Cardio Infective Endocarditis

Dr. Payawal
December 2008

Ok mga kapatid. Uunahin ko ang note ko. Ito ay lecture ni doc Predisposing Conditions to Bacteremia:
mga 2-3 years ago. Oks??? Pictures ang mga ito kaya minabuti
ko na iretype. As I always say this is for the good of all. Yung
Area heavily colonized is traumatized
mga pictures po ay walang Caption. (malamang. Di kasi na Dental procedures
lecture sa atin pero iadd ko na rin para magamit ng kabilang Bronchoscopy (rigid instrument)
section. Okies? ) Guys... favor lang ng malaki. Wag po
ipapaphotox sa Annies or Patricks. Pls. lang.
Cystoscopy during UTI
Biopsy of unrinary tract/prostate
ARALIN ninyo ang Book kung di ninyo gets since di na daw Tonsillectomy
ilelec ito ni doc
Esophageal dilatation/sclerotherapy
Definition Instrumentation of obstructed billiary tract
TURP
An endovascular microbial infection, usually Urethral instrumentation
bacterial or fungal, or intracardiac structures Lithotripsy
facing the blood including infections of large Gynecologic procedures in presence of
intrathoracic vesses and intracardiac foreign infection
bodies
Negative Valve Endocarditis
Classification: 65-80% of non-parenteral drugs users have
Acute predisposing cardiac lesions
Infection of a normal valve with virulent
organisms which rapidly destroy the value Predisposing Cardiac Lesions
Metastatic foci common o MVP with MR
Death within 6 weeks without treatment o RHD
MV, AV, TV
Subacute o Congenital Heart Disease
Infection of abnormal valies with relatively PDA, VSD, Bicuspid AV
avirulent organisms Coarctation of the Aorta
Indolent course Pulmonic Stenosis
Metastatic foci uncommon o Degenerative
Calcific aortic stenosis
Pathogenesis Calcific mitral annulus
Endothelial Injury o HOCM
Hypercoagualable state

Endothelial Injury
Hemodynamic Factors
High velocity jet striking endothelium
Flow from high to low pressure chamber
Flow across a narrow orifice at high velocity

Pathogenesis

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Cardio Infective Endocarditis
Dr. Payawal
December 2008

Prostetic Valve Endocarditis

Overall incidence is 1.4-3.1% per year
Cumulative risk 3-5.7% in 5 years

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 Cardio Infective Endocarditis
Dr. Payawal
December 2008

Janeaway
Clinical Features lesions- small
Local intracardiac infectious process and its erythematous or
complications hemorrhagic
Embolization macular nontender
Distant seeding lesions on palms
Immune complex disease and soles which
are result of septic
embolic events

Splinter hemorrhages dark red, linear to flame

shaped streakes in nail of fingers or toes

Roth
Spots- Oval
retinal

hemorrhages with pale centers

Oslers Node- small

tender subcutaneous
nodules in the pulp of
digits or proximal in
fingers that persists
for hours to days
Mycotic Aneurysm

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 Cardio Infective Endocarditis
Dr. Payawal
December 2008

Echocardiography
o Detects vegetation (TTE) in 60-80% of
cases in NVE and 15-35% in PVE,
TEE-85-95% in NVE and 82-96% in
PVE
o Lacks specificity
o Vegetations not visualized in first 2
weeks
o Vegetations may remain after therapy

MRI Cerebral Angiogram

Consider if:
Heart murmer with unexplained fever >1 week
Young person with stroke
Febrile patient with prosthetic heart valve
Relapse when therapy is stopped

Diagnosis
Blood Cultures
o Critical diagnosis finding
o ( + ) in 95% w/out previous antibiotics
o Bacteremia continuous
o 3 blood cultures obtained over 24
hours

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 Cardio Infective Endocarditis
Dr. Payawal
December 2008

o E. feacalis inhabitant of GIT and

anterior urethra

Management
Bactericidal agens used at high concentrations
given long enough to sterilized vegetations
Parentheral therapy preferred
Frequent dosing guarantees microbial
multiplication does not occur between dosages
Therapy before isolation of organism

Modified Duke Criteria for Diagnosis of IE

Major Criteria:
( + ) Blood cultures for typical organisms
IE isolated from 2 separated blood cultures
o Viridans Streptococci, Streptococcus
bovis, Stap aureus
o HACEK group
o Hemophilus species
o Actinobacillus actinoinycetemomitans
o Cardiobacterium hominis
o Eikenella corrodens
o Kingella kingae
Persistently ( + ) blood cultures
o > 2 ( + ) blood cultures > 12 hours
apart
o > 3 ( + ) blood cultures, 1st and last >
1hr apart
Single blood culture for Coxiella
burnetii
Antiphase I IgG antibody titer of
>1:800

Evidence of endocardial involvement

( + ) ECHO of IE (TEE for PV)
Oscillating vegetation of valve or structure on
path of regurgitant jet or on implanted material
without alternative explanation
Abscess
New partial dehiscence of valve prosthesis
New valvular regurgitation

Minor Criteria:
Predisposing heart disease or IV drug use
Fever >38C
Microbiology
Vascular phenomenon
Streptococcus (50-70 %)
o Major arterial emboli
o S. viridians normal inhabitant of
o Septic pulmonary infarcts
oropharynx
o Mycotic aneurysm
Staphylococcus (25%)
o Intracranial or conjunctival
o S. Epidermidis- skin commensal
hemorrhage
o Contaminates blood cultures
o Janeaway lesion
Enterococcus (10%)
Immunologic phenomenon

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 Cardio Infective Endocarditis
Dr. Payawal
December 2008

o Glomerulonephritis
o Oslers Nodes
o Roths Spots
o Rheumatoid factor
( + ) blood culture not meeting major criterion

Definitive Endocarditis:
2 major criteria
One major and 3 minor criteria
5 minor criteria

Possible Endocarditis:
1 major + 1 mnor
3 minor criteria

Therapy

Ampicillin
12g/day IV 6 divided doses
+
Gentamicin
1.7 mg/kg IVq 8 hours

Indications for Cardiac Surgery

Refractory CHF caused by valve dysfunction
Unstable prosthesis, prosthesis orifice
obstructed
Uncontrolled infection despite optimal
antimicrobial tx
Unavailable effective antimicrobial Tx (eg.
Fungal)
Staph aureus PVE with intracardiac
complication
Relapse of PVE after optimal therapy
Fistula to pericardial sac

Relative
Relapse of NVE after optimal antimicrobial tx
Large (>10mm diameter) hypermobile
vegetation
Culture (-) NVE/PVE with persistent fever
(>10d)
Myocardial abscess
Perivalvular extension of infection

Prevention
Good dental care
Identification of high risk patients
Infections treated promptly and adequately
Chemoprophylaxis

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