ENFECTIVE ENDOCARDITIS M.RASOOLINEJAD, MD DEPARTMENT OF INFECTIOUS DISEASE

1. ENFECTIVE ENDOCARDITIS M.RASOOLINEJAD, MD DEPARTMENT OF INFECTIOUS DISEASE TEHRAN UNIVERSITY OF MEDICAL SCIENCE

2. INFECTIVE ENDOCARDITIS Infection of the endocardial surface

4. INFECTIVE ENDOCADITIS

7. INTRUDUCTION • Clinical manifestations are so varied. • All of medical subspecialist must encounter • Successful management Medical & Surgical.

8. EPIDEMIOLOGY • 20% of cases are categorized as definite • Mean age of patients are increased • Underlying heart disease • Rheumatic heart disease • Degenerative heart disease • Congenital heart disease • Nosocomial endocarditis • Intracardiac prostheses • Injection Drug Users ( IDU )

9. PATHOGENESIS Endothelium Mucus membrane (Trauma, Turbulance, or metabolic change ) Colonized tissue Plt - fib deposition Trauma NBTE Bacteremia Adherence Colonization Mature Vegetation Local factor Bacteriocins IgA protease Bacterial adherence Complement Antibody

10. PATHOGENESIS • Nonbacterial Thrombotic Endocarditis (NBTA) • Hemodynamic factor • Transient Bacteremia • Microorganisms • Immunopathologic

11. ETIOLOGIC AGENTS Streptococci ( viridance, Fecalis,… ) 60 – 80 % Staphylococci ( +ve Or -ve coagolase ) 20 – 30 % Gram -ve bacteria 1.5 – 13% Fungi 2 - 4 % Culture negative 5 – 25 % Others 1 – 2 %

12. CULTURE – NEGATIVE ENDOCARDITIS • Subacute right – side infective endocarditis • Chronic course > 3 months • Uremia supervening chronic course • Mural IE as in VSD • Pacemaker wires infection

13. CULTURE - NEGATIVE ENDOCARDITIS • HACEK* • Brucella spp, • Prior administration of antibiotics • Rickettsiae, Chlamydia, Virus • Noninfective endocarditis * Haemophilus spp, Actinobacillus spp, Cardiobacterium spp, Eikenella, Kingella

14. PATHOLOGY HEART: • Vegetation ( fibrin, Plt, bacteria, PMN, RBC ) • Valve change perforation. • Rupture of chordae tendinae, septum and • papillary muscle • Ring abscess • Valvular stenosis • Valvular regurgitation • Myocardial abscess • Pericarditis, effusions • Coronary emboli

15. PATHOLOGY RENAL Renal architecture is abnormal in all cases, Even in the absence of clinical or biochemical of renal disease

16. PATHOLOGY RENAL • Focal glomerulonephritis • Diffuse glomeruonephritis • Membranoproliferative glomerulonephritis • Renal infarction • Renal abscess

17. PATHOLOGY CNS • Emboli (middle cerebral artery ) • Infarction • Arteritis • Abscess • Mycotic aneurysms • Hemorrhage:Intracerebral or Subarachnoid • Encephalomalacia • Meningitis

18. PATHOLOGY MYCOTIC ANEURYSMS • Usually during active IE • Occasionally mons or years after successful treatment • Direct bacterial invasion abscess • Septic embolic to vasa vasorum • Immun complex deposition • Cerebral vessels, abdominal aorta, sinus of Valsalva • Clinically silent until rupture

19. PATHOLOGY • SPLEEN: • LUNG: • SKIN: • EYE: Infarction, Abscess, Enlargement Emboli, Acute Pneumonia, Pleural Effusion Ptechiae, Osler node ( Arteriolar intimal proliferation ) Janeway lesions ( Becteria, Necrosis, PMN, Hemorrhage) Roth spots ( Lymphocyte, Edema, Hemorrhage )

20. CLINICAL JOINT MANIFESTATION CNS HEART FUO FEVER ICTER SEPTIC EMBOLI IE EYE SKIN PAIN KIDNEY LUNG

31. IE & IDU • More common in cocain users • Febrile IDU = IE • No underlying heart disease • More common in tricuspid valve • Aortic > Aortic + Mitral > Mitral valve • Pumonary septic emboli • S aureous, P aueroginosa • IDU & HIV / AIDS

32. IE & ELDERLY • Increased incidence in elderly • Prolonged survival with CVD, PHV in elderly, • Intravascular monitoring devises, Surgical implant material. • No specific symptoms & sings • Strep faecalis & bovis are common. • Diagnosis may be difficult. • Prompt empirical therapy : Vancomycin + Gentamycin • Cardiac complications : • CHF, Conduction abnormality, Arrhythmias, • Myocarditis, Myocardial abscess.

