Infective Endocarditis

Dr.S.Muthu krishnan, M.D. Asst. Professor in Medicine GVMCH, Vellore

Definition
Microbial infection of the ENDOTHELIAL SURFACE of the heart

Pathology
VEGETATION Amorphous mass of Platelets and Fibrin with abundant Microorganisms and scant Inflammatory cells

Vegetations - Comparison

RHD

IE

NBTE

SLE

Epidemiology

2 to 5 cases per 1,00,000 per annum Underlying Causes

Rheumatic H.D. Congenital H.D. Other (Calcified AoV, Floppy MV) Nil

24% 19% 25% 32%

50% occurred in age above 60 years Prosthetic valve endocarditis first 6 months

Sites

Heart valves Septal defects Chordae tendineae Mural endocardium Intra-Cardiac Devices Arteriovenous shunts Arterio-arterial shunts (PDA) Coarctation of the aorta

Infective Endarteritis

Classification

Acute

Subacute

Highly Virulent organisms Normal Valves Hectically febrile Rapid damage Hemat. Seeds Death within weeks

Low Virulent Organisms Damaged Valves Indolent Course Slow damage Rare metastasis Gradually progressive

Ventricular Surface of Aortic Valve Atrial Wall

Atrial surface of Mitral Valve

Chordae Tendinae / Papillary M.

Microbiology

Streptococci

Viridans group Enterococci Other Strep. Staph. aureus Coagulase-negative

30 40% 10 15% 20 25% 9 27% 1 3%

Staphylococci

Gram negative bacilli Hemophilus Anaerobes Ricketssiae, Fungi

3 8%
< 2%

Microbiology (ctd)
Prosthetic Valve Endocarditis

Early

Staphylococci Gram Negative Bacilli Fungi

50% 15% 10%

Late

Streptococci Staphylococci

40% 33%

Pathogenesis
Endocardial Injury Aberrant Flow

Direct Infection

Platelet Fibrin Thrombi

Pl. Fibrin Deposit

Bacteria Adhere

VEGETATIONS

Proliferate

More Pl. Fibrin Deposit

Clinical Features

CARDIOVASCULAR Varying / New murmurs Conduction Disorders Cardiac Failure Cerebral Emboli Systemic Emboli Loss of Pulses

85 90% 10 20% 40 50% 15% 7%

Clinical Features (ctd)

NON-CARDIOVASCULAR

Fever Chills and sweats Anorexia, weight loss, malaise Myalgias, arthralgias Back pain Splenomegaly Clubbing Neurologic manifestations Peripheral manifestations (Osler's nodes, subungual hges, Janeway lesions, Roth's spots) Petechiae

80 90% 40 75% 25 50% 15 30% 7 15% 15 50% 10 20% 20 40% 2 15%

10 40%

Janeway Lesions

Roth Spots

Splinter Hemorrhages

Oslers Nodes

Investigations
BLOOD CULTURE

3 Specimens; prior to antibiotics Dont wait for pyrexia Not from in-dwelling catheter Both Aerobic and Anaerobic culture

Investigations (ctd)
ECHOCARDIOGRAPHY

Anatomic confirmation Sizing of vegetations

TTE: > 3 5 mm TEE: > 1 1.5 mm

Detection of intracardiac complications Assessment of cardiac function

Investigations (ctd)

Elevated ESR Normocytic, normochromic anemia Leukocytosis Microscopic hematuria Thrombocytopenia Proteinuria Elevated CRP

> 90% 70-90% 20-30% 30-50%

Treatment

Difficult to eradicate organisms from avascular vegetations Bactericidal Parenteral; High concentration Knowledge of the susceptibility of the organism Prosthetic valves longer duration

Treatment (ctd)
Streptococci

Pen. Susc:

Pen G 2 3 mn units 4th hrly 4 wks Pen G 2 3 mn units 4th hrly + Gentamicin 1 mg / kg 8th hrly 2 wks Ceftriaxone 2 gm o.d. 4 wks Vancomycin 15 mg / kg b.d. 4 wks Pen G 3-4 mn units 4th hrly + Gentamicin 1 mg/kg 8th hrly 4-6 wks

