IN FEC TI VE

END OC AR DIT IS

B Y P R A J WA L R A O . K , 8 t h T E R M
 LEARNING OBJECTIVES
 Definition

 Causative organisms & its portal of entry

 Types

 Predisposing/risk factors, Etiology

 Pathogenesis, Pathophysiology, Histopathology
 Clinical features – symptoms & signs
 Clinical consequences/complications
 Management – Investigations, Prophylaxis & Treatment
 Prognosis
INTRODUCTION
 DEFINITION: Clinical Reasoning Infective endocarditis.mp4

 It is the colonisation of the heart valves with microbiologic

organisms, leading to the formation of friable, infected

vegetations and frequently valve injury.

o Right sided IE has a more favourable prognosis than the left

sided IE.

o However, when right sided IE vegetation size exceeds 2 cm,

the mortality increases.

 C A U S AT I V E O R G A N I S M S
 BACTERIAL:

 Common – Streptococcus viridans, Streptococcus faecalis and Staphylococcus

epidermidis.

 Uncommon – Pneumo/gono/meningococcus, B. proteus, B. pyocyaneus, Gram­

negative organisms from the bowel, and HACKE (Haemophilus spp.,

Actinobacillus spp., Corynebacterium spp., Eikenella corrodens, and Kingella

spp.).

 NON-BACTERIAL:

 (a) Rickettsial – Coxiella burnetii. (b) Fungal – Candida, monilia, aspergillus,

histoplasma and torulosis. (c) Chlamydia type B agent of psittacosis.

 P O R TA L O F E N T R Y
1. Dental extraction or scaling

2. Tonsillectomy

3. Genitourinary and rectal procedures – Catheterization, D and C,

sigmoidoscopy

4. Bedsores

5. Puerperal infection

6. Cardiac surgery or cardiac catheterization

7. Long­standing intravenous infusions

8. IV drug taking in addicts

9. Insertion of IUCD
 Acute Infective SubAcute Infective Endocarditis Prosthetic Valve
Endocarditis Endocarditis occurring in IV Endocarditis
drug abusers

Caused by highly Caused by Caused This may be early,

virulent organisms organisms of predominantly by due to
mainly S. aureus moderate or low organisms found on intraoperative
TYPES

(20–30%), seeding virulence mainly the skin (S. aureus, infection of the
a previously normal Streptococci (60– Candida) and valve or insertion of
valve. 70%), seeding an affecting the valves an infected valve or
abnormal or on the right side of late, due to late
previously injured the heart. bacteraemia or
valve. earlier infection
with
microorganisms
having a long
incubation period.
 P R E D I S P O S I N G FA C T O R S

1. Congenital cardiac anomalies (shunts or stenosis with jet

streams)

2. Rheumatic heart disease

3. Mitral valve prolapse

4. Degenerative calcific stenosis

5. Bicuspid aortic valve

6. Prosthetic valves

7. Indwelling catheters.
PAT H O P H Y S I O L O G Y
 H I S T O PAT H O L O G Y
A. An aortic cusp shows vegetation with
fibrinous exudate on the free edge and
organization in the basal portion.
B. Bacterial colonies present in fibrinous
exudate appear dark purple.
C. Neutrophilic infiltrates in the
granulation tissue are indicative of
ongoing infection .
D. Macrophages and multinucleated giant
cells are common in streptococcal
endocarditis with subacute presentation.
 SYMPTOMS
a) Fever
i. low grade in subacute IE

ii. high grade in acute IE

b) Malaise

c) Fatigue

d) Weakness

e) Anorexia

f) Weight loss.
 SIGNS
a) Clubbing (seen after 6 weeks in 10–20% of patients)

b) Splenomegaly (seen after 6 weeks in 30% of patients)

c) Pallor (anaemia)

d) Heart murmurs (new, esp. regurgitant murmurs, or changing murmurs)

e) Petechiae (seen after 6 weeks over conjunctiva, palate, buccal mucosa

and skin above clavicle)

f) Splinter subungual haemorrhages

 SIGNS – cont’d
a) Osler nodes (small tender nodules, 1–10 mm diameter, on

the finger or toe pads as a result of septic emboli and

immune complex deposition)

b) Janeway lesions (1–4 mm non-tender erythematous

macules over palms and soles due to septic emboli)

c) Roth’s spots (oval retinal haemorrhages with a pale centre)

d) Arthralgia or arthritis.
 CLINICAL
CONSEQUENCES

1. Injury to valves or myocardium (abscess formation or

perforation).

