Transcript ENDOCARDITIS AND ITS MANAGEMENT

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Inflammation of the endocardium
More commonly endocarditis is the infection of
the heart valves by various microorganisms
can be classified as infective or noninfective
endocarditis depending on whether a
microorganism is the source of the problem or
not.
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Endocarditis can be broken down into the
following categories:
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Native valve (acute and subacute) endocarditis
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Prosthetic valve (early and late) endocarditis
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Endocarditis related to intravenous drug use
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Acute bacterial endocarditis(ABE)
fulminating form
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high fevers
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systemic toxicity
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virulent organisms, such as Staphylococcus
aureus
If it is left untreated death can occur within few
days to weeks.
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Subacute endocarditis (SBE)
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indolent
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less invasive organisms such as viridans
streptococci
usually occurring in pre-existing vulvular
heart disease
death can occur within 6 weeks to 3 months.
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Early prosthetic valve endocarditis
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occurs within 60 days of valve implantation.
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Staphylococci, gram-negative bacilli, and Candida
species are the common infecting organisms.
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Late prosthetic valve endocarditis
occurs 60 days or more after valve
implantation.
Alpha-hemolytic streptococci, enterococci, and
staphylococci are the common causative
organisms.
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Endocarditis related to intravenous
drug use
commonly involves the tricuspid valve.
S. aureus is the most common causative
organism
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US-incidence of IE is 1.4-4.2 cases per 100,000
people per year.
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common in older adults.
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The median age of onset is about 50 yrs.
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The male or female ratio is approximately 2:1
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Increased mortality rates
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increased age
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infection involving the aortic valve
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congestive heart failure
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CNS complications, and underlying disease.
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also vary with the infecting organism.
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Mortality rates in native valve disease range
from 16-27%.
Mortality rates in patients with prosthetic valve
infections are higher.
More than 50% of these infections occur within
2 months after surgery.
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Gram positive cocci predominate.
Streptococci or styphylococci cause 80% of IE
on native valves.
Among the streptococci, alpha- haemolytic
streptococci from the mouth cause most cases
of SBE.
Others are gram negative aerobic bacilli, fungi,
rickettsia, Chlamydia etc.
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Endothelial surface of the heart is damaged.
Platelet and fibrin deposited at the damaged site
forming the nonbacterial thrombotic lesions(sterile
lesions).
The vegetations of (NBTE) are friable masses,
usually situated along the lines of valve closure.
They vary greately in size sometimes being rather
large and causing infarctions when they embolize.
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attachment of microorganisms circulating in the
bloodstream onto an endocardial surface
especially NBTE.
bacteria multiply rapidly because the vegetation
provides an ideal environment for the growth of
microbial colonies.
Formation of an abscess is one of the most
important complications of valvular infection
Developed by direct extention of valvular
infection into the fibrous cardiac skeleton
supporting the valves and it is mostly seen in case
of ABE.
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Pathogenesis of early PVE
surgery may directly inoculate the valve with
bacteria from patients skin or operating room
personnel.
The recently placed nonendothelialized valve
is more susceptible to bacterial colonization
than native valves.
Bacteria also may colonize the new valve from
contaminated bypass pumps, cannulas and
pacemakers and from a nosocomial bacteremia
subsequent with an intravascular catheter.
Symptoms of SBE
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fever
chills
rigors
night sweats
general malaise
anorexia, fatigue, weight loss and weakness.
Headaches and musculoskeletal complaints,
including myalgias, arthralgias and back pain
are common
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Symptoms of ABE
hectic fevers and rigors leading to
hospitalization within a few days.
Symptoms of cardiac failure may develop or
worsen suddenly in either acute or subacute
disease.
IE should be considered in any patient who
presents with the classic triad of fever, anemia
and murmur. Important physical signs of IE
include heart failure, spleenomegaly, signs of
embolization and peripheral signs
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One or more classic signs of infective
endocarditis are found in as many as 50% of
patients. They include the following:
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Petechiae - Common but nonspecific finding
Splinter hemorrhages - Dark red linear lesions in the
nail beds
Osler nodes - Tender subcutaneous nodules usually
found on the distal pads of the digits
Janeway lesions – Hemorrhagic, painless plaques on
the palms and soles
Roth spots - Retinal hemorrhages with small, clear
centers; rare and observed in only 5% of patients.
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Laboratory abnormalities
Anemia (normocytic, normochromic) of chronic
disease is common in subacute endocarditis
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Leukocytosis is observed in acute endocarditis.
