Endocarditis Jim Czarnecki, D.O. Internal Medicine Lecture Series.

EndocarditisEndocarditis

Jim Czarnecki, D.O.Jim Czarnecki, D.O.

Internal Medicine Lecture Internal Medicine Lecture SeriesSeries

IntroductionIntroduction

BackgroundBackground

Defined as an infection of the Defined as an infection of the endocardial surface of the heart, endocardial surface of the heart, which may include one or more which may include one or more heart valves, the mural heart valves, the mural endocardium, or a septal defect.endocardium, or a septal defect.

Three types:Three types: Native valve (acute and subacute)Native valve (acute and subacute) Prosthetic valve (early and late)Prosthetic valve (early and late) Related to intravenous drug useRelated to intravenous drug use

Native Valve Native Valve EndocarditisEndocarditis


Usually has an aggressive courseUsually has an aggressive course Typical causative agents are Typical causative agents are

Staphlococcus aureusStaphlococcus aureus and group B and group B streptococci.streptococci.

Underlying structural valve disease Underlying structural valve disease may not be present.may not be present.

Subacute endocarditis usually has a Subacute endocarditis usually has a more indolent course than the acute more indolent course than the acute form. form.


Alpha-hemolytic streptococci or Alpha-hemolytic streptococci or enterococci, usually in the setting of enterococci, usually in the setting of underlying structural valve disease, underlying structural valve disease, typically are the causative agents of typically are the causative agents of this type of endocarditis.this type of endocarditis.

Prosthetic Valve Prosthetic Valve EndocarditisEndocarditis


Early prosthetic valve endocarditis Early prosthetic valve endocarditis occurs within 60 days of valve occurs within 60 days of valve implantation.implantation.

Staphylococci, gram-negative bacilli, Staphylococci, gram-negative bacilli, and Candida species are the and Candida species are the common infecting organisms.common infecting organisms.


Late prosthetic valve endocarditis Late prosthetic valve endocarditis occurs 60 days or more after valve occurs 60 days or more after valve implantation.implantation.

Alpha-hemolytic streptococci, Alpha-hemolytic streptococci, enterococci, and staphylococci are enterococci, and staphylococci are the common causative organisms.the common causative organisms.

Endocarditis and Endocarditis and IV Drug UseIV Drug Use

Endocarditis and IV Drug Endocarditis and IV Drug UseUse

Commonly involves the tricuspid Commonly involves the tricuspid valve.valve.

S. aureusS. aureus is the most common is the most common causative organism.causative organism.

PathophysiologyPathophysiology


Infective endocarditis generally occurs Infective endocarditis generally occurs as a consequence of nonbacterial as a consequence of nonbacterial thrombotic endocarditis, which results thrombotic endocarditis, which results from turbulence or trauma to the from turbulence or trauma to the endothelial surface of the heartendothelial surface of the heart

Transient bacteremia then leads to Transient bacteremia then leads to seeding of lesions with adherent seeding of lesions with adherent bacteria, and infective endocarditis bacteria, and infective endocarditis develops.develops.


Pathologic effects due to infection Pathologic effects due to infection can include local tissue destruction can include local tissue destruction and embolic phenomena.and embolic phenomena.

Secondary autoimmune effects, such Secondary autoimmune effects, such as immune complex as immune complex glomerulonephritis and vasculitis, glomerulonephritis and vasculitis, can occur.can occur.

FrequencyFrequency

FrequencyFrequency

In the US: Incidence is 1.4 to 4.2 In the US: Incidence is 1.4 to 4.2 cases per 100,000 people per year.cases per 100,000 people per year.

Internationally: Incidence of disease Internationally: Incidence of disease appears to be similar throughout the appears to be similar throughout the developed world.developed world.

Mortality / Mortality / MorbidityMorbidity

Mortality / MorbidityMortality / Morbidity

Increased mortality rates are associated Increased mortality rates are associated with: with: Increased ageIncreased age Infection involving the aortic valveInfection involving the aortic valve Development of congestive heart failureDevelopment of congestive heart failure Central nervous system (CNS) complicationsCentral nervous system (CNS) complications Underlying diseaseUnderlying disease

Mortality rates also vary with the Mortality rates also vary with the infecting organism.infecting organism.

