Infective Endocarditis

• Infective endocarditis includes acute and

subacute bacterial endocarditis, as well as
nonbacterial endocarditis, caused by
viruses, fungi, and other microbiologic
agents.
Prevalence
• Infective endocarditis (excluding postoperative endocarditis) accounts for
0.5 to 1 of every1000 hospital admissions.

Pathogenesis
:Two factors are important in the pathogenesis of IE .1
(A) Damaged area of endothelium . (b) Bacteremia
 Almost all patients who develop IE have a history of .2
.congenital or acquired heart disease

All congenital heart defects, with the exception Of .3

secondum type (ASD), predispose to endocarditis

4. More frequently encountered defects are tetralogy of

Fallot (TOF), ventricular septal defect (VSD), aortic valve
disease, transposition of the great arteries (TGA), and
systemic to–pulmonary artery (PA) shunt.

3
Those with a prosthetic heart valve or prosthetic material in .5
the heart are at particularly high risk of developing
endocarditis. Patients with mitral valve prolapse (MVP) with
mitral regurgitation (MR) and those with rheumatic MR also
.are vulnerable to IE

Bacteremia resulting from dental procedures can cause IE. 6

4
Pathology
 Vegetation of IE is usually found on the low-pressure side of the defect, either around
the defect or on the opposite surface of the defect where endothelial damage is
established by the jet effect of the defect.

Microbiology
 In the past, Streptococcus viridans, enterococci, and Staph- ylococcus aureus were
responsible for more than 90% of the cases. In recent years, this frequency has
decreased to 50% to 60%, with a concomitant increase in cases caused by fungi and
HACEK organisms (Haemophilus, Actinobacil- lus, Cardiobacterium, Eikenella, and
Kingella spp.).

5 •
 HACEK organisms are particularly common in neonates and immu-
nocompromised children, accounting for 17% to 30% of cases.

 Alpha-hemolytic streptococci (S. viridans) are the most common

causes of endocarditis in patients who have had dental procedures

 Staphylococci (S. aureus and coagulase-negative staphylo- cocci)

account for more cases than S. viridans in developed countries.

 The organisms most commonly found in postoperative endocarditis

are staphylococci.

 IE associated with indwelling vascular catheters, prosthetic

material(staph aureus).

 Among newborn infants, S. aureus coagulase-negative

staphylococci (and Candida spp.) are the most common causes of
IE.
 Intravenous (IV) drug abusers are at risk for IE from S. aureus.

 Enterococci are the organisms most often found after genitourinary

(GU) or gastrointestinal (GI) surgery or instru- mentation

 Fungal endocarditis (which has a poor prognosis) may occur in sick

neonates, in patients who are on long-term antibiotic or steroid
therapy

 Culture-negative endocarditis.

• 8
Manifestations of Infective Endocarditis

• HISTORY
• Prior congenital or rheumatic heart disease
• Preceding dental, urinary tract, or intestinal
procedure
• Intravenous drug use
• Central venous catheter
• Prosthetic heart valve
• 9
Table 464.3 Manifestations of Infective Endocarditis

HISTORY
Prior congenital or rheumatic heart disease Preceding dental, urinary tract, or
intestinal procedure Intravenous drug use Central venous catheter Prosthetic heart
valve

SYMPTOMS
Fever
Chills
Chest and abdominal pain
Arthralgia, myalgia
Dyspnea
Malaise, weakness
Night sweats
Weight loss
CNS manifestations (stroke, seizures, headache)

SIGNS
Elevated temperature
Tachycardia
Embolic phenomena (Roth spots, petechiae, splinter nail bed
hemorrhages, Osler nodes, CNS or ocular lesions)
Janeway lesions
New or changing murmur
• Laboratory Studies

1. Positive blood cultures are found in more than 90% of patients in the
absence of previous antimicrobial therapy. Antimicrobial
pretreatment reduces the yield of positive blood culture to 50% to
60%.

