Infective Endocarditis

Dr. Kalpana Malla

MBBS MD (Pediatrics) Manipal Teaching Hospital

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Definition
Infective Endocarditis (IE): an infection of the heart s endocardial surface Classified into four groups:
Native Valve IE Prosthetic Valve IE Intravenous drug abuse (IVDA) IE Nosocomial IE

Epidemiology
The valves involved
Mitral Aortic Both 28-45% 5-36% 0-35%

Tricuspid Pulmonary

0-6% <1%

Epidemiology
Incidence - varies according to location Males > females May occur at any age and increasingly common in elderly Mortality 20-30%

Predisposing Factors
Iv drug use Central line Prosthetic valve Previous IE Murmur Dental procedure Rheumatic disease Miscellaneous

Risk for Endocarditis

High risk
Prosthetic cardiac valve Prior episodes of endocarditis Complex congenital cardiac defect Surgical systemic-pulmonary shunts

Intravenous drug abuse Intravascular catheters

Risk for Endocarditis

Moderate risk
PDA, VSD, primum ASD Co-Aorta Bicuspid aortic valve Hypertrophic cardiomyopathy Acquired valvular dysfunction MVP with mitral regurgitation

Risk for Endocarditis

Low risk
Isolated secundum atrial septal defect ASD, VSD, or PDA > 6 months past repair Innocent heart murmur by auscultation in the pediatric population

Further Classification
Acute Affects normal heart valves Rapidly destructive Metastatic foci Commonly Staph. If not treated, usually fatal within 6 weeks Subacute Often affects damaged heart valves Indolent nature If not treated, usually fatal by one year

 The terms acute and subacute are used to define duration of infection, however are older terms and should not be used A classification based on organism is preferable

Pathophysiology
1. Turbulent blood flow disrupts the endocardium making it sticky 2. Bacteremia delivers the organisms to the endocardial surface 3. Adherence of the organisms to the endocardial surface 4. Eventual invasion of the valvular leaflets

Infecting Organisms
Common bacteria in children
S viridans 50% cases S. aureus 40% cases S. fecalis ,Grp D sreptococcus (Enterococci)

Less common organisms

P. aeruginosa, Staph epidemidis Histoplasma, candida, Aspergillus Coxiella burnetti, Brucella, chlamydia HACEK grp Hemophilus, Actinobacillus, Cardiobacterium hominis, Eikenella, kingella

Symptoms
Acute High grade fever and chills SOB Arthralgias/ myalgias Abdominal pain Pleuritic chest pain Back pain Subacute Low grade fever Anorexia Weight loss Fatigue Arthralgias/ myalgias Abdominal pain

Signs
Fever Heart murmur Nonspecific signs petechiae, subungal or splinter hemorrhages, clubbing, splenomegaly, neurologic changes More specific signs - Osler s Nodes, Janeway lesions, and Roth Spots

Petechiae

1. Nonspecific 2. Often located on extremities or mucous membranes

Splinter Hemorrhages

1. Nonspecific 2. Nonblanching 3. Linear reddish-brown lesions found under the nail bed 4. Usually do NOT extend the entire length of the nail

Osler s Nodes

1. More specific 2. Painful and erythematous nodules 3. Located on pulp of fingers and toes 4. More common in subacute IE

Janeway Lesions

1. More specific 2. Erythematous, blanching macules 3. Nonpainful 4. Located on palms and soles

The Essential Blood Test

Blood Cultures
Minimum of three blood cultures Three separate venipuncture sites 5- 10mL in children to 1hr apart Out of three one should be for anaerobic organisms Positive Result
Typical organisms present in at least 2 separate samples

Detects over 95% of cases

Negative blood culture

Previous antibiotic Technical errors Unusual organisms- anaerobic organisms,fungus

Additional supportive Labs

CBC ESR and CRP Urinalysis-microscopic hematuria in 95% Immunologic tests Increase in gamma globulins Presence of cryoglobulin Low Complement levels (C3, C4) RF- positive (59%)

Imaging
Chest x-ray
Look for multiple focal infiltrates and calcification of heart valves

EKG
Rarely diagnostic Look for evidence of ischemia, conduction delay, and arrhythmias

Echocardiography- diagnostic tool for culture negative cases

mitral valve vegetation

Making the Diagnosis

Pelletier and Petersdorf criteria (1977) Von Reyn criteria (1981) Duke criteria (1994) Modified Duke Criteria

Diagnostic (Duke) Criteria

Major criteria Positive blood culture for IE Evidence of endocardial involvement

Duke s Major Criteria

positive blood culture for IE
typical microorganism (strep viridans, strep bovis, HACEK group, staph aureus or enterococci in the absence of a primary locus) for endocarditis from two separate blood cultures persistently positive blood culture from: blood cultures drawn more than 12 hr apart, or all of 3 or a majority of 4 or more separate blood cultures, with first and last drawn at least 1 hr apart

Duke s Major Criteria

Evidence of endocardial involvement
positive echocardiogram for endocarditis

Duke s Minor Criteria

Predisposing heart condition or iv drug use Fever of 100.40F or higher Vascular phenomena : - major arterial emboli - septic pulmonary infarcts - mycotic aneurysm - intracranial hemorrhage - conjunctive hemorrhages - Janeway lesions

