CARDIOINFECTION DISEASE &

VALVULAR HEART DISEASE:

Highlight on Infective Endocarditis
ISMAN FIRDAUS, MD, FIHA, FAPSIC, FASCC, FESC, FSCAI

NATIONAL CARDIOVASCULAR CENTRE HARAPAN KITA HOSPITAL

FAKULTAS KEDOKTERAN UNIVERSITAS INDONESIA
INFECTIOUS DISEASES OF THE HEART

• Infective endocarditis

• Myocarditis

• Pericarditis
 INFECTIVE ENDOCARDITIS - OUTLINE

• Introduction
• Etiology
• Pathophysiology
• Diagnosis
• Treatment
• Complications
• Prognosis
• Prophylaxis
 INTRODUCTION: DEFINITION

• Infective Endocarditis: a disease caused by microbial infection of

the endothelial lining of intracardiac structures
 EPIDEMIOLOGY

• IE is a relatively rare but serious disease with high mortality despite the
improvement in diagnosis and therapy
• Estimated annual incidence 3-10/100 000
• The profile of patients and pathogens has changed over time (rheumatic
fever x PM/ICD)
Incidence IE

Young < old Male: Female

14,5 episodes/ 100.000 person 2:1
in 70-80 y.o
PREDISPOSING FACTOR

• Population with higher risk:

• Prosthetic valves
• Previous IE
• Congenital Heart Disease
• elderly patients with
degenerated valves
• i.v. drug users
• i.v. catheters, pacemaker
electrodes
RISK FACTOR
 CLASSIFICATION
• • (Acute x subacute/ lenta)
• NVE - native valve endocarditis
• PVE - prosthetic valve
endocarditis
• IVDU - intravenous drug users
• IE on PM / ICD electrodes
• Relapse - repeat IE within 6 months
and proven identical pathogen
• Reinfection, - new microorganism,
or the same species but > 6 months
• Early PVE - within 1 year (usually
aggressive nosocomial infection of
sewing material)
• Late PVE - > 1 year after
surgery/implantation
ETIOLOGY
ETIOLOGY
MICROBIAL CAUSES OF ENDOCARDITIS

• Common:
• viridans (alpha) streptococci
• enterococci
• S. aureus
• Other streptococci
• coagulase-negative staphylococci (usually restricted to
prosthetic valves or internal devices)
• Less common or rare:
• HACEK group - (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)
• Gram-negative (e.g., Pseudomonas)
• fungi (e.g., Candida spp.)
• Coxiella burnetii
 Valve endothelium injury Pathophysiology

bacteremia
Platelet - fibrin
deposition

Non bacterial
trombotic endocarditis
(NTBE)

Adherence

1. Braunwald’s heart disease : a textbook

of cardiovascular medicine / edited by Colonization
Douglas L. Mann, Douglas P. Zipes,
Peter Libby, Robert O. Bonow, Eugene
Braunwald.—10th edition
Vegetation
PATHOPHYSIOLOGY CONT.
Embolization Hematogenous
of vegetations continuous
to distant sites bacteremia

Local destructive
effects of Antibody response
intracardiac infection to the infecting
organism
Clinical
manifestations
of IE

1. Braunwald’s heart disease : a textbook of cardiovascular medicine / edited by Douglas L. Mann, Douglas P.
Zipes, Peter Libby, Robert O. Bonow, Eugene Braunwald.—10th edition
DIAGNOSIS-

MODIFIED DUKE
CRITERIA
How to diagnose ?
DIAGNOSIS

SYMPTOMS

RISK FACTORS
 CLINICAL FEATURES OF ENDOCARDITIS

• Acute endocarditis (due to S. aureus) - symptoms develop slowly over days to a

few weeks
• Symptoms:
• Intense fever, shaking chills
• Exhaustion and prostration
• Signs:
• New or changing heart murmur
• Signs of sepsis syndrome or septic shock (may be rapidly progressive or fulminant)
• Peripheral manifestations: splinter hemorrhages, peripheral embolic phenomema, e.g., Janeway
lesions, infarctions of toes or fingers
 CLINICAL FEATURES OF ENDOCARDITIS
• Subacute endocarditis (due to alpha-streptococci and other relatively
non-virulent bacteria) - symptoms develop slowly over months
• Symptoms:
• Fatigue, malaise
• Fever, chills, drenching night sweats
• Anorexia, weight loss
• Back pain
• Signs:
• New or changing heart murmur
• Peripheral manifestations: petechiae, splinter hemorrhages or fingernals or toenails,
Osler’s nodes, Roth spots (in the retina)
• Splenomegaly
• Anemia (pallor)
PHYSICAL FINDINGS
 Osler’s
Splinter
hemorrhages
nodes Peripheral manifestations

ROTH’S SPOTS
Janeway
lesions

Conjunctival
petechiae

Varga Z and Pavlu J. N Engl J Med 2005;353:1041

Mylonakis E and Calderwood S. N Engl J Med 2001;345:1318-1330
 OTHER WORKUP

• Blood culture
• Echocardiography
• ECG test
• Other laboratory test
• Serology
• Chest x-ray

1. Braunwald’s heart disease : a textbook of cardiovascular medicine / edited by Douglas L. Mann, Douglas P. Zipes,
Peter Libby, Robert O. Bonow, Eugene Braunwald.—10th edition
ECHOCARDIOGRAPHY

1. Braunwald’s heart disease : a textbook of cardiovascular medicine / edited by Douglas

L. Mann, Douglas P. Zipes, Peter Libby, Robert O. Bonow, Eugene Braunwald.—10th
edition
VEGETATIONS ON THE MITRAL VALVE

CDC/Dr. Edwin P. Ewing, Jr., 1972

VEGETATION AS SEEN BY
ECHOCARDIOGRAPHY IN A LIVE PATIENT
HISTOPATHOLOGY OF A VALVULAR
VEGETATION

Blue areas
are bacterial
colonies

Pink areas are

composed of fibrin
and platelets

© 1994-2012 by Edward C. Klatt MD, Savannah, Georgia, USA.

