Infective endocarditis pptx - D. Tahsin

INFECTIVE ENDOCARDITIS

INFECTIVE ENDOCARDITIS: DEFINITION

Microbial infection of the endothelial surface of the heart

Characteristic lesion: VEGETATION

IE: DEFINITION:VEGETATIONS

Mass of platelets and fibrin, rich in bacteria, scanty inflammatory cells

Sites: heart valves, septal defect, chordae tendineae or mural endocardium

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INFECTIVE ENDOCARDITIS: DEFINITION

Infection of arteriovenous shunts or PDA or coarctation of the aorta is called infective endarteritis, but clinically resembles IE
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INFECTIVE ENDOCARDITIS: DEFINITION

Causative organism: bacteria, fungi, and rickettsiae

Most frequent organisms: streptococci, staphylococci, enterococci, and fastidious gram-negative coccobacilli

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INFECTIVE ENDOCARDITIS: PATHOGENESIS
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Vegatations on the mitral valve

Vegetations on top of mitral stenosis

Vegetations on a biologic valve

IE: UNDERLYING HEART DISEASE

Cardiac lesions with low or no pressure gradients are unlikely to be complicated by IE e.g. ASD
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IE: MICRO-ORGANISMS

S. viridans
Enterococcus fecalis
Staphylococcus aureus
Coagulase negative Staphylococci
Gram-negative bacilli
Brucella
Rickettsia
Fungi

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CLINICAL MANIFESTATIONS
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IE: CLINICAL MANIFESTATIONS

IE: PERIPHERAL MANIFESTATIONS

Splinter hemorrhage
Osler’s nodes: subcutaneous nodules, tender

Osler’s nodes

Dermal infarcts

IE: EYE MANIFESTATIONS

Roth’s spots: on fundoscopy

IE: EYE MANIFESTATIONS

Subconjunctival hemorrhage
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IE: PERIPHERAL MANIFESTATIONS: THE EYE

Petechiae: conjunctiva, buccal mucosa, limbs

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Janeway’s lesions: macular non-tender lesions on the palms and soles:

Evanesent: appear and disappear rapidly

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CLINICAL MANIFESTATIONS

LOCAL DESTRUCTIVE EFFECTS

IE: SYSTEMIC EMBOLI
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IE: NEUROLOGICAL MANIFESTATIONS

Headache
Confusion
Convulsions
Long tract signs & focal neurological deficit
Meningeal irritation
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IE: RENAL MANIFESTATIONS

Glomerulonephritis
Focal renal infarcts: hematuria
Renal failure:
immune-complex deposition
Congestive heart failure
drug-induced
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IE: CLINICAL SETUP

depending on the clinical presentation:
Acute IE:
Subacute IE (SBE)
Postoperative IE: following cardiac surgery
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ACUTE IE

Caused by virulent organisms on top of normal heart:
Usually staphylococcus aureus
E.g. cannula infection, staphylococcal septicemia, drug abusers
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ACUTE IE

ACUTE IE: CLINICAL MANIFESTATIONS
Severe febrile illness
Petechiae
Embolic events common
Rapid progression of cardiac and renal failure

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SUBACUTE IE

Caused by infection with low-virulence organisms on top of pre-existing cardiac disease
Persistent fever, tiredness, weight loss, night sweats
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PROSTHETIC VALVE ENDOCARDITIS

IE following cardiac surgery
Early postoperative IE:
infection is acquired at the time of surgery
High mortality: repeat surgery often required
Late postoperative IE:
Community-acquired infection
Complication rates lower than early form
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IE: INVESTIGATIONS

Blood cultures
Echocardiography: transthoracic (TTE) and transesophageal (TEE)
Vegetations
Serial follow up
Valve damage
Abscess fromation

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Vegatations on the aortic valve

VEGETATIONS

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IE: INVESTIGATIONS

High ESR
Anemia of chronic disease
Neutrophil leucocytosis
CRP
Hematuria
Proteinuria
Low serum complement
Rheumatoid factor
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IE: INVESTIGATIONS

ECG:
Heart block
Bundle branch block
arrhythmia
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IE: TREATMENT

Combination antibiotic therapy according to culture & sensitivity
Empirical regimes pending the results of blood culture

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IE: TREATMENT

Large doses
Given intravenously
Protracted duration of therapy:
usually 4 weeks
6 weeks in PVE

Combination AB therapy

Benzyl penicillin or ampicillin i.v
Plus gentamycin

For penicillin resistant or allergic: vancomycin infusion plus gentamycin

Oral rifampicin when staphylococcal infection suspected or confirmed
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CARIAC SURGERY: INDICATIONS

Failure to respond to medical treatment
Heart failure due to valve insufficiency
Large vegetations
Abscess formation
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PREVENTION OF IE

Susceptible patients: those with valvular or congenital heart disease
Good dental hygiene
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PREVENTION OF IE

Avoidance of bacteremia
Antibiotic prophylaxis:
Dental manipulation
Genito-urinary tract catheterization or surgery

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PROPHYLAXIS

For dental procedures:
Oral amoxicillin given 30 min before and 6 hours after the procedure
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