Infective Endocarditis

1. Infective Endocarditis Group 5 Dr. WALEED SAMY PROFESSOR OF INTERNAL MEDICINE Taif UNIVERISTY

2. Outcomes - Definition. - Pathogenisis. - Signs and symptoms. - Causes. - Classification. - Deferential diagnosis. - Investigation. - Diagnosis. - Prognosis. - Complication. - Prevention. - Treatment.

3. Case Study •  28-year-old man comes to the emergency room complaining of 6 days of fevers with shaking chills. Over the past 2 days, he has also developed a productive cough with greenish sputum, which occasionally is blood streaked. He reports no dyspnea, but sometimes experiences chest pain on deep inspiration. He does not have headache, abdominal pain, uri- nary symptoms, vomiting, or diarrhea. He has no significant medical history. He smokes cigarettes and marijuana regularly, but denies intravenous drug use.

4. Definition • Infective endocarditis (IE) is defined as an infection of the endocardial surface of the heart, which may include one or more heart valves or the mural endocardium. Its intracardiac effects include severe valvular insufficiency, which may lead to congestive heart failure and myocardial abscesses

5. Cont. • This infection itself can be : • On valves which have congenital or acquired defect • On normal valves with virulent organisms such as streptococcus bpneumoniae or staphylococcus aureus • On prosthetic valves when infection may be early “within 60 days of valve surgery “ or late “ following bacteraemia “

6. Pathogenisis Infective endocarditis typically affects the heart valves. However, it can also affect interventricular septum, the mural endocardium, chordaetendineae, and other structures. Infective endocarditis is usually consequence of two factors: 1)presence of organism in the blood stream 2)abnormal cardiac endothelium facilitating adherence of organism(endothelial injury)

7. Cont. Method of endothelial injury: Turbulence in blood flow – caused by valvular incompetence. Direct physical damage – trauma. (implantation of prosthetic valves) Degeneration- calcified valve in old age A blood clot will then form over this damaged part (non-bacterial thrombotic endocarditis). For progress to infective endocarditis, the individual must have bacteremia

8. Cont. Method of infective endocarditis: 1)endocardial surface injury, (2) thrombus formation at the site of injury, (3) bacterial entry into the circulation, (4) bacterial adherence to the injured endocardial surface.

9. Cont. The most common cause of endothelial injury is turbulent in the blood flow resulting from pre-existing valvular disease; -Rheumatic fever history -Old age – calcified valves -Mitral valve prolapsed with regurgitation -Prosthetic heart valves -Congenital defect(ventricular septaldefect,patentductusarterioses) -Cardiac surgery -Central lines -Pacemakers

11. Signs and symptoms General: Fever(90%) , Malaise , Clubbing. Cardiac: Murmurs (90%) , Regurgitation (b/c of progressive destruction of the valve) Skin: • Osler's nodes: Hard , Painful , Tender Subcutaneous Swelling in (hands,fingers,toes,palms & soles) • Splinter hemorrhage: are tiny blood clots that tend to run vertically under the nails(under the fingers & toes nails) • Janeway lesions: (non-tender, small erythematousmacular or nodular lesions on the palms or soles only a few millimeters in diameter that are indicative of infective endocarditis). Petechiae: (mucosal hemorrhages due to vacuities)

12. Cont. Eyes: Roth spots:  retinalhemorrhages with white or pale centers composed of coagulatedfibrin. Brain: Cerebral emboli - Aneurysm Spleen: Splenomegaly Kidney: Haematuria ( microscopic )

14. Causes • Everyday oral activity , e.g: chewing • Come from infection or other medical condition: Bacteria may spread from an infected area, such as a skin sore. Gum disease, a sexually transmitted disease or an intestinal disorder — such as inflammatory bowel disease — also may give bacteria the opportunity to enter your bloodstream. • Catheters or needles: bacteria enter your bloodstream through the needles used for tattooing or body piercing. Contaminated needles and syringes are a concern for people who use intravenous (IV) drugs. • Certain dental procedures: Some dental procedures that can cut your gums may allow bacteria to enter your bloodstream.

