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Definition
Microbial infection of the ENDOTHELIAL SURFACE of the heart
Pathology
VEGETATION Amorphous mass of Platelets and Fibrin with abundant Microorganisms and scant Inflammatory cells
Vegetations - Comparison
RHD
IE
NBTE
SLE
Epidemiology
Rheumatic H.D. Congenital H.D. Other (Calcified AoV, Floppy MV) Nil
50% occurred in age above 60 years Prosthetic valve endocarditis first 6 months
Sites
Heart valves Septal defects Chordae tendineae Mural endocardium Intra-Cardiac Devices Arteriovenous shunts Arterio-arterial shunts (PDA) Coarctation of the aorta
Infective Endarteritis
Classification
Acute
Subacute
Highly Virulent organisms Normal Valves Hectically febrile Rapid damage Hemat. Seeds Death within weeks
Low Virulent Organisms Damaged Valves Indolent Course Slow damage Rare metastasis Gradually progressive
Microbiology
Streptococci
Staphylococci
3 8%
< 2%
Microbiology (ctd)
Prosthetic Valve Endocarditis
Early
Late
Streptococci Staphylococci
40% 33%
Pathogenesis
Endocardial Injury Aberrant Flow
Direct Infection
Bacteria Adhere
VEGETATIONS
Proliferate
Clinical Features
CARDIOVASCULAR Varying / New murmurs Conduction Disorders Cardiac Failure Cerebral Emboli Systemic Emboli Loss of Pulses
Fever Chills and sweats Anorexia, weight loss, malaise Myalgias, arthralgias Back pain Splenomegaly Clubbing Neurologic manifestations Peripheral manifestations (Osler's nodes, subungual hges, Janeway lesions, Roth's spots) Petechiae
10 40%
Janeway Lesions
Roth Spots
Splinter Hemorrhages
Oslers Nodes
Investigations
BLOOD CULTURE
3 Specimens; prior to antibiotics Dont wait for pyrexia Not from in-dwelling catheter Both Aerobic and Anaerobic culture
Investigations (ctd)
ECHOCARDIOGRAPHY
Investigations (ctd)
Elevated ESR Normocytic, normochromic anemia Leukocytosis Microscopic hematuria Thrombocytopenia Proteinuria Elevated CRP
Treatment
Difficult to eradicate organisms from avascular vegetations Bactericidal Parenteral; High concentration Knowledge of the susceptibility of the organism Prosthetic valves longer duration
Treatment (ctd)
Streptococci
Pen. Susc:
Pen G 2 3 mn units 4th hrly 4 wks Pen G 2 3 mn units 4th hrly + Gentamicin 1 mg / kg 8th hrly 2 wks Ceftriaxone 2 gm o.d. 4 wks Vancomycin 15 mg / kg b.d. 4 wks Pen G 3-4 mn units 4th hrly + Gentamicin 1 mg/kg 8th hrly 4-6 wks
Pen. Resis:
Treatment (ctd)
Enterococci
Pen G 3 - 4 mn units 4th hrly + Gentamicin 1 mg/kg 8th hrly 4 - 6 wks Ampicillin 2 g 4th hrly + Gentamicin 1 mg/kg IV 8th hrly 4 - 6 wks Vancomycin 15 mg/kg b.d. + Gentamicin 1 mg/kg 8th hrly 4 - 6 wks
Treatment (ctd)
Staphylococci - Native valves
Methicillin-susceptible
Nafcillin or Oxacillin 2 g 4th hrly 4 - 6 wks + Gentamicin 1 mg/kg 8th hrly 3-5 days Cefazolin 2 g 8th hrly 4 - 6 wks + Gentamicin 1 mg/kg 8th hrly 3-5 days Vancomycin 15 mg/kg b.d. 4-6 wks
Methicillin-resistant
Treatment (ctd)
Staphylococci - Prosthetic valves
Methicillin-susceptible
Nafcillin or oxacillin 2 g 4th hrly 6-8 wks + Gentamicin 1 mg/kg 8th hrly 2 wks + Rifampicin 300 mg 8th hrly 6-8 wks
Methicillin-resistant
Vancomycin 15 mg/kg b.d. 6-8 wks + Gentamicin 1 mg/kg b.d. 2 wks + Rifampicin 300 mg 8th hrly 6-8 wks
Treatment (ctd)
HACEK organisms
Ceftriaxone 2 g/d o.d. 4 wks Ampicillin 2 g 4th hrly + Gentamicin 1 mg/kg 8th hrly 4 wks
Treatment (ctd)
Fungi
Treatment (ctd)
Empirical Therapy Ampicillin 2 g 4th hrly + Gentamicin 1 mg/kg IV 8th hrly 4 - 6 wks
Prosthetic Valve dysfunction Myocardial Abscess Large vegetations with rec. emboli Uncontrolled infection Staph. aureus inf. with intra-cardiac compl.
Perivalvular extension
Prophylaxis
Procedures Needing Prophylaxis Dental procedures Tonsillectomy / Adenoidectomy UGI / URTI surgeries Bronchoscopy Esophageal dilatation ERCP Urinary catheterisation Cystoscopy Urinary tract surgeries I/D of infected tissues
Prophylaxis (ctd)
Amoxicillin 2.0 g PO 1 h Ampicillin 2.0 g IV or IM < 30 min Clarithromycin 500 mg PO 1 h Cephalexin or cefadroxil 2.0 g PO 1 h Clindamycin 600 mg PO 1 h or IV 30 min Cefazolin 1.0 g IV or IM 30 min
Prophylaxis (ctd)
Ampicillin 2 g IV or IM + Gentamicin 1.5 mg/kg IV or IM within 30 min of procedure; repeat ampicillin 1 g IV or IM or amoxicillin 1 g PO 6 h later Vancomycin 1 g IV over 1-2 h + Gentamicin 1.5 mg/kg IV or IM within 30 min before procedure
Complications
Cardiac Failure Embolic phenomenon Renal Failure immune-complex mediated Neurological complications
Conduction abnormalities
Prognosis
Older age Severe co-morbid conditions Delayed diagnosis Involvement of prosthetic valves or the aortic valve Invasive (S. aureus) or antibiotic-resistant (P. aeruginosa, yeast) pathogen Intracardiac complications Major neurological complications
Prognosis (ctd)
Survival Rates
IVDU : 85 90% Non IVDU : 55 70% < 2 mths : 40 50% > 2 mths : 10 20%