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INFECTIVE ENDOCARDITIS

INFECTIVE ENDOCARDITIS. DEFINITION: Infective Endocarditis is the microbial

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INFECTIVE ENDOCARDITIS

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  1. INFECTIVE ENDOCARDITIS DEFINITION: Infective Endocarditis is the microbial infection of heart valve (Native or prosthetic) the lining of cardiac chamber or blood vessel, or congenital anomaly (v. Septal defect). Causative organism is usually bacteria, ricketsia (coxiella burnetii endocarditis), chlamydia or fungus.

  2. ESSENTIALS OF DIAGNOSIS • Preexisting organic heart lesion. • Fever • New or changing heart murmur • Evidence of systemic emboli • Positive blood culture • Evidence of vegetation on echocardiography.

  3. PATHOPHYSIOLOGY • Preexisting endocardial damage • Virulent organism (Staphylococci) cause endocarditis in normal valves of heart , tricuspid valve endocarditis in IVDU • Wide variety of acquired & congenital cardiac lesions are vulnerable to endocarditis

  4. Defects associated with jet lesions (High pressure jets of blood) of VSD, MR, AR, susceptible to endocarditis. • Low pressure lesions like large ASD endocarditis is less likely • At the sites of endocardial damage infection occur. • These areas attract platelet & fibrin. • Colonization of blood born organism • Vegetation break away & embolise. • Adjacent tissue may be destroyed

  5. When infections is established, vegetation consisting of organism, fibrin, platelets grow & become large. • Abscess formation of valve • Perforation or disruption of chordaeae. • Extra cardiac manifestation eg. vasculitis, skin lesions and emboli or immune complex deposit. • At postmortem: Infarction of kidney, spleen, immune complex GN.

  6. MICROBIOLOGY • Infective endocarditis of native valves • Prevalence of organism • Streptococci Str. Mitis Viridans Str. Sanguis Haemolytic streptococci

  7. Enterococci 10-15% • Other streptococci 20 – 25% • Staphylococci 9 – 27% • Staph aureus • Coagulase negative • Gram negative bacilli 1-3% • Haemophilus 3-8% • Anaerobes

  8. INFECTIVE ENDOCARDITIS OF PROSTHETIC VALVES • Within two months after valve implantation • Staphylococci coagulse(+ve),coagulase(-ve) • Gram negative organism • Fungi

  9. NATIVE VALVE ENDOCARDITIS IN IDU • Staphylo. Aureus 60% • Tricuspid valve 80-90%

  10. CLINICAL FINDINGSSYMTOMS & SIGNS • Febrile illness • Nonspecific symptom cough, dyspnea, arthalgia or arthritis, diarrhea, abdominal pain • Cerebral emboli 15% • Sub conjunctival haemorrage < 2-5% • Roth’s spot in fundi < 5%

  11. Petechial hemorrhage in mucous membrane & fundi (20-30%) • Varying murmurs 9% • Conduction disorders 10-20% • Cardiac failure 40-50% • Splenomegaly 30-40% • Hematuria 60-70%

  12. Osler’s nodes 5% • Digital clubbing 10% • Splinter haemorrhage 10% • Janeway lesions • Systemic emboli 7% • Petechial rash 40-50

  13. CLINICAL COURSE OF ENDOCARDITIS ACUTE ENDOCARDITIS: • Severe febrile illness • Changing heart murmur & peteche • Abscess or valve disruption in ECHO

  14. SUB ACUTE ENDOCARDITIS • Known congenital heart disease or valvular heart disease • Tiredness • Persistent fever • Signs of valve dysfunction • Petechial lesion, splinter hemorrhages & Osler’s node.

  15. Systemic emboli • Clubbing • Splenomegaly • Hepatomegaly (Coxiela burneti) & splenomegaly • Partially treated acute endocarditis behaves like subacute endocarditis.

  16. POST OPERATIVE ENDOCARDITIS • Few weeks of heart surgery • Affects valve rings • Resemble acute / subacute endocarditis

  17. INVESTIGATIONS • Blood culture three –1 hour interval from three different sites. • 50% of fungal endocarditis – negative blood culture

  18. ESR • CRP • CXR –PAV • ECG • Echocardiography Transthoracic-3-5mm of vegetation sensitivity(65%) • TEE –1-1.5mm of vegetation sensitivity (90%)

  19. DUKE’S CRITERIA OF DIAGNOSIS MAJOR CRITERIA: 1. Two (+ve) blood cultures 2. Evidence of endocardial involvement documented by Echo • Definitive vegetations • Myocardial abscess • New dehiscence of prosthetic valve. • New regurgitant murmur.

  20. MINOR CRITERIA: 1. Presence of predisposing condition 2. Fever >380c 3. Embolic disease 4. Immunologic phenomena: GN, osler node, Roth spots, Rh factor 5. Positive blood culture not meeting the major criteria. 6. Positive echo not meeting major criteria

  21. Definitive diagnosis with 80% accuracy if 2 major or 1 major and 3 minor or all 5 minor criteria (if no major criterion is met).If this not met within 4 days endocarditis is highly unlikely.

  22. COMPLICATIONS • Damage to valves & heart • Embolic episodes • Regurgitations • Extension of infection to myocardium • Abscess • Conduction disorders • Pulmonary abscesses.

  23. TREATMENT • Emperical • Penicillin 2-3 million units 4 hourly or Ampicillin 1.5gm 4 hourly + Inj. Gentamycin 1mg/kg I/V 8, hourly • Penicillin allergic or MRSA, vancomycin 15mg/kg I/V 12 hourly.

  24. Treatment organism specific

  25. Treatment organism specific

  26. E. HACEK ORGANISMS • Hacek organisms (Haemphilus aphrophilus haemobhilus parainfluenzae, actinolacillus actinomycetemcomitans, cardiobacterium hominis, Eikenella corrodens, kingella kingae) are slow growing, fastidious gram negative cocobacilli or bacilli that are normal flora and cause 5-10% of all cases of endocarditis • Produce B. lactamase

  27. Procedure recommended for prophylaxis

  28. Prophylaxis • Prophylaxis in patient with known valvular and congenital heart disease is very necessary and should be warned about the possibility of endocarditis if the extra cardiac infection are not treated properly. Recommended are: Dental treatment: penicillin V 2 g by mouth on an empty stomach one hour before dental treatment ,followed by 0.5 gm every 6 hrly for 3 days . Alternatively pt. can be given a single injection of all purpose penicillin (300000 units of crystalline ,300000 units of procaine and 600000 units of benzathine penicillin) one hr before the procedure. Pt. with prosthetic heart valves should be given injectable penicillin with streptomycin or gentamycin I.M. 1 hr before the procedure.

  29. Genitourinary and gastrointestinal operation • Amoxicillin 25mg/kg by mouth one hour before ,with 2 mg/kg IM gentamicin 30 mins before the operation . • Pt. who are going for the gastro intestinal operation should be given metronidazole in addition. Amoxicillin and gentamicin should be repeated at least for two more doses after the procedure.

  30. F. ROLE OF SURGERY • If infection does not respond to appropriate antibiotics even after 10 days, valve replacement in AR is must • Valve replacement in fungal endocarditis & gram negative bacilli. • Surgery is indicated in septal abscess. • In recurrent infection in prosthetic endocarditis valve replacement

  31. G. ROLE OF ANTICOAGULATION • Contraindicated in native valve endocarditis risk of intracerebral hemorrhage • Active prosthetic valve endocarditis controversial

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