2. Embolism (brain, spleen, kidneys and pulmonary

embolism).

3. Mycotic aneurysm.

4. Cerebral abscess.

5. Diffuse or focal glomerulonephritis or nephrotic syndrome.

 I N V E S T I G AT I O N S
 Blood cultures – In absence of recent or concurrent
antibiotic therapy, the first 3 random blood cultures
(2–4 hours apart) are positive in most patients, and
blood culture is positive by third day in 90%.
 Urine – Microscopic hematuria most common
finding. Slight albuminuria & hyaline and granular
casts also found.
 Haematology – Normocytic normochromic anaemia, usually

mild. May be raised ESR and raised C­reactive protein.

 Chest radiograph – may be diagnostic in right sided

endocarditis, with multiple shadows visible due to an embolic

pneumonia.

 ECG – Myocardial infarction seen on ECG may be due to

coronary embolism, and a conduction defect may be due to

development of an aortic root abscess.

  Echocardiography – Higher sensitivity in identifying vegetation with

TOE as compared to TTE.

a. Vegetations: An echodense structure attached to the valve or its

supporting structures, or lying in the track of a turbulent jet, which is

irregular in shape.

b. Leaflet perforation is best seen as regurgitant jet on color flow

mapping.

c. Annular and periprosthetic echolucent spaces (abscesses) and fistula

formation.
ECHO FINDINGS IN IE
 A young adult with a
history of intravenous
drug use, endocarditis
involving the tricuspid
valve with
Staphylococcus aureus,
and multiple septic
pulmonary emboli.

Pulmonary lesions on
chest radiograph are
Pulmonary embolic phenomena on radiographs strongly most prominent in the
suggest tricuspid disease
right upper lobe with
both solid and cavitary
appearance.
 N E G AT I V E B L O O D
C U LT U R E I N I E

1. Infection with fastidious organisms (H. parainfluenzae, Brucella)

2. Anaerobic infection

3. Candida, Aspergillus, Histoplasma, Coxiella burnetii, Chlamydia

psittaci endocarditis

4. Inadequate quantity of blood sample for culture or inadequate

amount of culture media

5. Prior antibiotic therapy

6. Right sided endocarditis.

 I N D I C AT I O N S F O R I E
PROPHYLAXIS

1. Dental procedures

2. Respiratory tract procedures – rigid bronchoscopy (not for

flexible)

3. GIT procedures
◦ Variceal sclerotherapy

◦ Stricture dilatation

◦ ERCP, biliary tract surgery

◦ Surgery involving mucosa

 Genito-urinary procedures:
◦ Cystoscopy
◦ Urethral dilatation
◦ Prostate/urethral surgery

 Cardiac conditions:
HIGH RISK MODERATE RISK
Prosthetic valves VSD
Prior IE Bicuspid aortic valve
Complex congenital CHD Acquired- AS, AR, MR,
MVPS
PDA/COA Congenital cardiac
malformations.
Created systemic pulmonary
shunts
IE PROPHYLAXIS
 T R E AT M E N T
 Inj. Benzyl penicillin 20–40 lakh units IV 4 hourly for

4 weeks.

 Parenteral aminoglycosides (SM, GM, Amikacin)

given in appropriate divided doses for the first 2

weeks.

 Appropriate antibiotic changes may be made on

receiving the results of blood culture.

 I N D I C AT I O N S F O R
SURGICAL MANAGEMENT

1. Failure of medical treatment as indicated by persistent

positive blood culture or refractory failure

2. Myocardial or valve ring abscess

3. Aortic valve endocarditis developing heart block

4. Prosthetic valve endocarditis

5. Presence of large vegetation with possible embolism

6. Fungal endocarditis.
 PROGNOSIS - POOR
Female Diabetes Mellitus
Staph. aureus Low serum albumin
Vegetation size Heart failure
Aortic valve Paravalvular abscess
Prosthetic valve Embolic events
Older age
 REFERENCES
1. Golwalla’s MEDICINE for students –
25th edition.
2. R. Alagappan manual of practical
medicine – 4th edition.
3. Images from google.