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Infective endocarditis: infection of the endothelium of the endocardial surfaceinner tissue of the heart- , mostly the valves but it can be anywhere where we
have a septal defect.
-Infective endocarditis is classified into acute and subacute according to the onset
of the symptoms
if a patient came with a fever for more than 2 months this is subacute and slowly
endocarditis
-another classification is according to the valve; native or prosthetic valve.
-Infective endocarditis is uncommon
-it happens more in the left side than the right and more in the prosthetic valves
than the native (mostly the prosthetic valve has more severe infection ).
-right sided infective endocarditis is more common in IV drug abuse affect the
tricuspid valve-, or in patient with central line, pace maker, catheter in the right
side, also in HIV patient, otherwise its more in the left side.
so when we talk about endothelial injury we mean that there is jet causing that
injury, this jet can be due to stenosis, or due to regurgitations or others
Jet
endothelial injury
this thrombus stays sterile until there is bacteremia for any reason- the bacteria
will infect this thrombus, where the bacteria gets away from the immune system
and starts vegetating inside the thrombus.
-we said before that it is a must to have endothelial injury in order to have
infective endocarditis, and we also said that this endothelial injury is caused by
1
Infective endocarditis
jet, now in ASD the opening is large so there is less turbulence in the blood flow,
there is less jet, less endothelial injury and so less infective endocarditis.
while in VSD the opening is smaller so we have more turbulence in the blood flow,
more jet, more endothelial injury and thus a higher risk to develop infective
endocarditis
keep in mind; jet turbulence endothelial injury is the cause of infective
endocarditis
Bacteremia:
-the American heart association 2007 gave a new guide line for prophylaxis.
they found that the duration of bacteremia is more important than the volume of
bacteremia.
-The highest risk of bacteremia is in periodontal procedures, and if the patient
already have a poor oral hygiene even chewing gum or brushing his teeth will
cause him bacteremia.
-aortic valve is most commonly affected.
-the vegetation may be large enough to cause stenosis, or it can cause
perforation, regurgitations, or even abscess which might extend to the AV node
leading to heart block.
-there is 2 types of prosthetic valve ; mechanical and biological (taken from pigs)
the risk of getting infective endocarditis in the first 3 months is higher in
mechanical valves, but after that they both have equal risk
- any patient with risk of developing infective endocarditis should be given
prophylaxis before any procedure mainly periodontal procedures
-in the first two months of prosthetic valve procedure the most common
microorganisms causing infective endocarditis are hospital acquired( esp. staph
epidermdis ), after these two months it will be infected with the same bacteria
infecting a native valve
-Nosocomial infective endocarditis can be a result of central line, pace maker, ICD
lead, dialysis catheter, hemodialysis, and mostly the invasive to the heart
procedures .. (mostly staph epidermis or staph aureus ) .
Infective endocarditis
do endoscopy to roll out colonic cancer
2-enteroccocus (enterococcus faecalis ,enterococcus faecium ) after
gastrointestinal procedures.
3-staph is NOW more common than strep and it is more virulence more resistance
and more aggressive; staph aureus in native valve and staph epidermidis in
prosthetic valve
4-gram negatives HACEK, they are fastidious organisms (the culture result is
negative; they need a special culture)
5-E.coli
6-klebsiella
7-psudomonas in IV drug abusers
8-Neisseria (rare)
- a culture negative endocarditis is a result of prior antibiotic
administration(mostly), fastidious or fungal infection ( such as Coxiella, brucella,
candida) all need special culture
-symptoms:
*fever(mostly)
*malaise
* weakness
*sweating
* new murmur (added to the one the patient already has because of the defected
valve)
*petechial rash
*this vegetation may cause a showering of emboli, which might go to the brain
creating an abscess, it's called septic emboli, or it can go to retina and then
Roth's spots can be seen during fundoscopy , or to the kidney causing kidney
impairment.