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Thrombocytopenia
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Elevated WBC count (ABE)
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Elevated ESR while not specific, is elevated in
more than 90% of cases.
Proteinuria and microscopic hematuria are
present in approximately 50% of cases
Elevated CRF
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BLOOD CULTURE
More than 90% of patients with IE have
positive blood cultures.
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Venous blood samples for these should be
drawn several hours apart, before antibiotic
therapy is started.
If the patient has ABE indicating that antibiotic
therapy must be started immediately, the three
sets should be drawn with short delay.
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ECHOCARDIOGRAPHY
It can detect vegetations, valve ring abscess,
myocardial abscess etc
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negative echocardiogram does not rule out IE.
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This test is particularly indicated with culturenegative cases, such as in fungal endocarditis.
The disappearance or persistence of vegetations
on echocardiograms during treatment are not
reliable for the success or failure of antibiotic
therapy but enlargement during therapy can
indicate treatment failure.
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CHEST RADIOGRAPHY:
Provide more diagnostic information
especially in a patient with right sided
endocarditis.
Pulmonary embolic phenomena strongly
suggest tricuspid disease.
ECG
Reveal heart block suggesting extension of the
infection.
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CT SCANNING AND MRI:
This can reveal cerebritis, embolic infarction or
hemorrhage in brain and infarcts or abscess
formation in the spleen or other sites.
CARDIAC CATHETERIZATION
Indicated to determine the degree of valvular
damage. It is especially useful when surgery is
being considered or when antibiotic treatment
seems to be failing.
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Duke Criteria
Definite Case of Endocarditis
Must have 2 major criteria or
 1 major criteria & 3 minor criteria or 5 minor criteria
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Possible Case of Endocarditis
Patient appears to have endocarditis but does
not have the necessary number of major and
minor criteria
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Rejected Possibility of Endocarditis
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While possibility considered initially an alternative
diagnosis established or pathologic diagnosis not
established
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Duke - Major Criteria
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Positive blood culture
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– Typical pathogen frequently associated with
endocarditis
– Multiple positive cultures (75-100% of
cultures positive)
– Positive cultures obtained throughout the day
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Evidence of endocardial involvement
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--Echocardiogram positive
-- Vegetation present
-- Evidence of intra-cardiac abscess
-- Dehiscence of prosthetic valve
-- New evidence of valve regurgitation
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Positive serology
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Duke - Minor Criteria
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Fever >38 C (100.4 F)
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predisposing heart disease
Positive Blood culture but not typical
pathogen
Echo not meeting major criterion
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Immununological phenomena
--Glomerulonephritis, RF +ve, osler nodes,
roth spots.
• Vascular phenomena
– arterial emboli, Janeway lesion, septic
pulmonary infarcts, intracranial hemorrhage
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Goals of the therapy
To relieve the signs and symptoms of the
disease.
To decrease the morbidity and mortality
associated with infection.
To eradicate the causative organism with
minimal drug exposure
To provide cost effective antimicrobial therapy.
To prevent IE from occurring or recurring in
high risk patients with appropriate
prophylactic antimicrobials.
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N0N PHARMACOLOGIC TREATMENT
Surgery is an important adjunct in the management of
endocarditis.
In most surgical cases, valvectomy and valve
replacement are performed to remove infected tissue
and to restore hemodynamic functions.
Persistent vegetations or an increase in the vegetation
size after prolonged antibiotic treatment, valve
dysfunction, perivalvular extention (eg: abscess) etc
suggests surgery
It may also be considered in case of PVE endocarditis
caused by resistant organisms ( eg: fungi or gram
negative bacteria), or if there is persistent bacteremia.
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Penicillin G:
DOC for streptococcal infection.
Interferes with cell-wall mucopeptide synthesis of
the microorganism.
Nafcillin :
Provides coverage for penicillinase-producing
staphylococci.
Use to initiate therapy in any patient in whom a
penicillin G–resistant staphylococcal infection is
suspected.
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Gentamicin:
Offers synergistic benefit with penicillins in the
treatment of gram-positive cocci.
Vancomycin:
Used for penicillin-resistant streptococci,
methicillin-resistant staphylococci (eg, S
epidermidis), and enterococci.
Potent antibiotic directed against gram-positive
organisms and is active against enterococci.
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Rifampin:
Used synergistically in the treatment of
staphylococcal infections associated with a
foreign body, such as a prosthetic heart valve.
Inhibits DNA-dependent RNA polymerase
activity in susceptible cells.