TREATMENT OF ENDOCARDITIS:
PRINCIPLES
• Treat It immidiately
• Therapy must be microbicidal, not static.
• Antibiotics should be given in maximal doses, usually intravenously
• Use Bactericidal Agents
- Penicilin G
- Vancomycin
- Gentamicin
- Flucloxacillin or oxacillin
• . . . and given for a long time (several weeks) → Sufficient Duration: 4-6 Weeks Or
Longer
 TREATMENT OF ENDOCARDITIS:
ANTIBIOTIC THERAPY

• Subacute (alpha-strep)
• duration depends on the isolate’s degree of sensitivity to beta-lactam antibiotics
• Sensitive strains treated with ceftriaxone 2gm IV daily x 2-4 weeks PLUS gentamicin
1mg/kg q12h x 2 weeks
• Acute (Staphylococcus aureus)
• (for MSSA) High-dose semisynthetic penicillin x 4-6 weeks
• (for MRSA) Vancomycin IV dosed to maintain 15-20mcg/ml trough levels x 6 weeks
• Enterococcal endocarditis
• High-dose penicillin or ampicillin PLUS gentamicin 1mg/kg q12h x 6 weeks (for drug
susceptible strains)
For a more detailed discussion, see treatment guidelines from the
UK: Gould et al. J Antimicrob Chemother 2012; 67: 269-289
US: Baddour et al. Circulation 2005; 111: e394-e434
Microorganism Antibiotic Duration class Level Alternative
( weeks) antibiotic

Streptococci Penicilin G 4 I B Amoxicilin,

And 12 – 18 Ceftiraxone
streptococcus With or without
million U/day gentamicin
bovis IV

Staphylococcus Flucloxacilin 4-6 I B Cotrimoxazole

(native valve) or oxacilin with
clindamycin,
12 gram/day daptomycin
IV
2. 2015 ESC Guideline for the management of Infective Endocarditis. Eur Heart J 2015;Aug
29
COMPLICATIONS OF ENDOCARDITIS:
CARDIAC CONSEQUENCES

• Congestive heart failure due to valvular destruction and

incompetency
• Perivalvular abscess
• Infection of the conduction with arrhythmias and/or heart block
• Acute myocardial infarction (due to coronary embolization)
• Pericarditis->hemopericardium->tamponade
• Cardiac fistulas due to erosion from one area of the heart to
another

2. 2015 ESC Guideline for the management of Infective Endocarditis. Eur Heart J 2015;Aug 29
3. Rosario V. Freeman and Catherine M. Otto . Hurst the Heart 13th ed
Paravalvular abscess with regurgitation in a patient
with rheumatic disease who presented with fever.

Didier D et al. Radiographics 2000;20:1279-1299

©2000 by Radiological Society of North America

COMPLICATIONS OF ENDOCARDITIS:
EMBOLIC CONSEQUENCES

• Infarction of any organ

• Splenic infarction +/- abscess can cause prolonged unremittent fever
and pain radiating to the left shoulder
• Pulmonary septic emboli from right-sided vegetations
Pulmonary septic emboli on a chest x-ray (left) and
chest CT (right) originating from tricuspid endocarditis

Septic emboli have cavitated and now show

air-fluid levels within the cavities that
communicate with the pulmonary airways.

Chen J and Li Y. N Engl J Med 2006;355:e27

COMPLICATIONS OF ENDOCARDITIS:
NEUROLOGICAL CONSEQUENCES
• Neurologic complications in 20-40% at
presentation (less common after antibiotics)
• New stroke with fever (think “endocarditis”)
• Complications include:
• mycotic aneurysms
• meningitis
• intracranial hemorrhage
 Mycotic
aneurysms

Mycotic aneurysms occur when bacteria

invade blood vessel walls via the vasa
vasorum. They infect and weaken the
walls allowing an aneurysm to form, and
eventually rupture with hemorrhage in
Intracerebral hemorrhage
the area of the aneurysm, and with
greatest consequence in the brain.
 When to do surgery ? - Principles

1.Worsening heart failure

2.Uncontrolled infection

3.Prevention of embolism

2. 2015 ESC Guideline for the management of Infective Endocarditis. Eur Heart J
2015;Aug 29
TREATMENT OF ENDOCARDITIS:
INDICATIONS FOR SURGERY
• Persistent positive blood cultures despite maximal antibiotic therapy

• Recurrent embolism (>2 episodes)

• Valvular dysfunction leading to severe heart failure

• Myocardial abscess - heart block, fistulas, arrhythmias

• Fungal endocarditis (usually cannot be cured with antibiotics alone)

Prognosis
 PROPHYLAXIS

2. 2015 ESC Guideline for the management of Infective Endocarditis. Eur Heart J 2015;Aug 29