Infective Endocarditis  CLINICAL FEATURES of infective Endocarditis (IE) causes the Infective Endocarditis With TREATMENT  of infective Endocarditis (IE)

Proliferation of microorganisms on the endot­helium of heart results in infective endocardi­tis. The typical feature–of the· disease is vegetation. Endocarditis may be caused by any microorganism;  of streptococci or staphylococci; Haemophilus spp. or other HACEK bacteria Vegetation is a mass of platelets, fibrin, microcolonies of microorganisms and inflammatory cells –

Hacek bacteria is the commonest cause of Infective Endocarditis this group is combined of   (e.g., Actinobacillus Eikenella corrodens, or Kingella kingae actinomycetem comitans, Cardiobacterium hominis,  ); chlamydiae; enteric bacteria; ricksettsiae; or some time  fungi.

 

Vegetation may form on :

• heart valves
• low pressure side of VSD (ventricular septal de­fect)
• Mural endocardium (damaged by jet of blood or foreign bodies)
• Intracardiac devices

 

Infective Endocarditis is the same process occur­ring in :

• Endocarditis is usually the consequence of two factors: the presence of organisms in the bloodstream and abnormal cardiac endothelium facilitating their adherence and growth.
• Arteries,
• Arteriovenous shunt
• Arterio-arterial shunts ex. PDA (Patent ductus arteriosus)
• Coarctation of aorta

 

 

Typical features of Acute Endocarditis

• This usually presents as a severe febrile illness with prominent and changing heart murmurs and petechiae.
• · Fever
• · Damage to cardiac structures by the disease
• · Extracardiac sites involved by hematogenous spread
• · Death in weeks, if untreated

 

Typical features of Subacute Endocarditis

   

• This should be suspected when a patient known to have congenital
• valvular heart disease develops a persistent fever,
• Structural cardiac damage present before the dis­ease
• · Extracardiac sites usually not involved
• · Embolic events always occur
• complains of unusual tiredness,
• night sweats or weight loss,
• develops new signs of valve dysfunction or heart failure.
• · Slow course, gradually progressive
• · Structural cardiac damage present before the dis­ease
• · Extracardiac sites usually not involved
• · Embolic events always occur

Organism that mainly causes the Infective Endocarditis —

Streptococcus viridans		From:
StaphylococciHACEK — Haemophilus Actinobacillus Cardiobacterium Eikenella Kingella		Oral cavity Skin Upper respiratory tract
Streptococcus bovis		GIT
EnteroccciNosocomial : Staphylococcus aureus Staphylococcus aureus Gram -ve bacilli, Diphtheroids Fungi, Pseudomonas aeruginosa, Candida, Lactobacillus, Corynebacterium, Bacillus, Bartonella, Coxiella, Brucella		Genitourinary tract Intravascular catheter wounds Urinary Tract Infection-UTI Prosthetic valve (within 2 months of valve surgery) (Coagulase negative methicillin resistant Staphylococcus  aureus) Pacemaker lead Implantable defibrillators Drugs users (Tricuspid valve involvement)

   

Endocarditis may be non–infective, non-bacte­rial —

NBTE (Nonbacterial thrombotic endocarditis)

• there is – uninfected platelet fibrin thrombus.
• During transient bacteraemia this gets changed to inf­ected vegetation as in MR, AR AS VSD MVP, Degenerative disease of heart valves and congenital heart diseases. .

Marantic endocarditis are uninfected vegetations in:

• SLE
• Malignancy
• Antiphospholipid syndromes

SIGNS and SYMPTOMS for Infective Endocarditis —

CLINICAL FEATURES of infective endocarditis (IE)

 

• Fever
• Weight loss
• Malaise
• Myalgia
• Chills
• Sweating (diaphoresis) Anorexia
• Arthralgia
• Back pain
• Heart murmurs – Regurgitant murmurs – MR, AR Arterial emboli can go to kidney, spleen, mesentery, brain, peripheral arteries.
• Splenomegaly
• Subungual haemorrhages – also called splinter hem­orrhages under the nails over the nail-bed.
• Javeway’s lesions – nodular hemorrhages on the skin Roth spots – flame-shaped hemorrhages seen on the retina by funduscopy
• Petechiae on the skin
• Clubbing’ may be due to embolisation or immune re­action
• Neurologic features like: Brain abscess, convulsions, hemiplegia, coma, pneumococcal meningitis
• Osler’s nodes are painful pulp of terminal digits of fingers

LABORATORY TESTS of infective endocarditis (IE)

• Anaemia
• Circulating immune complexes Decreased serum complement
• Leucocytosis Microscopic hematuria Increased ESR Rheumatoid factor

 

DUKE‘S CRITERIA FOR CLINICAL DIAGNOSIS

     

