Infective Endocarditis

Goals for Today

Recognize the risk factors, signs, and
symptoms of infectious endocarditis.
Understand the many approaches to
diagnosing infectious endocarditis.
Appreciate the necessity of rapid
treatment.
Anticipate possible complications.
Bring it all together with an actual patient
case!
 For Another Day…..
Pediatric infective endocarditis
Specifics of nosocomial and prosthetic
valve infective endocarditis
Specifics of treatment
Antibiotic prophylaxis
 Definition
Infectious Endocarditis (IE): an infection of
the heart’s endocardial surface
Classified into four groups:
– Native Valve IE
– Prosthetic Valve IE
– Intravenous drug abuse (IVDA) IE
– Nosocomial IE
 Further Classification
Acute Subacute
– Affects normal heart – Often affects damaged
valves heart valves
– Rapidly destructive – Indolent nature
– Metastatic foci – If not treated, usually
– Commonly Staph. fatal by one year
– If not treated, usually
fatal within 6 weeks
 Pathophysiology
1. Turbulent blood flow disrupts the
endocardium making it “sticky”
2. Bacteremia delivers the organisms to
the endocardial surface
3. Adherence of the organisms to the
endocardial surface
4. Eventual invasion of the valvular
leaflets
 Epidemiology
Incidence difficult to ascertain and varies
according to location
Much more common in males than in
females
May occur in persons of any age and
increasingly common in elderly
Mortality ranges from 20-30%
 Risk Factors
Intravenous drug abuse
Artificial heart valves and pacemakers
Acquired heart defects
– Calcific aortic stenosis
– Mitral valve prolapse with regurgitation
Congenital heart defects
Intravascular catheters
 Infecting Organisms
Common bacteria
– S. aureus
– Streptococci
– Enterococci
Not so common bacteria
– Fungi
– Pseudomonas
– HACEK
 Symptoms
Acute Subacute
– High grade fever and – Low grade fever
chills – Anorexia
– SOB – Weight loss
– Arthralgias/ myalgias – Fatigue
– Abdominal pain – Arthralgias/ myalgias
– Pleuritic chest pain – Abdominal pain
– Back pain – N/V

The onset of symptoms is usually ~2 weeks or less

from the initiating bacteremia
 Signs
Fever
Heart murmur
Nonspecific signs – petechiae, subungal
or “splinter” hemorrhages, clubbing,
splenomegaly, neurologic changes
More specific signs - Osler’s Nodes,
Janeway lesions, and Roth Spots
 Petechiae
1. Nonspecific
2. Often located on extremities
or mucous membranes
dermatology.about.com/.../
blpetechiaephoto.htm

Harden Library for the Health Sciences

Photo credit, Josh Fierer, M.D. www.lib.uiowa.edu/ hardin/
medicine.ucsd.edu/clinicalimg/ Eye-Petechiae.html md/cdc/3184.html
 Splinter Hemorrhages

1. Nonspecific
2. Nonblanching
3. Linear reddish-brown lesions found under the nail bed
4. Usually do NOT extend the entire length of the nail
 Osler’s Nodes
American College of Rheumatology
webrheum.bham.ac.uk/.../ default/pages/3b5.htm www.meddean.luc.edu/.../
Hand10/Hand10dx.html

1. More specific
2. Painful and erythematous nodules
3. Located on pulp of fingers and toes
4. More common in subacute IE
 Janeway Lesions

1. More specific
2. Erythematous, blanching macules
3. Nonpainful
4. Located on palms and soles
 The Essential Blood Test
Blood Cultures
– Minimum of three blood cultures1
– Three separate venipuncture sites
– Obtain 10-20mL in adults and 0.5-5mL in children2

