INFECTIVE ENDOCARDITS

Dr. Abhay kumar

MODERATOR- Dr. Rajesh kumar
Beginning of knowledge on Endocarditis

 Knowledge about origin of endocarditis

stems from the work of Fernel in the early
1500s, and yet this infection presents
physician with major diagnostic and
management dilemmas.
DEFINITION
An infection of the endocardial surface
of heart which may include one or
more heart valves, the mural
endocardium or a septal defect.
RISK GROUPS

1. Intra venous drug users

2. Survivors of cardiac surgery esp. those with
mechanical prosthesis.
3. Structural abnormalities of heart.
4. Patients taking immunosuppressant drugs.
5. Chronic intravascular catheter.
Etiology :
Bacterial agents in pediatric infective endocarditis

 Common: Native valve or other cardiac lesions

1. Viridans group streptococci (streptococcus mutan,

streptococcus sanguinis, streptococcus mitis)

2. Staphylococcus aureus

3. Group D streptococcus (enterococcus) (streptococcus

bovis, streptococcus faecalis)
 Etiology
 Uncommon: Native valve or Other cardiac lesions

1. Streptococcus pneumonia
2. Haemophilus influenza
3. Coagulase negative staphylococcus
4. Coxiella burnetti
5. Neisseria gonorrhoeae
6. Brucella
7. Chlamydia
8. Legionella
9. Bartonella
10. HACEK group
Etiology:
Leading cause-

1. No underlying heart disease – staphylococcus

2. After dental procedure – viridans gp. Streptococci
3. Lower bowel or genitourinary manipulation – Gp. D
enterococci
4. Intravenous drug users – pseudomonas or serratia
5. Open heart surgery – fungal organisms
6. Indwelling central venous catheter – coagulase negative
streptococci
Etiology…
PROSTHETIC VALVE

1. Staphylococcus epidermis
2. Staphylococcus aureus
3. Viridans gp. Streptococcus
4. Pseudomonas aeruginosa
5. Serratia
6. Diptheroids
Pathogenesis of infective endocarditis
Clinical features
 SYMPTOMS
1. Fever
2. Chills
3. Chest and abdominal pain
4. Arthralgia, myalgia
5. Dyspnoea
6. Malaise, weakness
7. Night sweats
8. Weight loss
9. CNS manifestations (headache, stroke, seizures)
SIGNS
1. Elevated temperature

2. Tachycardia

3. Embolic phenomenon (Roth spots, Osler nodes, splinter

hemorrhages, petechiae, CNS or ocular lesions)

4. Janeway lesions

5. New or changing murmur

6. Splenomegaly
7.Arthritis

8.Heart failure

9.Arrythmias

10.Metastatic infection (arthritis, meningitis, mycotic arterial

aneurysm, pericarditis, abscesses, septic pulmonary embolism)

11.clubbing
DIAGNOSIS
 Laboratory
1. Positive blood culture
2. Elevated ESR , CRP
3. Anemia
4. Leukocytosis
5. Immune complexes
6. Hyper gammaglobulinemia
7. Hypocomplementemia
8. Cryoglobulinemia
9. Rheumatoid factor
10. Hematuria
11. Renal failure – azotemia, high creatinine

 Chest xray : bilateral infilterates, nodules, pleural

effusion

 Echocardiography: valve vegetations, prosthetic valve

dysfunction or leak, myocardial
abscess, new onset valve
insufficiency
 Blood culture –

1. 5 separate blood collection should be obtained.

2. Timing of collection not important(bacteremia

expected to be relatively constant).

3. In 90% cases causative organisms recovered in 1st 2

cultures.

4. Nutritionally deficient & fastidious organism

cultured on enriched media for >7days.
 Blood culture …..

1. Sample should be obtained from separate venepuncture sites.

2. 5 – 10 ml in children
3. ½ - 1 hr apart
4. One should be for anaerobic organisms.

 Positive result :

1. Typical organisms present in at least 2 separate samples.

2. Detects over 95% of cases
 Other specimens that can be cultured-
1. Scrapings from cutaneous lesions
2. Urine
3. Synovial fluid
4. Abscesses
5. CSF

 Serological diagnosis or polymerase chain reaction of

resected valve tissue for unusual or fastidious organism.
Diagnostic
 approach to other pathogens causing
endocarditis :
Pathogen Diagnostic procedures

1.Brucellaspp. Blood culture, serology, culture, immunohistology & PCR

of surgical material.

