Transcript Slide 1
ENFECTIVE ENDOCARDITIS M.RASOOLINEJAD, MD DEPARTMENT OF INFECTIOUS DISEASE TEHRAN UNIVERSITY OF MEDICAL SCIENCE INFECTIVE ENDOCARDITIS Infection of the endocardial surface INFECTIVE ENDOCADITIS INTRUDUCTION •Clinical manifestations are so varied. •All of medical subspecialist must encounter •Successful management Medical & Surgical. EPIDEMIOLOGY 20% of cases are categorized as definite Mean age of patients are increased Underlying heart disease Rheumatic heart disease Degenerative heart disease Congenital heart disease Nosocomial endocarditis Intracardiac prostheses Injection Drug Users ( IDU ) PATHOGENESIS Endothelium (Trauma, Turbulance, metabolic change ) Mucus membrane or Colonized tissue Local factor Bacteriocins IgA protease Bacterial adherence Plt - fib deposition Trauma NBTE Bacteremia Adherence Complement Antibody Colonization Mature Vegetation PATHOGENESIS Nonbacterial Thrombotic Endocarditis (NBTA) Hemodynamic factor Transient Bacteremia Microorganisms Immunopathologic ETIOLOGIC AGENTS Streptococci ( viridance, Fecalis,… ) 60 – 80 % Staphylococci ( +ve Or -ve coagolase ) 20 – 30 % Gram -ve bacteria 1.5 – 13% Fungi 2 - 4% Culture negative 5 – 25 % Others 1–2% CULTURE – NEGATIVE ENDOCARDITIS Subacute right – side infective endocarditis Chronic course > 3 months Uremia supervening chronic course Mural IE as in VSD Pacemaker wires infection CULTURE - NEGATIVE ENDOCARDITIS HACEK* Brucella spp, Prior administration of antibiotics Rickettsiae, Chlamydia, Virus Noninfective endocarditis * Haemophilus spp, Actinobacillus spp, Cardiobacterium spp, Eikenella, Kingella PATHOLOGY HEART: •Vegetation ( fibrin, Plt, bacteria, PMN, RBC ) •Valve change perforation. •Rupture of chordae tendinae, septum and papillary muscle •Ring abscess •Valvular stenosis •Valvular regurgitation •Myocardial abscess •Pericarditis, effusions •Coronary emboli PATHOLOGY RENAL Renal architecture is abnormal in all cases, Even in the absence of clinical or biochemical of renal disease PATHOLOGY RENAL Focal glomerulonephritis Diffuse glomeruonephritis Membranoproliferative glomerulonephritis Renal infarction Renal abscess PATHOLOGY CNS Emboli (middle cerebral artery ) Infarction Arteritis Abscess Mycotic aneurysms Hemorrhage:Intracerebral or Subarachnoid Encephalomalacia Meningitis PATHOLOGY MYCOTIC ANEURYSMS Usually during active IE Occasionally mons or years after successful treatment Direct bacterial invasion abscess Septic embolic to vasa vasorum Immun complex deposition Cerebral vessels, abdominal aorta, sinus of Valsalva Clinically silent until rupture PATHOLOGY SPLEEN: Infarction, Abscess, Enlargement LUNG: Emboli, Acute Pneumonia, Pleural Effusion SKIN: Ptechiae, Osler node ( Arteriolar intimal proliferation ) Janeway lesions ( Becteria, Necrosis, PMN, Hemorrhage) EYE: Roth spots ( Lymphocyte, Edema, Hemorrhage ) CLINICAL MANIFESTATION JOINT CNS FUO FEVER SEPTIC EMBOLI IE ICTER EYE KIDNEY HEART SKIN PAIN LUNG IE & IDU More common in cocain users Febrile IDU = IE No underlying heart disease More common in tricuspid valve Aortic > Aortic + Mitral > Mitral valve Pumonary septic emboli S aureous, P aueroginosa IDU & HIV / AIDS IE & ELDERLY Increased incidence in elderly Prolonged survival with CVD, PHV in elderly, Intravascular monitoring devises, Surgical implant material. No specific symptoms & sings Strep faecalis & bovis are common. Diagnosis may be difficult. Prompt empirical therapy : Vancomycin + Gentamycin Cardiac complications : CHF, Conduction abnormality, Arrhythmias, Myocarditis, Myocardial abscess. LAB FINDING Anemia ( normochromic, normocytic, Fe, IBC ) Thrombocytopenia ( 5 – 15 % ) Leucocyte count ( or or ) Large mononuclear cells ( histiocyte ) ESR ( mean 57 mm/hr ) Hypergammaglobulinemia Positive RF ( 40 – 50 % ) Complement ( 5 – 15 % ) Positive VDRL & positive CIC U/A ( protein,RBC, WBC ) Positive blood culture & Positive ECHO Serology & Teichoic acids antibody DIAGNOSIS Durack DT, Lukes AS, Bright DK, Criteria Definite ( Pathologic & Clinical Criteria ) Possible Rejected