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Dosage and route
Duration(wks)
Antibiotic
SUSCEPTIBLE VIRIDANS STREPTOCOCCI AND STREPTOCOCCUS BOVIS
Aqueous crystalline
penicilllin G sodium
Or
ceftriaxone
12-18 million U/d IV
continuously or in 6
equally divided doses
2 gm once daily IV or IM
Aqueous crystalline
penicilllin G sodium
With gentamycin sulfate
12-18 million U/d IV
continuously or in 6
equally divided doses
1 mg/kg IV or IM every
8 hrly
Vancomycin
30 mg/kg/d IV in two
equally divided doses
4
4
2
2
4
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Antibiotic
Aqueous crystalline
penicilllin G sodium
With gentamycin sulfate
Vancomycin
Dosage and route
18 million U/d IV
continuously or in 6
equally divided doses
1 mg/kg IV or IM every 8
hrly
30 mg/kg/d IV in two
equally divided doses
Duration(wks)
4
2
4
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THERAPY FOR ENDOCARDITIS DUE TO
STAPHYLOCOCCUS IN THE ABSENCE OF
PROSTHETIC MATERIAL
Antibiotic
Dosage and
route
Methicillin susceptible Saphylococci
Regimens for non beta lactam allergic patients
Nafcillin
 or oxacillin sodium
With optional addition of
gentamycin sulfate
2 gm IV every 4
hrly
1 mg/kg IV or
IM every 8
hrly
Regimens for beta lactam allergic patients
Cefazolin
With optional addition of
gentamycin sulfate
2 gm IV every 8
hrly
1 mg/kg IV or
IM every 8
hrly
Vancomycin
30 mg/kg/d IV
in two
equally
divided
doses
Methicillin resistant Saphylococci
Vancomycin
30 mg/kg/d IV
in two
equally
divided
doses
Duration(w
ks
4-6
3-5
days
4-6
3-5
days
4-6
4-6
Antibiotic
Dosage and
route
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Regimens for Methicillin resistant Saphylococci
Vancomycin
With Rifampicin and with
and with
gentamycin sulfate
30 mg/kg/d IV
in two
equally
divided
doses
300 mg orally
every 8
hrly
1 mg/kg IV or
IM every 8
hrly
Regimens for Methicillin susceptible Saphylococci
Nafcillin or oxacillin sodium
With Rifampicin and with
gentamycin sulfate
2 gm IV every
4 hrly
300 mg orally
every 8
hrly
1 mg/kg IV or
IM every 8
hrly
Duration(w
ks
>/=6
>/=6
2
>/=6
>/=6
2
Antibiotic
Dosage and route
Duration(wks
Aqueous crystalline
penicilllin G sodium
with gentamycin sulfate
18-30million U/d IV
continuously or in 6
equally divided doses
1 mg/kg IV or IM every 8
hrly
4-6
Ampicillin sodium
with gentamycin sulfate
12 gm/24 h continuously
or in 6 equally divided
doses
1 mg/kg IV or IM every 8
hrly
4-6
4-6
Vancomycin
with gentamycin sulfate
30 mg/kg/d IV in two
equally divided doses
1 mg/kg IV or IM every 8
hrly
4-6
4-6
4-6
Antibiotic
Dosage and route
Ceftriaxone
2 gm once daily IV or
IM
Ampicillin sodium
with gentamycin sulfate
12 gm/24 h continuously
or in 6 equally
divided doses
1 mg/kg IV or IM every
8 hrly
Duration(wks
4
4
4
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CULTURE NEGATIVE ENDOCADITIS
Due to prior antibiotic therapy or unusual
microorganisms such as Legionela species,
Bartonella species, Coxiella burnetti or fungi.In
this condition patients can be treated
empirically with benzylpenicillin plus
gentamycin as for enterococcal endocardtis.
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Fungi cause between 2% - 4% of endocarditis
cases. When fungal IE is identified the
combined medical- surgical approach is
recommended. Amphotericin B can be used
with the possible addition of Flucytosin.
In case of Legionella IE prolonged parenteral
therapy with either doxycycline or
erythromycin , with prolonged oral therapy(617 mnths) elicited cure in some patients
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CONCLUSION :
Endocarditis is the inflammation of the
endocardium, which mainly affects the heart
valves.
It is mainly caused by certain gram positive
cocci. Large doses of parenteral antimicrobials
usually are necessary to achieve bactericidal
concentrations in the vegetations.
An extended duration of therapy is required
even for susceptible pathogens because
organisms are enclosed with in valvular
vegetations and fibrin deposits. Appropriate
therapy should be initiated, if left untreated it
is fatal.