Mortality / MorbidityMortality / Morbidity

Mortality rates in native valve Mortality rates in native valve disease range from 16-27%disease range from 16-27%

Mortality rates in patients with Mortality rates in patients with prosthetic valve infections are prosthetic valve infections are higher.higher.

More than 50% of these infections More than 50% of these infections occur within 2 months after surgery.occur within 2 months after surgery.

Gender / AgeGender / Age

Gender / AgeGender / Age

Gender:Gender: The male-to-female ratio is The male-to-female ratio is

approximately 2:1approximately 2:1

Age:Age: Can occur at any ageCan occur at any age Mean age of patients has gradually Mean age of patients has gradually

risen over the past 50 yearsrisen over the past 50 years Currently, more than 50% of patients Currently, more than 50% of patients

are older than 50 years of age.are older than 50 years of age.

Clinical AspectsClinical Aspects

HistoryHistory

HistoryHistory

Present illness history is highly Present illness history is highly variable.variable.

Symptoms are commonly:Symptoms are commonly: VagueVague Emphasize constitutional complaintsEmphasize constitutional complaints May focus on primary cardiac effectsMay focus on primary cardiac effects Secondary embolic phenomenaSecondary embolic phenomena

HistoryHistory

May present with signs of congestive May present with signs of congestive heart failure (due to valvular heart failure (due to valvular insufficiency)insufficiency)

Secondary phenomena could include Secondary phenomena could include focal neurological complaints due to:focal neurological complaints due to: Embolic strokeEmbolic stroke Back pain associated with vertebral Back pain associated with vertebral

osteomyelitisosteomyelitis Fever and chills are the most common Fever and chills are the most common

symptoms.symptoms.

History (Other)History (Other)

Other common Other common complaints complaints include:include: AnorexiaAnorexia Weight lossWeight loss MalaiseMalaise HeadacheHeadache MyalgiasMyalgias

Additional common Additional common complaints complaints include:include: Night sweatsNight sweats Shortness of breathShortness of breath CoughCough Joint painsJoint pains

PhysicalPhysical

PhysicalPhysical

Fever, either low-grade or intermittent, is Fever, either low-grade or intermittent, is present in 90% of patients.present in 90% of patients.

Heart murmurs are heard in Heart murmurs are heard in approximately 85% of patients.approximately 85% of patients.

Signs of neurologic disease occur in as Signs of neurologic disease occur in as many as 40% of patients. many as 40% of patients.

Embolic stroke with focal neurologic Embolic stroke with focal neurologic deficits is the most common etiology. deficits is the most common etiology. Others can be intracerebral hemorrhage Others can be intracerebral hemorrhage and multiple microabscesses.and multiple microabscesses.

PhysicalPhysical

Signs of systemic septic emboli are Signs of systemic septic emboli are due to left heart disease and are due to left heart disease and are more commonly associated with more commonly associated with mitral valve vegetations.mitral valve vegetations.

Multiple congestive heart failure Multiple congestive heart failure signs, such as distended neck veins, signs, such as distended neck veins, are frequently due to acute left-sided are frequently due to acute left-sided valvular insufficiency.valvular insufficiency.

PhysicalPhysical Classic signs of infective endocarditis are Classic signs of infective endocarditis are

found in as many as 50% of patients. They found in as many as 50% of patients. They include:include: PetechiaePetechiae – common by nonspecific finding – common by nonspecific finding Splinter hemorrhagesSplinter hemorrhages – dark red linear lesions – dark red linear lesions

in the nailbedsin the nailbeds Osler nodesOsler nodes – Tender subcuaneous nodules – Tender subcuaneous nodules

usually found on the distal pads of the digitsusually found on the distal pads of the digits Janeway lesionsJaneway lesions – Nontender maculae on the – Nontender maculae on the

palms and solespalms and soles Roth spotsRoth spots – Retinal hemorrhages with small, – Retinal hemorrhages with small,

clear centers; rare and observed in only 5% of clear centers; rare and observed in only 5% of patients.patients.