15. Don't forget Most people who develop endocarditis have a diseased or damaged heart valve.

16. Causative organism • Bacteremia: -Streptococcus viridans: most common organism. -Staph aureus / epidermidis -Diphtheroids -H.A.C.E.K ( Haemophilus-Actinobacillus-Cardiobacterium-Eikenella-Kingella). -Coxiellaburnetii. -Chlamydia.

17. Cont. Fungi: -Candida. -Aspergillus. -Histoplasma. Other: -SLE (Libman-sacks endocarditis), -Malignancy.

18. Classification • Native valve endocarditis (NVE), acute and subacute • Prosthetic valve endocarditis (PVE),early and late • Intravenous drug abuse (IVDA) endocarditis

19. Native valve endocarditis (NVE), acute Acute NVE frequently involves normal valves and usually has an aggressive course. It is a rapidly progressive virulent organisms, such as S aureus and group B streptococci.

20. Native valve endocarditis (NVE), subacute • Subacute NVE typically affects only abnormal valves. Its course is usually more indolent than that of the acute form and may extend over many months. • Alpha-hemolytic streptococci or enterococci, usually in the setting of underlying structural valve disease

21. Prosthetic valve endocarditis (PVE) • PVE accounts for 10-20% of cases of IE • Mechanical valves are more likely to be infected within the first 3 months of implantation, and, after 1 year, bioprosthetic valves are more likely to be infected. The valves in the mitral valve position are more susceptible than those in the aortic areas

22. Prosthetic valve endocarditis (PVE) • 1- Early PVE occurs within 60 days of valve implantation. Traditionally, coagulase-negative staphylococci, gram-negative bacilli, and Candida species have been the common infecting organisms

23. Prosthetic valve endocarditis (PVE) • 2-Late PVE occurs 60 days or more after valve implantation. Staphylococci, alpha-hemolytic streptococci, and enterococci are the common causative organisms. Recent data suggest that S aureus may now be the most common infecting organism in both early and late PVE.

24. Intravenous drug abuse (IVDA) endocarditis In 75% of cases of IVDA IE, no underlying valvular abnormalities are noted, and 50% of these infections involve the tricuspid valve.S aureus is the most common causative organism.

25. nosocomial IE (NIE) NIE is defined as an infection that manifests 48 hours after the patient is hospitalized or that is associated with a hospital, based on a procedure performed within 4 weeks of clinical disease onset.

26. nosocomial IE (NIE) • Two types of NIE have been described. • The right-sided variety affects a valve that has been injured by placement of an intravascular line (eg, Swan-Ganz catheter). • The second type develops in a previously damaged valve and is more likely to occur on the left side.

27. Deferential Diagnosis • Endocarditis . • Antiphosphlipid syndrome:is an autoimmune , hypercoagulable state caused by antiphospholipid antibody. . • Atrialmyxoma : is commonest benign tumour of the heart . • Reactive arthritis: is defined as an autoimmune condition that develops in response to an infection in another part of the body. • SLE .

28. Investigation 1- blood culturs A- before antibiotic : at least 3 sets(aerobic and anaerobic bottles) frome different sites , ideally spaced >1 h apart . B- after appropriate antibiotic :repaet q24-48 h until - . 2- CBC with diff ( increase WBC common in acute bacterial endocarditis , anemia in subacute bacterial endocarditis,ESR ,RF, BUN/CR, U/A ,URINE CULTURE

29. Cont. 3- ECG ( on admission and at regular intervals ) to assess for new coduction abnormalities 4-Echocardiogram : obtain TTE if low clinical suspiicion TEE :1 modrate to high clinical suspicion 2 high risk Pt( prosthetic valveprior IE .CHD ) 3 TTE non diagnostic 4 TTE - but endocarditis strongly suspected 5-culture – endocarditis : may be due to antibiotic prior to culture . Detailed hx : animal exposure ,travel ,unpasteurized dairy …

30. Diagnosis Duke criteria MAJOR CRITERIA: • Blood culture positive for typical IE-causing microorganism • Evidence of endocardial involvement. • Diagnosis • 2 major criteria • 1 major and 3 minor • 5 minor criteria MINOR CRITERIA: • Predisposition – heart condition or i.v. drug abuse • Fever – temp. >38 °C • Vascular phenomena – arterial emboli etc. • Immunologic phenomena – glomerulonephritis, jameway, Osler’s nodes, Roth’s spots etc • Microbiological evidence – positive blood cultures but do not meet major criteria

31. Blood cultures • Always before starting antibiotics • Always triple samples – aerobe, anaerobe and mycotic , 10 ml each • Three sets of samples required

32. Complication • Stroke and organ damage.In endocarditis, clumps of bacteria and cell fragments (vegetations) form in the heart at the site of the infection. These clumps can break loose and travel to the brain, lungs, abdominal organs, kidneys or extremities. This may cause various problems, including stroke or damage to other organs or tissues.