2. A complete blood cell count shows anemia, ), and leukocytosis with a

shift to the left. ), and leukocytosis with a shift to the left

3. The sedimentation rate is increased unless there is polycythemia.

4. . Elevated C-reactive protein (CRP)

5. Microscopic hematuria is found in 30% of patients.

• Echocardiography
1. Two-dimensional echocardiography is the main modality for
detecting endocardial infection

2. Site of infection,

3. Extent of valvular damage,

4. Cardiac function Baseline evaluation of ventricular function and

cardiac chamber dimension is important for comparison later in the
course of the infection.
1. Certain echo findings are included as major criteria in the modified Duke criteria. They
include:

 Oscillating intra cardiac mass on valve or support ing structures, in the path of
regurgitation jets, or on implanted material
 Abscesses
 New partial dehiscence of prosthetic valve
 N ew valvular regurgitation

2. trans esophageal echocardiography (TEE) may be an important adjunct to TTE in

 the obese or very muscular adolescents
 in post-cardiac surgery patients
 in the presence of compromised respiratory function or pulmonary hyperinflation.
 in identifying vegetations on prosthetic valves,
 detecting complications of left ventricular (LV) outflow tract endo carditis (either
valvular or subvalvular)
 detecting aortic root abscess and involvement of sinus of Valsalva.
13
3. The absence of vegetations on echo does not in itself rule out IE. Both TTE and
TEE may produce false-negative results if vegetations are small or have already
embolized, and they may miss initial perivalvular abscess.

4. Conversely, a false-positive diagnosis is possible. An echogenic mass may

represent a sterile thrombus.

5. Certain echo features suggest a high risk case or a need for surgery
 Large vegetations (greatest risk when the vegetation is >10 mm)
 Severe valvular regurgitation
 A bscess cavities
 Pseudoaneurysm
 Valvular perforation or dehiscence
 Decompensated heart failure
13
Diagnosis

• American Heart Association (AHA) (Baddour et al, 2005)

recommended the modified Duke criteria in the diagnosis and
management of IE. The usefulness of the criteria has been
validated in clinical studies. There are three categories of
diagnostic possibilities using the modified Duke criteria: definite,
possible, and rejected

14
 Definition of Infective Endo carditis According to the Modified Duke Criteria
Definite Infective Endo carditis
A. Pathological criteria
1. Microorganisms demonstrated by culture or histologic examination of a
vegetation, a vegetation that has em bolized, or an intra cardiac abscess specimen
or
2. Pathological lesions; vegetation or intra cardiac abscess confirmed by histo logic
examination showing active endocarditis
B. Clinical criteria
2. Two major criteria or
2. One major criterion and three minor criteria or
3. Five minor criteria
Possible Infective Endocarditis
1. One major criterion and one minor criterion or
2. Three minor criteria
Rejected
1. Firm alternative diagnosis explaining evidence of IE or
2. Resolution of IE syndrome with antibiotic therapy for <4 days or
3. No pathological evidence of IE at surgery or autopsy, with antibiotic therapy for <4
days or
4. Does not meet criteria for possible IE as above
Definition of Terms Used in the Modified Duke Criteria for the Diagnosis of Infective
Endocarditis

Major Criteria
A. Blood culture positive for IE
1. Typical microorganisms consistent with IE from two separate blood
cultures: Viridans streptococci, Strepto- coccus bovis, HACEK group,
Staphylococcus aureus

2. `Microorganisms consistent with IE from persistently positive blood

cultures defined as follows: at least two positive cultures of blood
samples drawn >12 hr apart or all of three or a majority of four
separate cultures of blood (with first and last sample drawn at least
1 hr apart)

3. Single positive blood culture for Coxiella burnetii or anti phase 1 IgG
antibody titer >1:800
Definition of Terms Used in the Modified Duke Criteria for the Diagnosis of Infective
Endocarditis

Major Criteria
B. Evidence of endocardial involvement Echocardiogram positive for IE
(TEE recommended for patient with prosthetic valveIE”, or
complicated IE [paravalvular abscess]; TTE as first test in other
patients) defined as follows:

1. Oscillating intracardiac mass on valve or supporting struc tures, in

the path regurgitant jets, or on implanted material
2. Abscess.
4. New valvular regurgitation (worsening or changing or pre- existing
murmur not sufficient)
Definition of Terms Used in the Modified Duke Criteria for the Diagnosis of Infective
Endocarditis

Minor Criteria
1. predisposing heart condition, or IDUs
2. Fever, temperature >38°C
3. Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic
aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway’s
lesions
4. Immunologic phenomena: glomerulonephritis, Osler’s nodes, Roth’s spots, and
rheumatoid factor .

