Infective Endocarditis

BACTERIAL ENDOCARDITIS

Prof. Dr. Mahmoud Mahfouz

M.D

Prof. Dr. Mahmoud Mafouz, M.D.

 Predisposing factors
1-Reduced immunity
 HIV
 DM
 Chemotherapy
 Malignancy

Prof. Dr. Mahmoud Mafouz, M.D.

 Reduced local integrity of the -2
endocardium
 Prosthetic valves
 Aortic and mitral regurge
 Previous infective endocarditis
 Rheumatic heart disease
 Mitral valve prolapse with regurge
 Mitral stenosis
 Congenital disorders
 ASD
 Pacemakers
 CABG

Prof. Dr. Mahmoud Mafouz, M.D.

 Source of bacteria-3
 Dental procedures that cause bleeding
 Oral surgery
 Genitourinary surgery
 Catheters
 IV drug abuse

Prof. Dr. Mahmoud Mafouz, M.D.

 Organisms
 Native valves
Strept viridans 50-60% (less virulent  subacute)
 In addicts (affects the right side of heart  tricuspid valve)

Staph aureus 60-95% (very virulent  causes acute

endocarditis)
Streptococci 10-20%
Fungi 4-5%
 Prosthetic valves (early or late)

Staph

Prof. Dr. Mahmoud Mafouz, M.D.

 Acute infective endocarditis
 S aureus is the most common cause
(VIRULENT)
 Normal valves
 Marked symptoms and fever
 May lead to septic shock
 Few days or weeks

Prof. Dr. Mahmoud Mafouz, M.D.

 Subacute infective endocarditis
 Strept viridans
 Abnormal valves
 Slow onset and vague symptoms
 Less fatal

Prof. Dr. Mahmoud Mafouz, M.D.

 New trends in infective
Endocarditis
 More prosthetic valves
 More nosocomial infections
 More tricuspid valve endocarditis with
intravenous drug abusers
 More staphylococcal and Polymicrobial
endocarditis
 Mean age of infection is getting older
 Genitourinary and urinary procedures are less
likely to cause IE
 Classification
 Old classification
 Sub-acute(death in 3-6 months)

 Acute (death in less than 6 weeks)

 New classification

 Native

 Prosthetic valve endocarditis

Prof. Dr. Mahmoud Mafouz, M.D.

 Cardiac pathologic changes
 Vegetations on valve closure lines
 Destruction and perforation of the valve leaflets
 Rupture of the chordae tendinae,inter-ventricular
septum and papillary muscles
 Valve ring abscess
 Myocardial abscess
 Conduction abnormalitiesVegetations may
become large enough to cause obstruction
 Break away as emboli
 Other pathologic complications
 Large friable vegetations (infective thrombi) can
result in major arterial emboli, metastatic infection,
or tissue infarction. This emboli could pass to the left
side to lungs and cause pulmonary embolism or to
the right side and cause systemic micro abscesses.
 Extra cardiac manifestations as vasculitis,mycotic
aneurysms and focal glomerulonephritis (immune
complex deposition) antigen antibody complex not
cleared from the circulation and deposit in kidney or
joints or skin
Prof. Dr. Mahmoud Mafouz, M.D.
Prof. Dr. Mahmoud Mafouz, M.D.
Signs of infective endocarditis
• Septic signs
• Cardiac signs
• Immune complex deposition
• Embolic phenomena
 Clinical manifestations
 The clinical features of endocarditis are nonspecific.
 The classic nonsuppurative peripheral manifestations of subacute
endocarditis are related to the duration of infection and, with early
diagnosis and treatment, have become infrequent
 Fever and weight loss
 Elderly, chronically ill patients with subacute IE may not have fever
 Skin and mucosal lesions (subcutaneous hemoorrages)
 arthritis
 Fundus manifestations
 Cardiac manifestations: new murmur, changing murmur, heart
failure, Myocardial abscesses, arrhythmias or high-degree
conduction block.
 Splenomegaly, splenic abscess,
 Systemic embolisation manifestations(cerebral, pulmonary in right
sided lesions
Prof. Dr. Mahmoud Mafouz, M.D.
 Major criteria
 Positive blood culture from two separate blood
cultures drown 12 hours apart or all three or
majority of four cultures with time between the
first and last samples is at least one hour apart at
the peak of the fever
 Echocardiography
 Oscillating intracardiac mass
 Abscess
 Newly identified partial dehiscence of prosthetic
valve or new valvular regurgitation
Prof. Dr. Mahmoud Mafouz, M.D.
 Minor criteria
 Fever (Any fever and new murmur is an endocarditis untill
proved otherwise)
 Predisposition to infective endocarditis
 Immunological phenomena
 Microbiological evidence of IE but major
criteria are not met
 Serological studies support an infection that is
consistent with diagnosis
Prof. Dr. Mahmoud Mafouz, M.D.
 Modified DUKE
 Definite
 2 major
 1 major and 3 minor

 5 minor

 Pssible
 1 major and 1 minor
 3 minor

Prof. Dr. Mahmoud Mafouz, M.D.