PetechiaePetechiae

Splinter HemorrhagesSplinter Hemorrhages

Osler NodesOsler Nodes

Osler NodesOsler Nodes

Janeway lesionsJaneway lesions

Roth SpotsRoth Spots

Physical (Other)Physical (Other)

Other findings:Other findings: SplenomegalySplenomegaly Stiff neckStiff neck DeliriumDelirium ParalysisParalysis HemiparesisHemiparesis AphasiaAphasia Conjunctival Conjunctival

hemorrhagehemorrhage

Additional Additional findings:findings: PallorPallor GallopsGallops RalesRales Cardiac arrhythmiaCardiac arrhythmia Pericardial rubPericardial rub Pleural friction rubPleural friction rub

CausesCauses

Causes: Native Causes: Native ValveValve

Causes: Native ValveCauses: Native Valve

Rheumatic valvular disease (30%) – Rheumatic valvular disease (30%) – primarily involves the mitral valve primarily involves the mitral valve followed by the aortic valve.followed by the aortic valve.

Congenital heart disease (15%) – Congenital heart disease (15%) – include patent ductus arteriosus, include patent ductus arteriosus, ventricular septal defect, tetralogy ventricular septal defect, tetralogy of Fallotof Fallot

Mitral valve prolapse with Mitral valve prolapse with associated murmur (20%)associated murmur (20%)

Causes: Native ValveCauses: Native Valve Degenerative heart disease – includes Degenerative heart disease – includes

calcific aortic stenosis due to bicuspid calcific aortic stenosis due to bicuspid valve, Marfan syndrome, or syphilitic valve, Marfan syndrome, or syphilitic diseasedisease

Approximately 70% of cases are caused Approximately 70% of cases are caused by Streptococcus species including by Streptococcus species including Streptococcus viridansStreptococcus viridans, , Streptococcus Streptococcus bovisbovis, and enterococci., and enterococci.

StaphlococcusStaphlococcus species cause 25% of species cause 25% of cases and generally demonstrate a more cases and generally demonstrate a more aggressitve acute course.aggressitve acute course.

Causes: Prosthetic Causes: Prosthetic ValveValve

Causes: Prosthetic ValveCauses: Prosthetic Valve Early disease, presenting shortly after Early disease, presenting shortly after

surgery, has a different bacteriology and surgery, has a different bacteriology and prognosis than late disease, which prognosis than late disease, which presents in a subacute fashion similar to presents in a subacute fashion similar to native valve endocarditis.native valve endocarditis.

Infection associated with aortic valve Infection associated with aortic valve prostheses is particularly associated with prostheses is particularly associated with local abscess and fistula formation.local abscess and fistula formation.

This may lead to heart block, shunting of This may lead to heart block, shunting of blood to the right atrium, or pericardial blood to the right atrium, or pericardial tamponade.tamponade.

Causes: Prosthetic ValveCauses: Prosthetic Valve

Endocarditis can occur in Endocarditis can occur in association with intravascular association with intravascular devices.devices.

Infection that occurs early after Infection that occurs early after surgery may be caused by a variety surgery may be caused by a variety of pathogens, including of pathogens, including S. aureusS. aureus and and S. epidermidisS. epidermidis. .

Late disease is most commonly Late disease is most commonly caused by streptococci.caused by streptococci.

Causes: IV Drug Causes: IV Drug UseUse

Causes: IV Drug UseCauses: IV Drug Use

Most commonly involves the tricuspid Most commonly involves the tricuspid valve, followed by the aortic valve.valve, followed by the aortic valve.

Two thirds of patients have no previous Two thirds of patients have no previous history of heart disease and no murmur history of heart disease and no murmur on admission.on admission.

Diagnosis of endocarditis in Diagnosis of endocarditis in intravenous drug users can be difficult intravenous drug users can be difficult and requires a high index of suspicion.and requires a high index of suspicion.

Causes: IV Drug UseCauses: IV Drug Use

S. aureusS. aureus is the most common is the most common (<50% of cases) etiologic organism. (<50% of cases) etiologic organism. Other causative organisms include Other causative organisms include streptococci, fungi, and gram-streptococci, fungi, and gram-negative rods (eg. Pseudomonads, negative rods (eg. Pseudomonads, SerratiaSerratia species). species).