Major

  Evidence of endocardial involvement supporting the diagnosis of IE

• New valvular regurgitation (increase or change in pre-existing murmur does not count as a criterion)
• ·Echocardiography: – Vegetations Abscess
• – Dehiscence of prosthetic valve
• – New valvular regurgitation
• Echocardiogram findings
  • (a) Oscillating intracardiac mass present:
    • on valve or supporting structures, or
    • in the path of regurgitant bloodstream flow, or
    • on implanted material, in the absence of an alternative anatomical explanation, or
  • (b) Abscess, or
  • (c) Newly identified partial dehiscence of prosthetic valve, or

 

• Positive blood culture for infective endocarditis
  • Persistently positive blood culture, defined as growth and identification of a microorganism consistent with IE originating from:
    • blood cultures that are obtained more than 12 hours apart, or
    • 3/3 or 3/4 or more separate blood cultures, with the first and last blood cultures obtained at least 60 minutes apart
    • Positive blood culture from 2 separate blood cul­tures or single +ve culture for Coxiella burnetti
  • · Evidence of endocarditis
  • Expected microorganisms for infective endocarditis from two separate blood cultures – viridans streptococci,* HACEK^†groups, Streptococcus bovis, or community-acquired Staphylococcus aureus or enterococci, without known primary focus, or

 

Minor

    1. Predisposing conditions present like valvular heart disease and h/o recent dental extraction 2. Fever> 100AF 3. Vascular phenomenon:

• Echocardiogram: findings may be consistent with IE, but major criteria as stated above are not met
• Major arterial emboli
• Septic pulmonary infarcts
• Mycotic aneurysms
• Intracranial haemorrhages
• Conjunctival haemorrhages
• Janeway’s lesions

4.Immunologic phenomenon:

• Immunological phenomena present: Roth spots, Osler’s nodes, glomerulonephritis, rheumatoid factor via laboratory analysis
• Glomerulonephritis
• Osler’s nodes
• Roth’s spots
• Rheumatoid factor

5. Microbiology:

• Vascular phenomena present: major arterial emboli, mycotic aneurysm, septic pulmonary infarcts, conjunctival haemorrhages, intracranial haemorrhage, Janeway lesions
• – Positive blood culture
• – Serology positive
• Microbiological evidence of IE: blood cultures are positive but major criteria are not met as previously described,^‡ or serological studies support an infection that is consistent with the diagnosis of IE

 

Application of Duke’s criteria

   

• 2 Major OR 5 minor OR 1 major and 3 minor criteria Should be present.
• Diagnosis is rejected if symptoms subside in 4 days of antibiotic treatment otherwise alternative diagnosis made.

• Standard antimicrobial therapy for infective endocarditis is generally administered to patients characterized as definite or probable by the Duke criteria.
• The diagnosis of infective endocarditis (IE) is usually based upon a constellation of history, clinical findings, laboratory studies etc.
• Treatment is appropriate antibiotic

Streptococcus bovis

• 1. Penicillin G – 2-3 million units 4 hrly for 4 wks.
• + Gentamycin 1 mg/kg 1M I IV 8 hrly for 2 wks .. OR
• 2. Ceftriaxone 2gm/d IV OD for 4 wks.
• OR
• 3. Vancomycin 15 mg/kg/IV 12-hourly for 4 wks.

Resistant Streptococci / Enterococci

• Penicillin G 3-4 million units (MU) 4-hourly
• + Gentamycin 1 mgjkg 1M j IV 8-hrly for 6 wks. OR
• 2. Ampicillin 2 9 IV 4 hly
• + Gentamycin 1 mgjkg IV 8-hrly for 4-6 wks. OR
• Vancomycin 15 mgjkg IV 12-hrly for 4-6 wks + Gentamycin 1 mgjkg IV 8-hrly for 4-6 wks.

Staphylococi

• Methicillin-susceptible strains
• 1. Nafcillin 2g IV 4 hly for 4-6 weeks
• + Gentamycin 1 mgjkg 1M j IV 8 hly for 3-5 days
• OR
• 2. Vancomycin 15 mgjkg 1M j IV 8 hrly for 4-6 wks
• Methicillin-resistant strains
• 1. Vancomycin, 15 mgjkg 1M j IV 8 hrly for 4-6 weeks

For Prosthetic Valve Endocarditis

• Nafcillin + Gentamycin + Rifampicin (300 mg OD 8 hrly) for 6 wks.

For Methicillin-resistant Prosthetic Valve en­docarditis

• Vancomycin + Genticin + Rifampicin

HACEK (Hemophilus, Actinobacilus, Cardiobac­terium, Eikenella, Kingella)

• Ceftriaxone 2 gm IV OD for 4 weeks.