Duke s Minor Criteria

Immunologic phenomena: - Glomerulonephritis - Osler s nodes - Roth spots - Rheumatoid factor) Microbiologic evidence: - positive blood culture not meeting major criteria or serologic evidence of active infection with organism consistent with IE) Echocardiogram -consistent with IE but not meeting major criteria)

Modified Duke Criteria

Definite IE Microorganism (via culture or histology) in a valvular vegetation, embolized vegetation, or intracardiac abscess Histologic evidence of vegetation or intracardiac abscess Possible IE 2 major 1 major and 3 minor 5 minor

Modified Duke Criteria

Rejected IE Resolution of illness with four days or less of antibiotics

Treatment
Parenteral antibiotics Surgery
Intracardiac complications

Surveillance blood cultures

Antimicrobial Therapy
Antibiotics IV for 2-6 weeks

1. Penicillin-susceptible streptococcal (PSSE) on native cardiac valves: Penicillin G - 4 weeks or Penicillin G or ceftriaxone + gentamicin - 2 wks 2. Penicillin-resistant streptococcal (PRSE) on native cardiac valves Penicillin, ampicillin, or ceftriaxone for 4 weeks + gentamicin for the first 2 weeks

Antimicrobial Therapy
3.PSSE on prosthetic valve penicillin, ampicillin, or ceftriaxone - 6 wks + gentamicin for the first 2 wks. 4. PRSE on prosthetic valve penicillin, ampicillin, or ceftriaxone for 6 weeks + gentamicin for first 2 wks

Antimicrobial Therapy
5. Enterococcal infection on native valves penicillin or ampicillin + gentamicin for 4-6 weeks

Antimicrobial Therapy
6.Methicillin-susceptible S aureus (MSSA) on native valves : - Nafcillin or oxacillin for at least 6 weeks + gentamicin for 3-5 days is optional 7. Methicillin-resistant S aureus (MRSA) on native valves: - vancomycin for at least 6 weeks, with or without 3-5 days of gentamicin

Antimicrobial Therapy
8. MSSA infection on prosthetic valve : - Nafcillin or oxacillin + rifampin for at least 6 weeks, in combination with gentamicin for 2 weeks. 9. MRSA infection on prosthetic valve: - Vancomycin + rifampin for at least 6 weeks, in combination with gentamicin for 2 weeks

Antimicrobial Therapy
10. Gram negative endocarditis caused by HACEK organisms: - ceftriaxone or ampicillin plus gentamicin for 4 weeks

Culture Negative Endocarditis

Intracellular organisms
Bartonella henselae Coxiella burnetti Mycoplasma pneumonia Legionella pneumophila

Diagnosis is made by checking IgM/IgG serologies

Culture Negative Endocarditis Treatment

One should cover for the HACEK organisms, alpha streptococci & last slide Ceftriaxone 2 grams IV daily + vancomycin 1 g q 12 - 6 weeks

New Treatments
Right-sided infective endocarditis due to methicillinsusceptible S aureus (MSSA) in IV drug users
2-wk therapy with a penicillinase-resistant penicillin and an aminoglycoside 2-wk monotherapy with IV cloxacillin short-term therapy is inappropriate if complicated by ostomyelitis, meningitis, myocardial abscess, or concomitant left-sided involvement

New Treatments
Highly penicillin-susceptible Streptococcus viridans or bovis
Once-daily ceftriaxone for 4 wks
cure rate > 98% easily administered as outpatient, avoid hospitalization, offers significant cost savings

Once-daily ceftriaxone 2 g for 2wks followed by oral amoxicillin qid for 2 wks Once-daily ceftriazone and netilmicin for 2 wks

New Treatments
Prosthetic valve endocarditis due to fluconazolesusceptible Candida species
many are due to bloodstream invasion chronic oral suppressive therapy with fluconazole for inoperable disease

Surgical Treatment
15-25% of patients with IE are treated surgically Indications Antibiotic therapy fails Persistent vegetation after systemic embolization Increase in vegetation size after antimicrobial therapy Valvular dysfunction Fungal endocarditis

Complications of Endocarditis
Cardiac Neurologic Emboli Metastatic Abscesses 33-50% 25-35% 15-35% <5%

Neurologic Complications
Acute encephalopathy Meningitis Embolic stroke Cerebral hemorrhage Brain abscess

Embolic Phenomena
Stroke Ischemic extremities Pulmonary emboli Paralysis due to embolic infarction of either the brain or spinal cord Hypoxia from pulmonary emboli Abdominal pain (splenic or renal infarction

Metastatic Spread of Infection

Metastatic abscess
Kidneys, spleen, brain, soft tissues

Meningitis and/or encephalitis Vertebral osteomyelitis Septic arthritis

Local Spread of Infection

Heart failure
Extensive valvular damage

Paravalvular abscess (30-40%)

Most common in aortic valve, IVDA, and S. aureus May extend into adjacent conduction tissue causing arrythmias Higher rates of embolization and mortality

Pericarditis Fistulous intracardiac connections

Septic Pulmonary Emboli

Poor Prognostic Factors

Female S. aureus Vegetation size Aortic valve Prosthetic valve Older age Diabetes mellitus Low serum albumen Apache II score Heart failure Paravalvular abscess Embolic events

Thank you
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