33. Cont. • Infections in other parts of your body.Endocarditis can cause you to develop pockets of collected pus (abscesses) in other parts of the body, including the brain, kidneys, spleen or liver. An abscess may develop in the heart muscle itself as well, causing an abnormal heartbeat. Severe abscesses may require surgery to treat them.

34. Cont. • Heart failure.Left untreated, endocarditis can damage the heart valves and permanently destroy the heart's inner lining. This can cause your heart to work harder to pump blood, eventually causing heart failure — a chronic condition in which the heart is unable to pump enough blood to meet the body's needs. If the infection progresses untreated, it's usually fatal.

35. Prognosis The incidence of infective endocarditis in a general population has been estimated at between 2 and 6 cases per 100,000 person-years. Furthermore, invasive procedures performed in our technically robust health care system may cause bloodstream infections and result in endocarditis.

36. Cont. Although historically rheumatic valvulitiswas considered a frequent predisposing factor for endocarditis, times have changed. Mitral valve prolapse, aortic sclerosis, and bicuspid aortic valvular heart disease are now more frequent causes. In addition, prosthetic valvular heart disease accounts for about one third of all cases of endocarditis, and occurs in 1% to 3% of patients after valvular heart surgery.

37. Cont. Prognosis largely depends on whether or not complications develop. If left untreated, IE is generally fatal. Early detection and appropriate treatment of this uncommon disease can be lifesaving. The overall mortality rate has remained stable at 14.5%.

38. Cont. Cure rates for appropriately managed (including both medical and surgical therapies) NVE are as follows: For enterococci and S aureusinfection in individuals who abuse intravenous drugs, the rate is 90%. For community-acquired S aureus infection in individuals who do not abuse intravenous drugs, the rate is 60-70%. For infection with aerobic gram-negative organisms, the rate is 40-60%. For infection with fungal organisms, the rate is lower than 50%

39. Prevention There are several easy ways to reduce the risk of infective carditis: Keep teeth healthy by sensible eating habits and twice daily brushing Have regular 6 monthly check-ups by the dentist If a dentist removes a tooth or does some deep work on the teeth or gums give antibiotics. Some non dental operations can cause bacteria to be scattered into the blood and require antibiotics to be given. Always tell doctors and dentists that your child has a heart abnormality so that they can decide if antibiotics are needed for what they are dealing with.

41. Treatment basics -Sucess relies on eradication of pathogen. -Bactericidal regiment should be used. -Drug choice due to pathogen. -Surgery is used mainly to cope with structural complications.

42. Cont. -NVIE standard therapy - it takes 2-6 weeks to eradicate the pathogen -PVIE – longer regime is necessery – over 6 weeks -In Streptococcal IE shorter, 2 week course, can be used when combining β-laktams with aminoglycosides -Most widely used drugs – amoxycylin, gentamycin -In case of β-laktams alergy - vancomycin

43. Cont. -First and most important – proper oral hygiene -Regular dental review -Antibiotics only in high-risk group patients -Prosthetic valve or foreign material used for heart repair -History of IE -Congenital heart disease -Cyanotic without correction or with residual lickeage -CHD without lickeage but up to 6 months after surgery -Use amoxycilin or ampicylin 30-60 min prior to intervention

44. Summary 1-IE is rare but serious disease, with high mortality rate 2-Every case of fever of unknown origin should be suspected for IE 3-Blood cultures are essential for diagnosis 4-TTE/TEE is the best method to monitor and follow-up of IE 5-Antibiotics are main treatment 6-CHF is the most common complication 7-Pharmacological prophylaxis is reserved for a narrow group of high risk patients