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ENDOCARDITIS

ENDOCARDITIS. CLASSIFICATION OF ENDOCARDITIS. CATEGORIES OF ENDOCARDITIS. Native valve Prosthetic valve IVDA. AETIOLOGY OF NATIVE VALVE ENDOCARDITIS. Streptococci 55% Staphylococci 30% Enterococci 6% Gram negative bacilli rare Fungi rare.

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ENDOCARDITIS

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  1. ENDOCARDITIS

  2. CLASSIFICATION OF ENDOCARDITIS

  3. CATEGORIES OF ENDOCARDITIS • Native valve • Prosthetic valve • IVDA

  4. AETIOLOGY OF NATIVE VALVE ENDOCARDITIS • Streptococci 55% • Staphylococci 30% • Enterococci 6% • Gram negative bacilli rare • Fungi rare

  5. EPIDEMIOLOGY OF NATIVE VALVE ENDOCARDITIS • Male • Age > 50 yrs • Mitral valve > aortic valve >>> tricuspid • Predisposing Factors • mitral valve prolapse • congential heart disease

  6. PROSTHETIC VALVE ENDOCARDITIS • Early onset - symptoms within 60 days of surgery • usually valve contaminated during surgery • S. epidermidis • S. aureus • Gram-negative bacilli • Late onset - symptoms occur > 60 days after surgery • usually due to Streptococci

  7. INTRAVENOUS DRUG ABUSERS Tricupsid (50%) > aortic (25%) > mitral (20%) • S. aureus >50% • Streptococci 20% • Enterococci 20% • Gram negative bacilli 5% • Fungi 5%

  8. CLINICAL MANIFESTATIONS OF ENDOCARDITIS SymptomsPercentage Fever 80 Chills/Weakness/Dyspnoea 40 Cough/Anorexia/Wt loss 25 Skin lesions/Stroke/N/V/HA 20 Myalgia/Arthralgia/Oedema/CP 15 Delirium/Haemoptysis/Back pain 10

  9. CLINICAL MANIFESTATIONS OF ENDOCARDITIS Physical FindingsPercentage Fever 90 Heart murmur 85 Embolic phemomenom >50 Skin manifestations 18-50 Splenomegaly 20-57 Septic complications 20 Clubbing 12-52

  10. CLINICAL INVESTIGATIONS • FBC U+E Cr LFT • Multiple Blood Cultures (At least 3 from 2 different sites) • ESR CRP • TTE  TOE • CT/MRI (embolic phenomena)

  11. CRITERIA FOR DIAGNOSIS OF ENDOCARDITIS • Definite • Pathologic criteria • Clinical criteria • 2 major or 1 major and 3 minor or 5 minor • Possible if not definite or rejected • Rejected • Alternate diagnosis • No evidence at surgery or resolution of endocarditis with < 4 days of abx therapy

  12. MAJOR CRITERIA FOR IE • Positive blood culture for IE • Typical organism from 2 separate blood cultures or • Persistently positive blood cultures • Evidence of endocardial involvement • Positive echocardiogram • New valvular regurgitation

  13. MINOR CRITERIA FOR IE • Predisposition • Fever • Vascular phenomena • Immunologic phenomena • Echocardiogram • Microbiologic evidence

  14. INDICATIONS FOR SURGERY NVE PVE 5 or more points suggest the need for valve replacement

  15. VIRIDANS STREPTOCOCCI • S. sanguis • S. mutans • S. mitis • S. milleri • S. bovis • Normal inhabitants of the oropharynx

  16. RARE ORGANISMS • Corynebacterium • Listeria • Bartonella Species • Coxiella Burnetti (Q fever)

  17. NATIVE VALVE ENDOCARDITIS DUE TO PENICILLIN SUSCEPTIBLE VIRIDANS STREPTOCOCCI (MIC 0.1 µg/ml) JAMA 1995;274:1706-1713.

  18. NATIVE VALVE ENDOCARDITIS DUE TO VIRIDANS STREPTOCOCCI (MIC 0.1 AND < 0.5 µg/ml) JAMA 1995;274:1706-1713.

  19. ENTEROCOCCI ENDOCARDITIS JAMA 1995;274:1706-1713.

  20. STAPHYLOCOCCUS ENDOCARDITIS IN THE ABSENCE OF PROSTHETIC VALVE JAMA 1995;274:1706-1713.

  21. STAPHYLOCOCCAL ENDOCARDITIS IN THE PRESENCE OF A PROSTHETIC VALVE JAMA 1995;274:1706-1713.

  22. HACEK ORGANISMS • Haemophilus parainfluenzae • Haemophilis aphrophilus • Actinobacillus actinomycetemcomitans • Cardiobacterium hominis • Eikenella corrodens • Kingella kingae

  23. ENDOCARDITIS DUE TO HACEK ORGANISMS JAMA 1995;274:1706-1713.

  24. CARDIAC CONDITIONS ENDOCARDITIS PROPHYLAXIS RECOMMENDED • High Risk Conditions • Prosthetic valves • Previous bacterial endocarditis • Complex congenital heart disease • Surgically constructed pulmonic shunts • Moderate Risk Conditions • Most other Coronary Heart Diseases • Mitral prolapse with regurgitation • Hypertrophic cardiac myopathy

  25. CARDIAC CONDITIONS ENDOCARDITIS PROPHYLAXIS NOT RECOMMENDED • Cardiac pacemakers and implanted defibrillators • Rheumatic fever without valve dysfunction • Physiologic, functional heart murmurs • Mitral valve prolapse without MI • Previous CABG • Atrial septal defect

  26. DENTAL AND OTHER PROCEDURES FOR ENDOCARDITIS PROPHYLAXIS • Dental - extractions, periodontal procedures, implants, root canal • Respiratory - T&A, rigid bronchoscopy • GI - ERCP with biliary obstruction, Sclerotherapy of esophageal varices, dilation of esophageal • Biliary tract surgery, surgery on/through intestinal mucosa • GU - prostate surgery, cystoscopy, urethral dilatation

  27. PROCEDURES ENDOCARDITIS PROPHYLAXIS IS NOT RECOMMENDED • Dental - filling cavities, orthodontic adjustments, dental x-rays • Respiratory - Intubation, flexible bronchoscopy • GI - transoesophageal echo • GU - vaginal hysterectomy, vaginal delivery, C-section, insert/remove IUD, foley catheter • Other - cardiac catheter, balloon angioplasty, implanted pacemaker, defibrillators, circumcision, skin biopsy, coronary stents

  28. PROPHYLACTIC REGIMENS FOR GU/GI PROCEDURES

  29. PROPHYLACTIC FOR DENTAL, ORAL, RESPIRATORY OR OESOPHAGEAL

  30. FAILURE TO RESPOND TO TREATMENT • Abscess formation - paravalvar - metastatic • Low cardiac output - flail mitral valve or perforation - coronary embolism - free aortic regurgitation • Wrong diagnosis - lymphoma - SLE - TB - sarcoidosis - AIDS • Major Immune Activation - renal failure - emboli - vasulitis

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