*splinter hemorrhage
*splenomegaly (usually in subacute infective endocarditis)
*glomerulonephritis
*hematuria
*proteinuria
*murmur
*heart block (if it reaches the AV node)
*Janeway lesions: in the soles and palms, hemorrhagic, not painful caused by
septic embolization
*Osler's nodes : swollen, tender, palmer nods (immunological)
*conjunctival bleeding
Infective endocarditis
-presentation :
Mostly fever of unknown origin for long time .
-Investegation :
1-blood culture :
Advisable to take 3 specimen , at least 2 .. from different locations , bcz the most common
m.o are staph.aureus , staph.epidermidis , which are normal flora , so may appear in
contaminated specimen .. to rule out contamination do more than one culture . if one is
positive others are ve, mostly this +ve is contamination . if the patient is stable the interval
btw specimens taking should be 2 hours , if not 10 minutes is enough .. give him anti-biotic
after taking the specimens .
2-echo :
Best method . we have 2 types :
a.Trans-thorasic :Simple , non-invasive , low sensitivity ( can't see the small
vegetations , also there is ribs , muscles , lung .. that ) so ve transthoracic doesn't
rule out infective endocarditis .
b.Trans-esophageal [ TEE ] : like endoscope with ultrasound camera .. insert it in the
mouth , when it reaches the esophagus it will be directly behind the left atrium so the
valves can be seen , even the small vegetations can be seen .. if it is ve then it is 95%
truly ve
3-CBC
4-Esr
5-CRP
6-Rf will be +ve , bcz it is hyper immunological response
7-Mid stream urine analysis .. hematuria
-diagnostic criteria :
Revised Duke Clinical Diagnostic Criteria
The majors :
1-+ve blood culture with typical mo ( ex. staph or strep , not Chlamydia )
2-New valvular defect
3-vigitations
The minors :
1-risk factors ; ex. already having mitral stenosis
2-fever
3-Osler's nodes
4
Infective endocarditis
4-splenomegaly
5-Janeway lesions
6-leukocytosis
7-+veRf
For diagnosis u should have :
2 majors , 1 major with 3 minor or 5 minors .
*false ve culture mostly in specimens taken post Anti-biotic taken .
*there is non-infectious endocarditis / immunological like SLE (LibmanSacks
endocarditis) .
*complications :
1- valve stenosis
2-regurge ; acute valve regurgitation is top emergency can cause (3-) heart
failure . may extend cause (4-) abscess , if on the AV node he will came with
heart block
5-septic emboli , go to brain stroke , kidney renal impairment .
*treatment :
1-the main safe treatment is Anti-biotic : Most microorganisms are resistant so
start with strong Ab from the binging.
IV ; vancomycin+/- gentamicin(aminoglycoside antibiotic) with prosthetic valve or
suspicion of staph epid. We Add rifampicin .
Duration = 4-6 weeks .
After treatment if the fever still here think of : 1- resistant mo , so go back to the
culture , 2- other problems appear after the admission ( DVT , pneumonia , allergy (
vancomycin SE ) )
2- surgery :
Indicated in : 1- Perforated valve.
2-Severe Heart failure.
3-Abscess.
4-Prosthetic valve which is avascular.
5-Large vegetations ( > 1cm) ( high risk of emboli ) .
6-Fungal / pseudomonal cause .
7- heart block .
Infective endocarditis
*Mortality :
depend on the organism ; higher in candida , pseudomonal than in strep . depend also on
the presentation ; heart failure , not like others . also on Extension , abscess .
*Prevention :
In high risk :
1- prosthetic valve , prosthetic material
2-Unrepaired cyanotic heart disease
3-repaired cyanotic heart disease in the first 6 months
4-repaired cyanotic heart disease With residual defect
5-Post heart transplant with valvular heart disease
In hi risk procedure ;periodontal
Now ..
This is the guideline but dr.Sukaina has another opinion ; because of economic and other
causes she follows this:
Low risk : 3g amoxicillin 1 hour pre-op clindamycin if allergic.
High risk : 2 gm IV amoxicillin 0.5 hr pre-op + 1.5 mg / kg gentamycin .. 6 hours post-op 1 gm
amoxicillin
If allergic : vancomycin + gentamicin 1 gm 0.5hr pre-op and 12 hrs post 1gm vancomycin