2.Coxiella
burnetti serology(IgG Phase I >1 in 800), tissue culture,
immunohistology & PCR of surgical material.

3.Bartonella
spp. Blood culture, serology, culture, immunohistology &
PCR of surgical material.

4.Chlamydia spp. serology, culture, immunohistology & PCR of

surgical material.
 Pathogen Diagnostic procedures

1. Mycoplasma spp. serology, culture,

immunohistology & PCR of
surgical material.

2. Legionella spp. Blood culture, serology,

culture, immunohistology &
PCR of surgical material.

3. Trophyrema whipplei histology & PCR of

surgical material.
 Two dimensional echocardiography & Doppler
study:
1. Can identify shape, size, location, and mobility of
lesions.

2. Presence of valve dysfunction(regurgitation,

obstruction, effect on left ventricular
performance quantified).

3. Predicting embolic complications (lesions >1 cm

and fungating masses are at greatest risk of
embolization).
 DUKE criteria for diagnosis of endocarditis:
2 major criteria, 1 major & 3 minor criteria or 5 minor criteria.

 Major criteria includes-

1. Positive blood cultures (2 separate cultures for a usual

organism or > 2 for less typical pathogen.)

2. Evidence of endocarditis on echocardiography (intracardiac

mass on a valve or other site, regurgitant flow near a
prosthesis, abscess, partial dehiscence of prosthetic valves,
or a new valve regurgitant flow)
 Minor criteria:

1. Predisposing conditions
2. Fever
3. Embolic vascular signs
4. Immune complex phenomena (glomerulonephritis, arthritis,
Osler nodes, Roth spots).
5. A single positive blood culture or serological evidence of
infection.
6. Echocardiographic signs not meeting major criteria.
 Following minor criteria are added recently to the list:

1. Clubbing
2. Splinter haemorrhage & petechiae
3. Microscopic hematuria
4. Splenomegaly
5. Raised ESR & CRP
6. Presence of central feeding lines & peripheral lines.
 Prognosis & Complications.

1. Mortality - 20-25%
2. Serious morbidity 50-60% of children with documented
infective endocarditis; most common is heart failure due
to vegetation involving mitral or aortic valve.
3. Myocardial abscesses and toxic cardiomyopathy may also
lead to heart failure.
4. Septic embolization to central nervous system and
pulmonary emboli (if VSD or TOF is present.)
5. Mycotic aneurysm
6. Rupture of sinus of valsalva
7. Obstruction of valve secondry to large vegetations
8. Acquired VSD

9. Heart block (abscess of conduction system) & purulent pericarditis

10. Meningitis

11. Osteomyelitis

12. Arthritis

13. Renal abscess

14. Immune complex mediated glomerulonephritis.

 Treatment

1. Empirical therapy – vancomycin & gentamicin

before infectious agent is recovered without a
prosthetic valve and when there is high risk of S.
aureus, enterococcus, or viridans streptococci.
duration – 4-6 wks.

2. Heart failure – diuretics, afterload reducing agents,

digitalis.
 Surgical intervention

1. severe aortic, mitral or prosthetic valve involvement with

intractable heart failure.

2. Myocardial abscess.

3. Recurrent emboli.

4. Increasing size of vegetations while receiving therapy.

5. Fungal endocarditis
 Fungal endocarditis

1. Difficult to manage & has poorer prognosis.

2. Encountered after cardiac surgery, in severely debilitated

or immunocompromised patients, patients on prolonged
course of antibiotics.

3. Drug of choice- Amphotericin B and 5- fluorocytosine.

 Prevention :
Improving general dental hygiene is important.

 Prophylaxis
1. invasive respiratory tract procedure.
2. Prophylaxis with dental procedures As recommended by
AHA.
3. For patients undergoing cardiac surgery with placement of
prosthetic material.
4. No longer recommended for gastrointestinal or
genitourinary procedures.
 Prophylaxis with dental procedures as per AHA :
1. Prosthetic cardiac valve or prosthetic material used for cardiac
valve repair.

2. Previous infective endocarditis.

3. Congenital heart disease.

I. Unrepaired cyanotic CHD.
II. Completely repaired CHD within 1st 6 months after the
procedure.
III. Repaired CHD with residual defects.
IV. Cardiac transplant recipients who develop cardiac
valvulopathy.
Therapy for native valve endocarditis caused
by highly penicillin susceptible viridans gp.
Streptococci & streptococcus bovis
Therapy for endocarditis caused by
staphylococci in absence of prosthetic
material
Prophylactic antibiotic regimens for a
dental procedure