Causes: Fungal Causes: Fungal EndocarditisEndocarditis

Found in intravenous drug users and Found in intravenous drug users and intensive care unit patients who intensive care unit patients who receive broad-spectrum antibiotics.receive broad-spectrum antibiotics.

Blood cultures are often negative, Blood cultures are often negative, and diagnosis frequently is made and diagnosis frequently is made after microscopic examination of after microscopic examination of large emboli.large emboli.

Causes: DiagnosisCauses: Diagnosis

Usually made using Duke Criteria Usually made using Duke Criteria ((link is on IM websitelink is on IM website). Major ). Major criteria include:criteria include: Multiple positive blood cultures for the Multiple positive blood cultures for the

infecting organisminfecting organism Echocardiographic evidence of Echocardiographic evidence of

endocardial involvement or a new endocardial involvement or a new regurgitant murmur on physical regurgitant murmur on physical examinationexamination

DifferentialsDifferentials

DifferentialsDifferentials

Connective tissue diseaseConnective tissue disease Fever of unknown originFever of unknown origin Intra-abdominal infectionsIntra-abdominal infections Septic pulmonary infectionSeptic pulmonary infection Tricuspid regurgitationTricuspid regurgitation

WorkupWorkup

Lab StudiesLab Studies

Send baseline studies:Send baseline studies: CBCCBC ElectrolytesElectrolytes CreatinineCreatinine BUNBUN GlucoseGlucose Coagulation PanelCoagulation Panel


Two sets of blood cultures have greater Two sets of blood cultures have greater than 90% sensitivity when bacteremia is than 90% sensitivity when bacteremia is present.present.

Anemia of chronic disease is common in Anemia of chronic disease is common in subacute endocarditissubacute endocarditis

ESR, while not specific, is elevated in ESR, while not specific, is elevated in more than 90% of cases.more than 90% of cases.

Proteinuria and microscopic hematuria Proteinuria and microscopic hematuria are present in approximately 50% of are present in approximately 50% of cases.cases.


Leukocytosis is observed in acute Leukocytosis is observed in acute endocarditisendocarditis

Anemia is present in subacute Anemia is present in subacute endocarditis.endocarditis.

Rheumatoid factor is noted in subacute Rheumatoid factor is noted in subacute endocarditis.endocarditis.

Serology for Serology for ChlamydiaChlamydia, Q fever , Q fever ((CoxiellaCoxiella), and ), and BartonellaBartonella may be may be useful in culture-negative endocarditis.useful in culture-negative endocarditis.

Imaging StudiesImaging Studies

EchocardiographyEchocardiography Transthoracic echocardiography has Transthoracic echocardiography has

a sensitivity of approximately 60%.a sensitivity of approximately 60%. Transesophageal echocardiography Transesophageal echocardiography

has a sensitivity of more than 90% has a sensitivity of more than 90% for valvular lesions.for valvular lesions.

Both techniques are highly specific Both techniques are highly specific for valvular vegetations.for valvular vegetations.

Vegetation on Mitral Vegetation on Mitral ValveValve


Imaging studies are particularly indicated Imaging studies are particularly indicated with culture-negative cases, such as in fungal with culture-negative cases, such as in fungal endocarditis.endocarditis.

Echocardiography is highly useful to assess Echocardiography is highly useful to assess local complications, such as abscesses.local complications, such as abscesses.

Chest radiography: Pulmonary embolic Chest radiography: Pulmonary embolic phenomena strongly suggest tricuspid phenomena strongly suggest tricuspid disease.disease.

Ventilation/perfusion (V/Q) scanning: This may Ventilation/perfusion (V/Q) scanning: This may be useful in right-sided endocarditis.be useful in right-sided endocarditis.

CT scanning: helpful in localizing abscesses.CT scanning: helpful in localizing abscesses.