Positive Result
– Typical organisms present in at least 2 separate samples
– Persistently positive blood culture (atypical organisms)
Two positive blood cultures obtained at least 12 hours apart
Three or a more positive blood cultures in which the first and
last samples were collected at least one hour apart
 Additional Labs
CBC
ESR and CRP
Complement levels (C3, C4, CH50)
RF
Urinalysis
Baseline chemistries and coags
 Imaging
Chest x-ray
– Look for multiple focal infiltrates and
calcification of heart valves
EKG
– Rarely diagnostic
– Look for evidence of ischemia, conduction
delay, and arrhythmias
Echocardiography
Indications for Echocardiography
Transthoracic echocardiography (TTE)
– First line if suspected IE
– Native valves
Transesophageal echocardiography (TEE)
– Prosthetic valves
– Intracardiac complications
– Inadequate TTE
– Fungal or S. aureus or bacteremia
 Making the Diagnosis
Pelletier and Petersdorf criteria (1977)
– Classification scheme of definite, probable, and possible IE
– Reasonably specific but lacked sensitivity
Von Reyn criteria (1981)
– Added “rejected” as a category
– Added more clinical criteria
– Improved specificity and clinical utility
Duke criteria (1994)
– Included the role of echocardiography in diagnosis
– Added IVDA as a “predisposing heart condition”
 Modified Duke Criteria
Definite IE
– Microorganism (via culture or histology) in a valvular vegetation,
embolized vegetation, or intracardiac abscess
– Histologic evidence of vegetation or intracardiac abscess

Possible IE
– 2 major
– 1 major and 3 minor
– 5 minor

Rejected IE
– Resolution of illness with four days or less of antibiotics
 Treatment
Parenteral antibiotics
– High serum concentrations to penetrate
vegetations
– Prolonged treatment to kill dormant bacteria
clustered in vegetations
Surgery
– Intracardiac complications
Surveillance blood cultures
 Complications
Four etiologies
– Embolic
– Local spread of infection
– Metastatic spread of infection
– Formation of immune complexes –
glomerulonephritis and arthritis
 Embolic Complications
Occur in up to 40% of patients with IE
Predictors of embolization
– Size of vegetation
– Left-sided vegetations
– Fungal pathogens, S. aureus, and Strep.
Bovis
Incidence decreases significantly after
initiation of effective antibiotics
 Embolic Complications
Stroke
Myocardial Infarction
– Fragments of valvular vegetation or
vegetation-induced stenosis of coronary ostia
Ischemic limbs
Hypoxia from pulmonary emboli
Abdominal pain (splenic or renal infarction)
Septic Pulmonary Emboli

http://www.emedicine.com/emerg/topic164.htm
Septic Retinal Embolus
 Local Spread of Infection
Heart failure
– Extensive valvular damage
Paravalvular abscess (30-40%)
– Most common in aortic valve, IVDA, and S. aureus
– May extend into adjacent conduction tissue causing
arrythmias
– Higher rates of embolization and mortality
Pericarditis
Fistulous intracardiac connections
 Local Spread of Infection

Acute S. aureus IE with perforation of the Acute S. aureus IE with mitral valve ring
aortic valve and aortic valve vegetations. abscess extending into myocardium.
Metastatic Spread of Infection
Metastatic abscess
– Kidneys, spleen, brain, soft tissues
Meningitis and/or encephalitis
Vertebral osteomyelitis
Septic arthritis
 Poor Prognostic Factors
Female Diabetes mellitus
S. aureus Low serum albumen
Vegetation size Apache II score
Aortic valve Heart failure
Prosthetic valve Paravalvular abscess
Older age Embolic events
 What do these patients
have in common?
Pt. A: 65 y/o female with PMH of
esophageal cancer who presents to clinic
with deyhdration, cough, SOB, and
“oozing” near her mediport site.

Pt. B: 30 y/o male IVDA with a several

weeks of fatigue and low grade fevers.

Pt. C: 24 y/o female IVDA with severe

N/V/abd pain and fevers up to 104 for two
weeks. Pt also c/o cough with DOE.
All these patients have
MRSA endocarditis!
 Patients A, B, and C
Try to classify each patient’s IE.