33. LAB FINDING • Anemia ( normochromic, normocytic, Fe, IBC ) • Thrombocytopenia ( 5 – 15 % ) • Leucocyte count ( or or ) • Large mononuclear cells ( histiocyte ) • ESR ( mean 57 mm/hr ) • Hypergammaglobulinemia • Positive RF ( 40 – 50 % ) • Complement ( 5 – 15 % ) • Positive VDRL & positive CIC • U/A ( protein,RBC, WBC ) • Positive blood culture & Positive ECHO • Serology & Teichoic acids antibody

34. DIAGNOSIS Durack DT, Lukes AS, Bright DK, Criteria • Definite ( Pathologic & Clinical Criteria ) • Possible • Rejected CLINICAL CRITERIA • Major or • Major & 3 Minor or • 5 Minor

35. MAJOR CRITERIA • Positive blood culture • Evidence of endocardial involvement MINOR CRITERIA • Predisposing heart disease or IDU • Fever > 38 • Vascular phenomena • Immunologic phenomena • ECHO • Microbiologic evidence

36. POSITIVE BLOOD CULTURE • Typical microorganisms: • ( S. viridance, S. bovis, HACEK, Entrococci, S. aureous • in the absence of primary focus) • Persistently positive blood cultures • (B/Csdrown more than 12 hr apart, or • All of 3 or majority of 4 separate B/Cs with 1st • & last drawn at least 1 hr apart ) HACEK: Haemophilus spp, Actinobacillus spp, Cardiobacterium homonis, Ekinella corrodence Kingella kingae

37. EVIDENCE OF ENDOCARDIAL INVOLVEMENT • Positive ECHO for IE • New valvular regurgitation • Oscillating intracardiac mass • Abscess • New dehiscence of prosthetic valve

40. veg

41. Mitral valve Vegetation

42. Mitral valve vegetation

43. TREATMENT • Antimicrobial therapy High dose, prolonged & IV antibiotics • Surgical therapy ANTIMICROBIAL THERAPY • Empirical therapy • Organisms based therapy • Duration of treatment

44. MONITORING ANTIMICROBIAL THERAPY • Serum concentration of antibiotic • should be monitoring. • Antibiotic toxicities should be considered. • Blood culture should be repeated daily  Sterile • Rechecked B/C if there is recrudescent fever. • Performed B/C 4 – 6 WKS after therapy • to document cure.

45. MONITORING ANTIMICROBIAL THERAPY • B/C became sterile after start antibiotics: • 2 days in  S.Viridance • Enterococci • HACEK organisms • 3 – 5 days in  S. Aureus + beta lactam • 7 days in  S. Aureus + Vancomycin

46. MONITORING ANTIMICROBIAL THERAPY • If fever persist for 7 days in spite appropriate AB  Evaluate patient for: • Paravalvular abscess • Extracardiac abscess • Embilic event • Vegetation became smaller with effective therapy 3 months after cure: 50% unchanged 25% are slightly larger

47. SURGICAL THERAPY • Refractory CHF • > One serious systemic emboli • Uncontrolled infection • Valve dysfunction ( ECHO ) • Fungal & Brucella endocarditis • Mycotic aneurysms • Prosthetic valve • Local suppurative complications • Large vegetation > 1 cm • Vegetation size after 4 WKS • Aortic valve endocarditis • Acute valve insufficiency • Recurrent endocarditis

48. INDICATION FOR SURGICAL INTERVENTION • Surgery required for optimal outcome • Surgery to be strongly considered • for improved outcome

49. INDICATION FOR SURGICAL INTERVENTION • Surgery required for optimal outcome: *Moderate to severe CHE due to valvular dysfunction. *Partially dehisced unstable prosthetic valve. *Persistent bacteremia despite optimal AB therapy. *Lake of effective microbial therapy ( fungal, Brucella…) *S. Aureus PVIE + intra cardiac complication. *Relapse of PVIE after optimal therapy

50. INDICATION FOR SURGICAL INTERVENTION • Surgery to be strongly considered for improved outcome: *Peivalvular extension of infection *Poorly responsive S. aureus in aortic or mitral valve. *Large > 10 Cm hypermobile vegetation *Persistent unexplained fever >10 days in culture -ve IE. *Poorly responsive or relapse ( Entrococci & Gram-ve )