EKG:EKG: Nonspecific changes are commonNonspecific changes are common First-degree AV block and new First-degree AV block and new

interventricular conduction delays may interventricular conduction delays may signal septal involvement in aortic valve signal septal involvement in aortic valve disease; both are poor prognostic signs.disease; both are poor prognostic signs.

Cardiac catheterization – indicated Cardiac catheterization – indicated to determine the degree of valvular to determine the degree of valvular damage.damage.

TreatmentTreatment

TreatmentTreatment

Focus is on making the correct diagnosis Focus is on making the correct diagnosis and stabilizing the patient with acute and stabilizing the patient with acute disease and cardiovascular instabilitydisease and cardiovascular instability

Most cases the etiologic microbial agent Most cases the etiologic microbial agent is not knownis not known

General recommendations: three (3) sets General recommendations: three (3) sets of blood cultures over a few hours, and of blood cultures over a few hours, and then empiric antibiotic therapy may be then empiric antibiotic therapy may be administered.administered.

TreatmentTreatment

General Measures:General Measures: Treatment of congestive heart failureTreatment of congestive heart failure OxygenOxygen Hemodialysis (may be required in Hemodialysis (may be required in

patients with renal failure)patients with renal failure) Consultations:Consultations:

CardiologyCardiology Cardiothoracic Surgery ServiceCardiothoracic Surgery Service Infectious Diseases ServiceInfectious Diseases Service

MedicationMedication


Empiric antibiotic therapy is chosen Empiric antibiotic therapy is chosen based on the most likely infecting based on the most likely infecting organism.organism.

Native valve disease usually is treated Native valve disease usually is treated with penicillin G and gentamicin for with penicillin G and gentamicin for synergistic treatment of streptococci.synergistic treatment of streptococci.

Patients with history of IV drug use – Patients with history of IV drug use – treated with nafcillin and gentamicin to treated with nafcillin and gentamicin to cover methicillin-sensitive cover methicillin-sensitive straphylococci.straphylococci.


Infection of a prosthetic valve may Infection of a prosthetic valve may include methicillin-resistant include methicillin-resistant Staphylococcus aureus – thus Staphylococcus aureus – thus vancomycin and gentamicin may be vancomycin and gentamicin may be used.used.

Rifampin also may be helpful in patients Rifampin also may be helpful in patients with prosthetic valves or other foreign with prosthetic valves or other foreign bodies; however, it should be used in bodies; however, it should be used in addition to vancomycin or gentamicin. addition to vancomycin or gentamicin.

Follow-upFollow-up

Deterrence / PreventionDeterrence / Prevention

Consider prophylaxis against Consider prophylaxis against infective endocarditis in patients at infective endocarditis in patients at high risk:high risk: Presence of prosthetic heart valvePresence of prosthetic heart valve History of endocarditisHistory of endocarditis History of rheumatic heart diseaseHistory of rheumatic heart disease Congenital heart disease with a high-Congenital heart disease with a high-

pressure gradient lesion and mitral pressure gradient lesion and mitral valve prolapse with a heart murmurvalve prolapse with a heart murmur


The presence of coronary artery The presence of coronary artery stenting is not considered to place stenting is not considered to place the patient at high risk for the patient at high risk for endocarditis.endocarditis.


Consider prophylaxis in patients before Consider prophylaxis in patients before they undergo procedures that may they undergo procedures that may cause transient bacteremia, such as:cause transient bacteremia, such as: Ear, nose, and throat (ENT) procedures Ear, nose, and throat (ENT) procedures

associated with bleeding, including dental associated with bleeding, including dental manipulations and nasal packingmanipulations and nasal packing

Incision and drainage of an abscessIncision and drainage of an abscess Anoscopy and Foley catheter placement Anoscopy and Foley catheter placement

when a urinary tract infection is present or when a urinary tract infection is present or suspectedsuspected

ComplicationsComplications

ComplicationsComplications Myocardial infarction, pericarditis, cardiac Myocardial infarction, pericarditis, cardiac

arrhythmiaarrhythmia Cardiac valvular insuffiencyCardiac valvular insuffiency Congestive heart failureCongestive heart failure Sinus of Valsalva aneurysmSinus of Valsalva aneurysm Aortic root or myocardial abscessesAortic root or myocardial abscesses Arterial emboli, infarcts, mycotic aneurysmsArterial emboli, infarcts, mycotic aneurysms Arthritis, myositisArthritis, myositis Glomerulonephritis; acute renal failureGlomerulonephritis; acute renal failure Stroke syndromesStroke syndromes Mesenteric or splenic abscess or infarctMesenteric or splenic abscess or infarct