CLINICAL CRITERIA 2 Major or 1 Major & 3 Minor or 5 Minor MAJOR CRITERIA Positive blood culture Evidence of endocardial involvement MINOR CRITERIA Predisposing heart disease or IDU Fever > 38 Vascular phenomena Immunologic phenomena ECHO Microbiologic evidence POSITIVE BLOOD CULTURE Typical microorganisms: ( S. viridance, S. bovis, HACEK, Entrococci, S. aureous in the absence of primary focus) Persistently positive blood cultures ( B/Cs drown more than 12 hr apart, or All of 3 or majority of 4 separate B/Cs with 1st & last drawn at least 1 hr apart ) HACEK: Haemophilus spp, Actinobacillus spp, Cardiobacterium homonis, Ekinella corrodence Kingella kingae EVIDENCE OF ENDOCARDIAL INVOLVEMENT Positive ECHO for IE Oscillating intracardiac mass Abscess New dehiscence of prosthetic valve New valvular regurgitation veg Mitral valve Vegetation Mitral valve vegetation TREATMENT Antimicrobial therapy High dose, prolonged & IV antibiotics Surgical therapy ANTIMICROBIAL THERAPY Empirical therapy Organisms based therapy Duration of treatment MONITORING ANTIMICROBIAL THERAPY •Serum concentration of antibiotic should be monitoring. •Antibiotic toxicities should be considered. •Blood culture should be repeated daily Sterile •Rechecked B/C if there is recrudescent fever. •Performed B/C 4 – 6 WKS after therapy to document cure. MONITORING ANTIMICROBIAL THERAPY •B/C became sterile after start antibiotics: 2 days in S.Viridance Enterococci HACEK organisms 3 – 5 days in S. Aureus + beta lactam 7 days in S. Aureus + Vancomycin MONITORING ANTIMICROBIAL THERAPY If fever persist for 7 days in spite appropriate AB Evaluate patient for: Paravalvular abscess Extracardiac abscess Embilic event Vegetation became smaller with effective therapy 3 months after cure: 50% unchanged 25% are slightly larger SURGICAL THERAPY Refractory CHF > One serious systemic emboli Uncontrolled infection Valve dysfunction ( ECHO ) Fungal & Brucella endocarditis Mycotic aneurysms Prosthetic valve Local suppurative complications Large vegetation > 1 cm Vegetation size after 4 WKS Aortic valve endocarditis Acute valve insufficiency Recurrent endocarditis INDICATION FOR SURGICAL INTERVENTION Surgery required for optimal outcome Surgery to be strongly considered for improved outcome INDICATION FOR SURGICAL INTERVENTION Surgery required for optimal outcome: *Moderate to severe CHE due to valvular dysfunction. *Partially dehisced unstable prosthetic valve. *Persistent bacteremia despite optimal AB therapy. *Lake of effective microbial therapy ( fungal, Brucella… *S. Aureus PVIE + intra cardiac complication. *Relapse of PVIE after optimal therapy INDICATION FOR SURGICAL INTERVENTION Surgery to be strongly considered for improved outcome: *Peivalvular extension of infection *Poorly responsive S. aureus in aortic or mitral valve. *Large > 10 Cm hypermobile vegetation *Persistent unexplained fever >10 days in culture -ve IE. *Poorly responsive or relapse ( Entrococci & Gram-ve ) Valve Ring abscess Intra operation After repair Intraoperative TEE PROPHYLAXIS OF ENDOCADITIS Potential Interventions Alleviation of predisposing condition Immunization against bacteria Inhibition of bacterial adherence Application of antiseptic in the mouth Administration of antibiotics Procedure Causing Bacteremia: Oral cavity Respiratory tract Genitourinary tract Gastrointestinal tract Vascular system RISK OF IE WITH CARDIAC DISORDERS HIGH RISK: PHV, PID, Cyanotic CHD, PDA, AS, MR, VSD, Coarctation of aorta INTERMEDIATE RISK Prolapse +MR, MS, TS, TR Bicaspid Aorta, Degenerative Heart Disease LOW / NO RISK Prolapse Mitral, ASD, Aterosclerosic Plaques, CAD, Pacemaker. ANTIBIOTIC PROPHYLAXIS High risk procedures Recommended & High risk of cardiac disease High risk procedures Recommended & Intermediate risk of cardiac disease Low risk procedures Optional & High risk of cardiac disease RECOMMENDED REGIMENS Procedures: Dental, upper Res, GI, GU, Implantation of Prosthetic Valve Amoxicillin PO Clindamycin Po Ampicillin + Gentamycin Cefazolin Vancomycin + Gentamycin Before & After