Prof. Dr. Mahmoud Mafouz, M.D.
Prof. Dr. Mahmoud Mafouz, M.D.
Flat painless red spots on
the palms and soles
Prof. Dr. Mahmoud Mafouz, M.D.
Prof. Dr. Mahmoud Mafouz, M.D.
Prof. Dr. Mahmoud Mafouz, M.D.
Prof. Dr. Mahmoud Mafouz, M.D.
Investigations
Blood culture
Blood tests
Urine analysis
CXR
ECG
Echocardiography
 Blood culture
 Multiple blood culture before empiric therapy
 3 blood cultures over one hour if the patient is
critically ill
 3 blood cultures over 12- 24 hours if not ill
 No more than 2 from the same venepuncture
 At the height of the fever

Prof. Dr. Mahmoud Mafouz, M.D.

 Culture negative endocarditis
 Special media is required
 Longer incubation period HACEK
 Patient is on antibiotics

Prof. Dr. Mahmoud Mafouz, M.D.

Prof. Dr. Mahmoud Mafouz, M.D.
Prof. Dr. Mahmoud Mafouz, M.D.
Echo Cardiography

Prof. Dr. Mahmoud Mafouz, M.D.

Treatment

Prof. Dr. Mahmoud Mafouz, M.D.

 Principles of drug therapy
 Empiric antibiotics are started only after cultures are taken
 In Strept  gentamycin and penicillin is given (4-6 weeks)
 In Staph  vancomycin
 Serum levels of gentamycin and vancomycin need to be
monitored
 In patients with penicillin allergy one of glycopeptides
antibiotics vancomycin can be used
 2 antibiotics are preferred to be given at time
 Fully compliant patients who have sterile blood cultures, are
afebrile during therapy, and have no clinical or
echocardiographic findings that suggest an impending
complication may complete therapy as outpatients.
Bactericidal antibiotics
are chosen

Prof. Dr. Mahmoud Mafouz, M.D.


Notes
Most patients respond within 2 days
 Long courses are needed for prosthetic valve
endocarditis,major embolic manifestations, symptoms
longer than 2 months
 In most patients, effective antibiotic therapy results in
subjective improvement and resolution of fever within
5–7 days. Blood cultures should be repeated daily
until sterile, rechecked if there is recrudescent fever,
and performed again 4–6 weeks after therapy to
document cure. Blood cultures become sterile within 2
days after the start of appropriate therapy
 Persistent fever is taken seriously: abscess, drug
reaction ,Nosocomial infection, pulmonary embolism
 Treatment
 Benzyl penicillin 1.2 gm 4 hourly and
gentamycin 80 mg 12 hourly
 If you suspect staph,recent intravscular
devices or cardiac surgery give vancomycin
instead of benzyl penicillin
 In MRSA give also vancomycin instead of
penicillin plus gentamycin as usual
 In MSSA give flucloxacillin plus gentamycin

Prof. Dr. Mahmoud Mafouz, M.D.

Prof. Dr. Mahmoud Mafouz, M.D.
 Treatment of complications
 Neurological complications avoid
anticoagulation except in mechanical valves
you may give the lowest therapeutic range
 Abscess; surgery
 Heart failure: anti failure measures or urgent
surgery

Prof. Dr. Mahmoud Mafouz, M.D.

 Surgery
 Extensive damage to a valve
 Prothetic valve endocarditis
 Persistent infection despite surgery
 Serious embolization
 Fungal endocarditis
 Severe heart failure

Prof. Dr. Mahmoud Mafouz, M.D.

 Drug prophylaxis
 Under local anaesthesia;amoxycillin 2 gram 1
hour before or zithromax
 Under general for dental or esophageal
procedures Amoxicillin IV 1 gm at induction
and 500 mg 6 hours later
 Genitourinary:amoxycillin plus gentamycin
 Cardiac valve: cephalosporin
 Hospital with high rate of MRSA:vancomycin
 In allergy to penicillin give also vancomycin
Prof. Dr. Mahmoud Mafouz, M.D.
Prof. Dr. Mahmoud Mafouz, M.D.
 Notes
 Right sided endocarditis is a disease of intravenous
abusers that sometimes lead to areas of apparent
consolidation suggestive of bronchopneumonia on
chest x ray, raise JVP
 Older age, severe comorbid conditions, delayed
diagnosis, involvement of prosthetic valves or the
aortic valve, an invasive (S. aureus) or antibiotic-
resistant (P. aeruginosa, yeast) pathogen,
intracardiac complications, and major neurologic
complications adversely impact outcome.
Prof. Dr. Mahmoud Mafouz, M.D.
Prophylaxis is advised only for those patients at
highest risk for severe morbidity or death from
endocarditis (Prophylaxis is recommended only for
dental procedures wherein there is manipulation of
gingival tissue or the periapical region of the teeth or
perforation of the oral mucosa (including surgery on
the respiratory tract). Although prophylaxis is not
advised for patients undergoing gastrointestinal or
genitourinary tract procedures, it is recommended that
effective treatment be given to these high-risk patients
before or when they undergo procedures on an
infected genitourinary tract or on infected skin and
related soft tissue.
Prof. Dr. Mahmoud Mafouz, M.D.
Prof. Dr. Mahmoud Mafouz, M.D.