PrognosisPrognosis

PrognosisPrognosis

Acute endocarditis due to Acute endocarditis due to S. aureusS. aureus is is associated with a high mortality rate associated with a high mortality rate (40%), except when it is associated (40%), except when it is associated with IV drug use.with IV drug use.

Endocarditis due to streptococci has a Endocarditis due to streptococci has a mortality rate of approximately 10%.mortality rate of approximately 10%.

Prognosis largely depends on whether Prognosis largely depends on whether or not complications develop.or not complications develop.

Competency Competency ExamExam

Question OneQuestion One

1) Signs of systemic septic emboli are 1) Signs of systemic septic emboli are associated with:associated with:

A)A) Pulmonic valve vegetationsPulmonic valve vegetations

B)B) Mitral valve vegetationsMitral valve vegetations

C)C) Tricuspid valve vegetationsTricuspid valve vegetations

D)D) Aortic valve vegetationsAortic valve vegetations

E)E) All valves of the heartAll valves of the heart

Question OneQuestion One

1) Signs of systemic septic emboli are 1) Signs of systemic septic emboli are associated with:associated with:

A)A) Pulmonic valve vegetationsPulmonic valve vegetations

B)B) Mitral valve vegetationsMitral valve vegetations

C)C) Tricuspid valve vegetationsTricuspid valve vegetations

D)D) Aortic valve vegetationsAortic valve vegetations

E)E) All valves of the heartAll valves of the heart

Question TwoQuestion Two

2) All are true of IV drug use-induced 2) All are true of IV drug use-induced endocarditis, except:endocarditis, except:

A)A) Involves tricuspid valveInvolves tricuspid valve

B)B) Involves the aortic valveInvolves the aortic valve

C)C) Can be difficult to diagnosisCan be difficult to diagnosis

D)D) Streptococci species is usually the Streptococci species is usually the etiologic organismetiologic organism

E)E) There is usually no murmur on There is usually no murmur on admission.admission.

Question TwoQuestion Two

2) All are true of IV drug use-induced 2) All are true of IV drug use-induced endocarditis, except:endocarditis, except:

A)A) Involves tricuspid valveInvolves tricuspid valve

B)B) Involves the aortic valveInvolves the aortic valve

C)C) Can be difficult to diagnosisCan be difficult to diagnosis

D)D) Streptococci species is usually the Streptococci species is usually the etiologic organismetiologic organism

E)E) There is usually no murmur on There is usually no murmur on admission.admission.

Question ThreeQuestion Three

3) Pulmonay embolic phenomena 3) Pulmonay embolic phenomena strongly suggest:strongly suggest:

A)A) Pulmonic valve diseasePulmonic valve disease

B)B) Mitral valve diseaseMitral valve disease

C)C) Tricuspid valve diseaseTricuspid valve disease

D)D) Aortic valve diseaseAortic valve disease

E)E) Does not involve any heart valvesDoes not involve any heart valves

Question ThreeQuestion Three

3) Pulmonay embolic phenomena 3) Pulmonay embolic phenomena strongly suggest:strongly suggest:

A)A) Pulmonic valve diseasePulmonic valve disease

B)B) Mitral valve diseaseMitral valve disease

C)C) Tricuspid valve diseaseTricuspid valve disease

D)D) Aortic valve diseaseAortic valve disease

E)E) Does not involve any heart valvesDoes not involve any heart valves

End of LectureEnd of Lecture

Thank you for your Thank you for your attendance.attendance.

This lecture will be made This lecture will be made available at the Internal available at the Internal

Medicine Residency website:Medicine Residency website:

http://IM.official.wshttp://IM.official.ws

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Endocarditis Jim Czarnecki, D.O. Internal Medicine Lecture Series.

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