Which of these patients likely has acute

IE? Which has subacute IE?

What was the likely etiology of each

patient’s bacteremia?
 Patient C: History
2 wks of high fever, cough, green sputum,
and DOE.
2 wks of N/V (5x/day), diarrhea (20x/day),
and diffuse abdominal pain.
Diagnosed with PNA after a (-) LP and (+)
CXR and an outside ER. Given PO abx
but didn’t fill Rx.
Last IVDA 3 wks ago.
 Patient C: History

Which symptoms does Patient C have that

suggest IE?

Does Patient C have any symptoms you

can’t explain?
 Patient C: Exam
Vitals: T 104.7, BP 100/50, HR 130, RR 48, 94%
on 3L FM
Pale, distressed
Petechia to palate, dry mucus membranes
2/6 SEM at 4th intercostal space with radiation to
axilla
Diffuse wheezing and crackles
Diffuse abdominal pain and right flank pain
without rebound or guarding
Multiple track marks, otherwise neg. skin exam
 Patient C: Exam

Which signs does Patient C exhibit that

suggest IE?

Does Patient C have any signs you can’t

explain?
 Patient C: Labs
WBC 20, H/H of 9/27, Platelets 66
pH 7.45, pO2 54, pCO2 27
Albumen 1.7
UA: 2+ protein,3+ blood
EKG: WNL except sinus tachycardia
CXR: enlarged right heart, bilateral
infiltrates with nodularity
Chest CT: multiple pulmonary abscesses
 Patient C: Labs

Can you explain these results?

Are there other lab values you would like

to know?
 Patient C: Diagnosis
Blood Cx: three out of three bottles grew MRSA.

Initial TTE: tricuspid valve not well visualized but

severe regurg. with PA systolic pressure of 55
mmHg.

Repeat TTE (~2 wks after coding!): oscillating

mass on at least two leaflets of tricuspid valve
that prolapse into R atrium during systole as well
as thickened pulmonary valve with possible
vegetation.
 Patient C: Diagnosis

What major Duke criteria does Patient C

meet?

What minor Duke criteria does Patient C

meet?
 Patient C: Today
s/p chest tube with removal
2 separate episodes of respiratory failure with
intubation (now extubated)
1 episode of V. fib with cardioversion and a
lidocaine gtt. (now weaned off after 1 episode of
lidocaine toxicity)
CT surgery evaluated the pt and felt she wasn’t
a surgical candidate.
She is currently still requiring 3L oxygen and c/o
N/V and SOB on telemetry.
 Summary
IVDA and the elderly are at greatest risk of
developing IE.
The signs and symptoms of IE are
nonspecific and varied.
A thorough but timely evaluation (including
serial blood cultures, adjunct labs, and an
echo) is crucial to accurately diagnose and
treat IE.
Beware of life-threatening complications.
 References

Sexton, D.J., Infective endocarditis: Epidemiology and risk factors.

Up To Date (updated September 2, 2005)
Brusch, J.L., Infective Endocarditis. eMedincine (updated August
15, 2005) www.emedicine.com.
Sexton, D.J., Diagnostic approach to infective endocarditis. Up To
Date (updated September 7, 2005) www.uptodate.com.
Sexton, D.J., Corey, G.F., Infective endocarditis:Historical and Duke
Criteria. Up To Date (updated August 29, 2005) www.uptodate.com.
Spelman, D., Sexton D.J., Complications of infective endocarditis.
Up To Date (updated September 7, 2005)
Cohen & Powderly: Infectious Diseases, 2nd ed., Copyright © 2004
Mosby; pp. 653-665.
Zipes: Braunwald's Heart Disease: A Textbook of Cardiovascular
Medicine, 7th ed., Copyright © 2005 Saunders, pp. 1633-1654.