Pen. Resis:

Treatment (ctd)
Enterococci

Pen G 3 - 4 mn units 4th hrly + Gentamicin 1 mg/kg 8th hrly 4 - 6 wks Ampicillin 2 g 4th hrly + Gentamicin 1 mg/kg IV 8th hrly 4 - 6 wks Vancomycin 15 mg/kg b.d. + Gentamicin 1 mg/kg 8th hrly 4 - 6 wks

Treatment (ctd)
Staphylococci - Native valves

Methicillin-susceptible

Nafcillin or Oxacillin 2 g 4th hrly 4 - 6 wks + Gentamicin 1 mg/kg 8th hrly 3-5 days Cefazolin 2 g 8th hrly 4 - 6 wks + Gentamicin 1 mg/kg 8th hrly 3-5 days Vancomycin 15 mg/kg b.d. 4-6 wks

Methicillin-resistant

Vancomycin 15 mg/kg b.d. 4-6 wks

Treatment (ctd)
Staphylococci - Prosthetic valves

Methicillin-susceptible

Nafcillin or oxacillin 2 g 4th hrly 6-8 wks + Gentamicin 1 mg/kg 8th hrly 2 wks + Rifampicin 300 mg 8th hrly 6-8 wks

Methicillin-resistant

Vancomycin 15 mg/kg b.d. 6-8 wks + Gentamicin 1 mg/kg b.d. 2 wks + Rifampicin 300 mg 8th hrly 6-8 wks

Treatment (ctd)
HACEK organisms

Ceftriaxone 2 g/d o.d. 4 wks Ampicillin 2 g 4th hrly + Gentamicin 1 mg/kg 8th hrly 4 wks

Treatment (ctd)
Fungi

Amphotericin B 1 mg / kg / day or Flucytosine 150 mg / kg / day 4 wks

Treatment (ctd)
Empirical Therapy Ampicillin 2 g 4th hrly + Gentamicin 1 mg/kg IV 8th hrly 4 - 6 wks

Indication for Surgery

Congestive Cardiac Failure

6 mth mortality: 60 90% vs. 20 50%

Prosthetic Valve dysfunction Myocardial Abscess Large vegetations with rec. emboli Uncontrolled infection Staph. aureus inf. with intra-cardiac compl.

>70% vs. 25%

Perivalvular extension

Prophylaxis

Procedures Needing Prophylaxis Dental procedures Tonsillectomy / Adenoidectomy UGI / URTI surgeries Bronchoscopy Esophageal dilatation ERCP Urinary catheterisation Cystoscopy Urinary tract surgeries I/D of infected tissues

Prophylaxis (ctd)

Dental, oral and URT procedures

Amoxicillin 2.0 g PO 1 h Ampicillin 2.0 g IV or IM < 30 min Clarithromycin 500 mg PO 1 h Cephalexin or cefadroxil 2.0 g PO 1 h Clindamycin 600 mg PO 1 h or IV 30 min Cefazolin 1.0 g IV or IM 30 min

Prophylaxis (ctd)

Genitourinary and Gastrointestinal tract procedures

Ampicillin 2 g IV or IM + Gentamicin 1.5 mg/kg IV or IM within 30 min of procedure; repeat ampicillin 1 g IV or IM or amoxicillin 1 g PO 6 h later Vancomycin 1 g IV over 1-2 h + Gentamicin 1.5 mg/kg IV or IM within 30 min before procedure

Complications

Cardiac Failure Embolic phenomenon Renal Failure immune-complex mediated Neurological complications

Embolic Stroke Intra-cranial hemorrhages A-V blocks Bundle branch blocks

Conduction abnormalities

Prognosis

Older age Severe co-morbid conditions Delayed diagnosis Involvement of prosthetic valves or the aortic valve Invasive (S. aureus) or antibiotic-resistant (P. aeruginosa, yeast) pathogen Intracardiac complications Major neurological complications

Prognosis (ctd)

Survival Rates

Streptococci, others : 85 90% Staph. aureus

IVDU : 85 90% Non IVDU : 55 70% < 2 mths : 40 50% > 2 mths : 10 20%

Prosthetic valve endocarditis