Infective endocarditisInfective endocarditis

OverviewOverview

Infection of the endocardiumInfection of the endocardium Incidence :1/1000 hospital addmisionsIncidence :1/1000 hospital addmisions Risks :Structural heart Risks :Structural heart

disease,immunosupression,PPMs,prologed disease,immunosupression,PPMs,prologed cardiac surgery,redos,catheter based cardiac surgery,redos,catheter based infections,sternal wound infection.infections,sternal wound infection.

Mortality still 20 %Mortality still 20 %

Clinical presentationClinical presentation Acute with toxicity metastatic infection and Acute with toxicity metastatic infection and

progress over days to weeks .Subacute with progress over days to weeks .Subacute with progression over weeks to months with less progression over weeks to months with less toxicity and metastatic infection.toxicity and metastatic infection.

Fever and new murmur(85 %)Fever and new murmur(85 %) CHF 55%( more in AV 75 %)CHF 55%( more in AV 75 %) Neurological (embolic 20 %),encephalopathy10 Neurological (embolic 20 %),encephalopathy10

%,myctic aneurysm 5 %%,myctic aneurysm 5 % Petechia 20-40%,splinter haemmg.10-30 %,Osler Petechia 20-40%,splinter haemmg.10-30 %,Osler

nodes 10-25 %,Janeway lesions 5 %nodes 10-25 %,Janeway lesions 5 %Clubbing 10-20 %,splenomegaly 30-50 %,Roth Clubbing 10-20 %,splenomegaly 30-50 %,Roth

spots<5 %spots<5 %

Systemic embolisation 25 -50 % Systemic embolisation 25 -50 % depends on the respective organsdepends on the respective organs

Complications of IE

1. Heart failure (60%)

2. Abscesses (30%)

3. Embolism (30%)

4. Mortality (1O-20%)

EtiologyEtiology

70-75 % have valvular abnormalities70-75 % have valvular abnormalities Source of infection cannot always be Source of infection cannot always be

identifiedidentified

Infective Endocarditis: a changing disease

new high-risk subgroups

IVDA elderly intracardiac devices nosocomial diseases

more difficult to prevent more difficult to treat

Native valve endocarditisNative valve endocarditis

Step.(60%),S.aures(25 %),Strep.Bovis( GI Step.(60%),S.aures(25 %),Strep.Bovis( GI cansers),Enterococcus,HACEK(3%)cansers),Enterococcus,HACEK(3%)

Drug abusers ,usually S.aureus 60 %,less Drug abusers ,usually S.aureus 60 %,less severe disease ,usualyy TVsevere disease ,usualyy TV

Pseudomonas endocarditis is usually Pseudomonas endocarditis is usually destructive and needs surgery.destructive and needs surgery.

Strep pneumoniae ,1-3 % and in the Strep pneumoniae ,1-3 % and in the setting of alcaholismsetting of alcaholism

Congenital lesions:commoly Bicuspid Congenital lesions:commoly Bicuspid AV,PDA,VSD,Coarct. and TOFAV,PDA,VSD,Coarct. and TOF

Prothetic valve endocarditisProthetic valve endocarditis

10-20 % of all cases10-20 % of all cases Risk highest in the first 6/12Risk highest in the first 6/12 Similar incidence in mechanical and Similar incidence in mechanical and

bioprotheticbioprothetic Equal in AV and MVEqual in AV and MV Less 2/12 post op is early,usualyy Less 2/12 post op is early,usualyy

coagulase –ve staph.and S.aureuscoagulase –ve staph.and S.aureus Late has similar organisms to native IE,but Late has similar organisms to native IE,but

there is 10-15 % fungal endocarditis. there is 10-15 % fungal endocarditis.

PPM endocarditisPPM endocarditis

0.2-7 % ,mainly staph.0.2-7 % ,mainly staph.

CS negative endocarditisCS negative endocarditis

10 %10 % Usually due to prior antibiotic Usually due to prior antibiotic

therapytherapy Also fastiduous organisms Also fastiduous organisms

HACEK,Legionella,Coxiella,Bartonella,HACEK,Legionella,Coxiella,Bartonella,BrucellaBrucella

Non bacterial endocarditisNon bacterial endocarditis

PathophysiologyPathophysiology

Non bacterial thrombotic Non bacterial thrombotic endocarditis then with bacteraemia endocarditis then with bacteraemia becomes septic becomes septic

Impairement of valve function Impairement of valve function Conduction defectsConduction defects emboli emboli

LabsLabs

Basic- mainly an acute inflamatory Basic- mainly an acute inflamatory responseresponse

Blood C/SBlood C/S Histology and C/S of resected Histology and C/S of resected

specimensspecimens UrinalysisUrinalysis ECGECG CXRCXR

Imaging Imaging

TTE TTE TEETEE CT brain scanCT brain scan angiogramangiogram

Aortic Valve Brucella EndocarditisAortic Valve Brucella Endocarditis

Aortic Valve Brucella EndocarditisAortic Valve Brucella Endocarditis

TreatmentTreatment

MultidisciplinaryMultidisciplinary Patient and organism specific RX Patient and organism specific RX

neededneeded

Fungal endocarditisFungal endocarditis

Use ampho B and flucytosine ( toxic Use ampho B and flucytosine ( toxic to B. marrow and kidneysto B. marrow and kidneys

Almost always needs surgery .Almost always needs surgery . Long term oral prophylaxis is often Long term oral prophylaxis is often

given to prevent relapsegiven to prevent relapse

New guidelines 2009: timing of surgery

Vikram– JAMA 2003 ; 290 : 3207

513 patients with complicated IE , 230 (40%) surgical therapy513 patients with complicated IE , 230 (40%) surgical therapy 6 month mortality6 month mortality

Impact of surgery on mortalityImpact of surgery on mortality