surface of the heart
Prototypic lesion –the vegetations( mass of platelets,
fibrin, microcolonies of microorganisms, scant
inflammatory cells
Most commonly involves valves ( native and
prosthetic), may also affect mural endocardium,
intracardiac devices, A-V shunts, PDA, coarctation of
AO

3. Acute febrile illness, rapid damage of cardiac
structures, hematogenically seeds extracardiac sites
resulting in death within weeks if untreated
Subacute-cardiac damage is slow, gradual progression

4. Potentially any bacteria or fungi
1.COMMUNITY –ACQUIRED
mostly from oral cavity, skin, URT –Streptococci
viridans, Staphylococci, HACEK ( Haemophilis,
Actinobacilli, Cardiobacterius, Eikinella, Kingella)
GIT –Streptococcus bovis
GUT -enterococci

5. 2. NOSOCOMIAL IE.
Prosthetic valve endocarditis 2 months after surgery –
intraoperative contamination-usually coagulase-
negative Staphylococci, Gram(-) bacilli, diphteroids,
fungi
Transvenouspacemaker leads or implanted
defibrillators –Staph.aureusand other Staph.

6. 3. DRUG USERS
Staph.aureus, Pseudomonas aeruginosa, Candida
Fungi –difficult to diagnose and treat, mostly Candida
and Aspergilles
5-15% of ptswith IE have (-) blood culture. 1/3-1/2 of
them due to prior antibiotic exposure

7. Normal endocardium is resistant to infection ( by
most bacteria) and to thrombus formation
Endocardial injury (e.g. at the site of high velocity jets
or on the low pressure side of cardiac structure lesion)
–causes aberrant flow and allows direct infection by
virulent organism or the development of uninfected
platelet-fibrin thrombi –non-bacterial thrombotic
endocarditis (NBTE), subsequently site of bacterial
attachment

8. Organisms enter the bloodstream from mucosa, skin,
sites of focal infection
Some of them adhere directly to intact endocardium or
injured endothelium
Others –adhere to thrombi, where they proliferate and
form vegetations

9. Damage to cardiac structures causes hemodynamic
changes
Embolization –infarction of other organs
Infection of remote tissues due to dissemination of
infection, mycotic aneurysms
Tissue injury due to deposition of circulating immune
complexes or immune response to deposited bacterial
antigens
Cytokines release –constitutional symptoms

10. Very variable
Complete history including travel Hx and review of
systems, Hx of URTI, dental, surgical and other
procedures
Fever, constitutional symptoms ( fatigue, malaise,
weight loss)
Myalgias, arthritis, low back pain, pleuritic chest pain

11. Thorough examination , search for stigmata of IE
Fever
Splinter hemorrhages on nail beds
Osler’s nodes –painful nodes on palmar surfaces of toes
and fingers
Janeway lesions –hemorrhagic papules on the palm and
soles
Roth’s spots on fundoscopy

12. IV injection marks
Anemia
Heart –cardiac murmurs, feature of CHF ( due to
valvular lesions, myocarditis or intracardiac fistulas),
various heart blocks (infectious process affecting
conduction system)

13. Embolic events –extremities, spleen, kidneys, bowel,
brain
Neurological complications –meningitis, intracranial
hemorrhages due to hemorrhagic infarcts, or ruptured
mycotic aneurysms, seizure, encepalopathy,
microabscesses
Immune complex deposition on glomerular basement
membrane –diffuse glomerulonephritis and renal
dysfunction, emboli -hematuria

14. Drug users –infection of Tricuspid V, high fever, faint
murmur, cough, chest pain, pulmonary infiltrates,
pyopneumothorax
Prosthetic valves –CHF, arrhythmias, new murmurs

15. Blood culture (+) for above mentioned organisms, at
least initially 3 sets
FBC-Anemia of chronic illness
WBC –normal or increased
Urinalysis-Hematuria, proteinuria
Abnormal CXR
ECHO-Valvular Vegetations
ECG –conduction blocks, MI
Elevated ESR, (+) Rheumatoid factor

16. Direct valvular damage-valve erosion ( perforation), or
erosion of adjacent myocardial wall –fistula
Embolic events-large mobile vegetations on the MV
(high risk)-kidney, spleen, brain, large arteries, lungs
Metastatic infection-osteomyelitis, septic arthritis,
epidural abscess, purulent meningitis
Immunologic phenomena-Glomerulonephritis,
musculoskeletal conditions

17. Duke criteria remain the clinical gold standard for
diagnosis
2 major
1 major + 3 minor
5 minor
Major : 1-+veBlood culture in 2 separate
cultures;atleast24 hrs apart
2-Endocardialinvolvement, +veEcho.by
doing an echo e.gvulvularfunctions.

18. Minor : 1-predisposition.e.gpeople whozhad
extracted a tooth and
2-fever > 38°c
3-vascular/immunological signs.
(roth’sspots, splinter hemorrhages, osler’s
nodes & janewaylesions)
4-+veBlood Culture not meeting major
criteria.
5-+veEchocardiogram.e.gaffected heart
function .

19. Antibiotic for 4-6 weeks
Streptococci –Penicillin, Ceftriaxone, Vancomycin,
Gentamycin
Enterococci –penicillin + gentamycin, ampicillin +
gentamycin, vancomycin
Staphylococci-nafcillin, oxacillin, cefazolin,
gentamycin, vancomycin. If MRSA –vancomycin
HACEK –ceftriaxone, ampicillin
Candida –amphotericin B + flucytosin

20. CHF
Affected prosthetic valves
Persistent bacteremia
Lack of effective microbicide therapy ( Brucella, fungi)
Staph.aureus prosthetic valve IE
Relapse of prosthetic valve IE with optimal a/b
treatment
Large > 10 mm vegetations

21. Prognosis is poor :
Older age
Severe co morbidities.combination of different
conditions e.g cch and id and menngitis
Delayed diagnosis
Involvement of prosthetic valve or Aortic valve.e.g with
history of surgical RHD
S.aureus or Pseudomonas, yeasts
Intracardiac complications
Neurologic complications

22. Dental procedures: extraction, periodontal
procedures, implants, root canal, surgery beyond apex;
Respiratory procedures: operations involving mucosa,
bronchoscopy with rigid bronchoscope
GIT –esophageal stricture dilatation, sclerotherapy of
varices, endoscopic retrgrade cholangiography, biliary
tract surgery, surgery involving mucosa

23. GUT –urethral dilation, prostate and urethral surgery,
cystoscopy
CVS-prosthetic valves, prior IE, complex cyanotic
CHD, PDA, coarctation of Ao, surgical shunts,
Hypertrophic CMP, MVP, RHD

24. Use of antibiotics before procedure:
Amoxyl 2 g PO 1 hour before or ampicillin 2 g IV 30
min before proceure, Cefazolin 1 g IV 30 min before.
If allergic to penicillin –clarythromycin 500 mg PO 1
hour before, Clindamycin 600 mg PO before
Ampicillin + Gentamycin
Vancomycin + Gentamycin

25. Maintain good dental hygiene
Aggressive treatment of local infections