INFECTIVE ENDOCARDITIS.pptx by Dr. Humna

Infective endocarditis occurs when microorganisms, usually bacteria that circulate in the bloodstream (bacteremia), adhere to damaged areas of the endocardium or heart valves. These microorganisms then multiply, forming a vegetation—a mass of infected tissue and blood cells. The infection can lead to valve damage, heart failure, and systemic complications due to embolization of infected material.

Epidemiology:
IE affects approximately 1-12 people per 100,000 population annually, with a higher incidence among individuals with predisposing factors such as structural heart disease (e.g., congenital heart defects, prosthetic heart valves), intravenous drug use, and healthcare-associated infections.

Clinical Presentation:
Symptoms of infective endocarditis can vary widely and may include:

Persistent fever
New or changing heart murmurs
Malaise, fatigue, and weakness
Petechiae (small red spots) on the skin, conjunctiva, or oral mucosa
Splinter hemorrhages (small linear streaks) under the nails
Signs of embolic events, such as stroke, peripheral emboli causing ischemia in extremities, or renal infarcts leading to renal failure.

1. INFECTIVE ENDOCARDITIS DR.HAMNA UZAIR

2. CONTENTS OF LECTURE Definition Classification Microbiology Pathogenesis Clinical Presentation Investigations and Diagnosis Treatment Prophylaxis Complications

3. Definition Infective endocarditis is a microbial infection of the endocardial surface of heart affecting heart valves(native or prosthetic), the lining of cardiac chamber or blood vessels or a congenital anomaly(e.g. septal defect).

4. MICROBIOLOGY

5. PATHOGENESIS

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9. CLINICAL FEATURES

10. SUBACUTE ENDOCARDITIS Persistent fever with complains of unusual tiredness Night sweats or weight loss Osler’s nodes are tender swellings at the fingertips that are probably the products of vasculitis Embolic stroke or peripheral arterial embolism Purpura and petechial hemorrhages inskin and mucous membrane Splinter hemorrhages under fingernails or toenails Digital clubbing is a late sign Spleenomegaly significantly in coxiella infection Microscopic hematuria is common

11. ACUTE ENDOCARDITIS Severe febrile illness with prominent heart murmurs Petechiae Embolic events are common Cardiac and Renal failure may develop rapidly Abscesses may be detected on echocardiography Partially treated acute endocarditis behave like subacute endocarditis

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13. Fig. OSLER NODES .

14. Fig. ROTH SPOTS ON FUNDOSCOPY .

15. Fig. SPLINTER HEMORRHAGES

16. INVESTIGATIONS AND DIAGNOSIS

17. . Blood culture is the crucial investigation . Blood cultures should be collected at least 3 times from different venipuncture sites. The first and second collections should be taken at least 1 hour apart. Echocardiography for detecting and following the progress of vegetations and abscess formation. Elevated ESR Normocytic normochromic anemia and leucocytosis

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20. . Urine D/R to detect proteinuria and hematuria. ECG may show the development of AV Block(due to Aortic root abscess formation) OR Ocassionally infarction due to emboli. CNS Imaging to evaluate complications. The chest X-ray may show evidence of cardiac failure and cardiomegaly.

21. MODIFIED DUKE CRITERIA

22. VON REYN CRITERIA

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24. ECG FINDINGS Non-specific, but electrocardiographic abnormalities common and may include: prolongation of the PR interval with progressive degrees of AV block sinus tachycardia right atrial enlargement bundle branch blocks left or right ventricular strain pattern voltage criteria for hypertrophy with regional ST depression and T wave inversion may be secondary to conduction system invasion or underlying predisposition (e.g.  aortic stenosis )

25. MANAGEMENT

26. . A Multidisciplinary approach with cooperation between the physician, surgeon and microbiologist increases the chance of survival. Any source of infection should be removed as soon as possible; for example, a tooth with apical abscess should be extracted. If the presentation is acute, flucloxacillin and gentamicinare recommended. If presentation is subacute, benzyl penicillin and gentamicin are preferred.

27. . In those with penicillin allergy, a prosthetic valve or suspected methicillin-resistant staph. Aureus(MRSA) infection, triple therapy with VANCOMYCIN,GENTAMICIN, and oral RIFAMPICIN should be considered. A 2 weeks treatment regimen for fully sensitive strains of streptococci may be sufficient.

28. . Linezolid should be considered in pts. With unstable renal function as a substitute of vancomycin. Cardiac surgery(debridement of infected material and valve replacement) is advisable in some patients, particularly with staph. Aureus or fungal infections. Antimicrobial therapy would be started before surgery.

29. PROPHYLAXIS

30. . The antibiotic prophylactic regimens recommended by the AHA are only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis while undergoing dental procedures, invasive respiratory procedure, skin or musculoskeletal tissue procedures. High risk cardiac conditions are as follow: Prosthetic cardiac valve  History of infective endocarditis Congenital heart disease (CHD) (1 ) unrepaired cyanotic CHD, including palliative shunts and conduits; (2) completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure; and (3) repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device Cardiac transplantation recipients with cardiac valvular disease

31. . All doses shown below are administered once as a single dose 30-60 min before the procedure. Standard general prophylaxis Amoxicillin Adult dose: 2 g PO Pediatric dose: 50 mg/kg PO; not to exceed 2 g/dose Unable to take oral medication Ampicillin Adult dose: 2 g IV/IM Pediatric dose: 50 mg/kg IV/IM; not to exceed 2 g/dose

32. . Allergic to penicillin Clindamycin Adult dose: 600 mg PO Pediatric dose: 20 mg/kg PO; not to exceed 600 mg/dose Azithromycin  or  clarithromycin Adult dose: 500 mg PO Pediatric dose: 15 mg/kg PO; not to exceed 500 mg/dose

33. COMPLICATIONS

34. . Valvular heart diseases: Most common is aortic regurgitation. Heart failure. Pulmonary embolism. Kidney damage Spleenomegaly

35. . CNS Embolization leading to STROKE. INFECTIOUS ANEURYSM: Aneurysms of arteries supplying the brain make up approximately 15% of the aneurysms occurring in infective endocarditis. Intracranial hemorrhage. Meningeal irritation leading from hemorrhage resulting in aseptic meningitis.

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