5. Microbiological evidence: positive blood culture but does not meet a major
criterion as noted above or serologic eV idence of active infection with organism
consistent with IE
Management
1. Blood cultures are indicated for all patients with fever of unexplained origin and a pathologic heart murmur, a
his tory of heart disease, or previous endocrditis.

a. Usually three blood cultures are drawn by separate venipunctures over 24 hours unless the patient is very
ill.

b. If there is no growth by the second day of incubation, two more may be obtained.

c. I t is not necessary to obtain the cultures at any particular phase of the fever cycle.

d. A dequate volume of blood must be obtained

e. A erobic incubation alone suffices because it is rare for IE to be caused by anaerobic bacteria

2. Initial empirical therapy is started with the following anti- biotics while awaiting the results of blood cultures.

a. Th e usual initial regimen is an antistaphylococcal semi- synthetic penicillin (nafcillin, oxacillin, or methicillin)
and an aminoglycoside (gentamicin).
 b. I f a methicillin-resistant S. aureus is suspected, vancomy- cin should be
substituted for the semisynthetic penicillin.

c. V ancomycin can be used in place of penicillin or a semisynthetic penicillin in

penicillin-allergic patients.

3. The final selection of antibiotics depends on the organism isolated and the results
of an antibiotic sensitivity test.

a. S treptococcal IE

1) I n general, native cardiac valve IE caused by a highly sensitive S. viridans can be

successfully treated with IV penicillin (or ceftriaxone given once daily) for 4 weeks.

2) IE caused by penicillin-resistant streptococci, 4 weeks of penicillin, ampicillin, or

ceftriaxone combined with gentamicin for the first 2 weeks is recommended.

b. S taphylococcal endocarditis
1) The drug of choice for native valve IE by methicil- lin-susceptible staphylococci is
one of the semisyn- thetic beta-lactamase-resistant penicillin (nafcillin, oxacillin,
and methicillin) for a minimum of 6 weeks (with or without gentamicin for the first
3–5 days).

2) 2) P atients with methicillin-resistant native valve IE are treated with vancomycin

for 6 weeks (with or without gentamicin for the first 3–5 days).

e. F ungal endocarditis (usually caused by Candida spp.) is very difficult to treat.

Amphotericin B, with or with- out Flucytosine, is the most often used

f. C ulture-negative endocarditis Treatment is directed against staphylococci,

streptococci, and the HACEK organisms using ceftriaxone and gentamicin.

5. Patients with prosthetic valve endocarditis should be treated for 6 weeks based on
the organism isolated and the results of the sensitivity test.
Prognosis
The overall recovery rate is 80% to 85%; it is 90% or better for S. viridans and
enterococci and about 50% for Staphylococcus organ- isms. Fungal endocarditis is
associated with a very poor outcome. Prevention
Procedures
c Regimens for Prophylactic
Adults children Agent Situation

2g 50 mg/kg Amoxicillin Oral

2 g (IM, IV) 50 mg/kg (IM, IV) Ampicillin, or Unable to take oral
1 g (IM, IV) medications
2g 50 mg/kg (IM, IV) Cefazolin or ceftriaxone
600 mg 50 mg/kg Cephalexina,b or Allergic to penicillin or
500 mg 20 mg/kg Clindamycin or ampicillin (PO)
500mg 15 mg/kg Azithromycin or
1 g (IM, IV) 15 mg/kg Clarithromycin
600 mg (IM, IV) 50 mg/kg (IM, IV) Cefazolin or ceftriaxone Allergic to penicillin or
20 mg/kg (IM, IV) Clindamycin ampicillin and unable to
take oral medication