INFECTIVE ENDOCARDITIS

(IE)
Dr. Raveendra K R
Asst . Prof of Medicine
BMCRI
 Definition
Its a medical emergency characterized by
the infection of the cardiac endothelium,
macroscopically seen as vegetations

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Virtually fatal if untreated

Mortality rate even with treatment is 25%

 Classifications of IE
Acute IE : fatal in < 6 weeks
SBE : fatal between 6 weeks- 6
months
Chronic IE: persists > 6 months
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Native valve endocarditis
Prosthetic valve endocarditis
Endocarditis in I.V. drug users
Culture negative endocarditis
 Predisposing factors
CHD 20%
RHD 30%
VHD
IHD
MVP 10-33%
Prosthetic valves 10-20%
IV drug abuse
Unknown 20-40%
 Symptoms of IE
Fever (specially on cardiac patient) but
absent in elderly/ uremia/
Fatigue
Weight loss
Malaise
Night sweats
Muscular Pains
Sudden onset of CCF
 Physical signs
Progressive pallor
Petechiae (20-40%) frequently on
conjunctiva, palate, buccal mucosa, upper
extremities.
Splinter hemorrhages (10-30%) sub-
ungual, linear dark red streaks
(DD trauma)
Oslers nodes- small tender nodules on
fingers/ toe pads for hours-days
 Physical signs
Janeway lesions(<5%) small hemorrhagic
nodules over palms & soles non tender
Clubbing (10-20%)
Roths spots (<5%) oval retinal
hemorrhages with clear pale centre
Spleenomegaly ( 25-60%)
Arterial embolism - femoral in fungal
endocarditis, pulmonary embolism in drug
abusers
 Physical signs
Cardiac manifestations CCF 55%
patients, mitral followed by aortic valve &
tricuspid

Appearance of a new murmur or changing

of an existing murmur- suspect IE

Neurological manifestations- cerebral

emboli 20%, meningitis/ brain abscess
< 5%
 Native valve endocarditis
Commonest organism streptococcus viridans,
later S.sanguis, S. mutans, staphylococci,
enterococci, etc.

Streptococci 60-80% and staphylococci 25%

HACEK group 3% - (Haemophilus,

Actinobacillus, Cardiobacterium, Eikenella &
Kingella) gram ve organisms, sometimes
more commensals in URT
 Native valve endocarditis
Fungal endocarditis candida , aspergillus

More in males, more in elderly

Most common valve Mitral then Aortic

(on RHD)
 IE in drug abusers
More in young males, source through skin
Organisms S. aureus 50%, streptococci
15%, fungi (candida) & gram ve
(pseudomonas) 10-15%
Valve affected Tricuspid 50%, Aortic 25%,
mitral 20%
Acute onset/ multiple organisms common
Septic pul. Emboli causing pneumonia-
common
 Prosthetic valve endocarditis
Any intra vascular/ intra cardiac device
predisposes for IE

Accounts for 10-20% of all IE

Risk is similar in mechanical & bioprosthesis

Highest risk <6 m , < 2m virtually

nosocomial
 Prosthetic valve endocarditis
Intra vascular sutures, pacemaker lines, teflon
silastic tubes act as foci of infection

Aortic valve > mitral valve prosthesis

Fungi account for 10-15 %, has high mortality

Organisms S.epidermidis, S. aureus, gram

ve bacteria, fungi, etc
Non bacterial Endocarditis (NBE)
Culture negative endocarditis 10%
usually by fastidious organisms- fungi,
HACEK group, anerobes, legionella,
chlamydia, coxiella brunetti, Libmans Salk,
anti phospholipid syndrome, infections
after previous antibiotics

Late diagnosis, difficult to treat,

sometimes poor prognosis
 Pathogenesis

Invasions of micro-organisms to heart

Localizations of micro-organisms

Sterile vegetation formations ( platelets+ fibrin)

 Pathogenesis
Organisms invade / infect the vegetations

Septic foci spread local (abscess) & emboli

Heal-scar- stenosis/ regurgitation

 Diagnosis of IE
Suspicion of IE
- fever with predisposing factors
- PUO
- acute CCF
- appearance of a new murmur
- changing murmurs
 Investigations
Routine blood
increased WBC,
decreased Platelet count,
increased ESR

Blood culture 3 sets of cultures at 3

different venepuncture before antibiotic use,
for aerobic/anerobic/ fungal cultures
 Investigations
ECG- non specific, MI. tachycardia

Chest- X ray acute CCF, pleural effusion ,

infiltrates

2D ECHO- vegetations,abscess, etc

identify, localise & characterise
 Duke criteria
Major positive blood culture
evidence of endocardial
involvement
- + ve ECHO finding
- new valvular regurgitations

Minor criteria predisposing factors

- fever >38 C
-vascular phenomenon
- microbiological
phenomenon
-ECHO
 Management of IE
Medical emergency- hospitalization ICU

Antibiotic ( broad spectrum) drug of choice

penicillin G 12-18million U/24 hr x 4 weeks
ceftriaxone 2gm daily iv x 4 weeks
GM 1 mg/ kg iv tid x 2 weeks
vancomycin 30 mg/d bid x 4 weeks
 Procedure
Usually pen + GM x 4 weeks
Or ceftriaxone+ GM x 4 weeks

Broad spectrum penicillin

Or third generation cephalosporins used

After sensitivity report the antibiotics

may be changed appropriately

Anti- fungal for fungal IE

 Surgery in IE
Uncontrolled CCF (valve dysfunction)
Fungal IE
Large vegetations
Myocardial/ valve abscess/ fistula
Unstable prosthetic valves
Culture ve endocarditis
 Worst prognostic features
Non streptococcal group
Age > 70 years
Aortic valve involvement
Fungal IE
Large vegetations
Culture ve endocarditis
Prosthetic valve endocarditis
Development of CCF only
 Complications of IE
Acute CCF death
Abscess ( pericadial/ aortic/ myocardial)
Coronary embolism
Valve regurgitation/ stenosis
Septal perforation ( VSA)
Systemic embolism ( kidney/spleen/brain/
lungs/retina/ limbs)
Mycotic anneurysm
Thank you