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Transcript of Infective endocarditis
This term includes:
caused by viruses, fungi, and other microbiologic agents.
Definition of infective endocarditis (IE).
Who are at risk for developing IE?
What's the cause of IE?
What's the clinical picture&investigations.
How can you diagnose a case of IE?
How can you prevent IE?
How can you treat IE?
1)Positive blood cultures:
Two separate cultures for a usual pathogen, 2 or more for less typical pathogen.
2)Evidence of endocarditis on ECHO:
Intracardiac mass on a valve or other site, regurgitant flow near a prosthesis, abscess, partial dehiscence of prosthetic valves, or new valve regurgitant flow.
If a positive blood culture is obtained and the organism is identified,
specific therapy should be instituted immediately.
If blood cultures are negative after 48 hr and there is other evidence of infective endocarditis,
it is advisable to begin
(200,000 U/kg/day) IV in 4–6 equally divided doses or
(100 mg/kg/day) IV/IM in 1 dose “for 4 days”
“ for 2 days”
Bed rest, digitalis, salt restriction and diuretic therapy should be used
when congestive heart failure occurs.
Removal of vegetations & valve replacement:
Intractable HF due
to aortic or mitral involvement, infected prosthetic valve, unresponsiveness to medical ttt, fungal endocarditis.
in case of rupture of aortic sinus of valsalva & mycotic aneurysm.
Prior congenital or rheumatic HD.
Prior cardiac surgery.
Prosthetic material or valve.
Central venous catheter.
IV drug abuse.
Preceding dental, urinary or GIT procedure.
Chest & abdominal pain.
Arthralgia & myalgia.
Malaise & dyspnea.
Weight loss & night sweat.
By “The Duke's criteria”
Major criteria of Duke
Minor criteria of Duke
2 major criteria, or
1 major and 3 minor, or
5 minor criteria
Dental and oral procedures or surgery of the upper respiratory tract or esophagus:
can detect the cardiac lesion and its effect on ventricular size and function.
can detect the valvular vegetations larger than 2-3 mm to confirm the diagnosis of infective endocarditis
(> 1 cm predicts embolic complications).
Urine, synovial fluid, abscesses, and CSF (in case of meningitis).
Complete blood count:
Anemia & Leucocytosis with shift to the left.
Increased sedimentation rate
Increased C- reactive protein.
However, the absence of vegetations does not exclude endocarditis (very small in early phase)!!!!
Jane –way lesions
Infection of the endocardial surface of the heart or the intimal surface of certain arterial vessels (endarteritis) as coarcted segment of aorta and PDA.
Dental procedures (streptococcus viridans),
Nonsterile instrumentation of GIT or genitourinary systems (group D enterococci).
IV drug use (Pseudomonas aeruginosa).
Open heart surgery (fungi),
Central venous catheter (coagulase negative staphylococcus).
is responsible for 50% of cases.
is the most common organism that affects patients who do not have underlying heart disease (acute infective endocarditis).
Features of the underlying cardiac disease.
Appearance of new murmur or change in the character of the present murmur.
Loud (sea-gull) murmur in case or rupture of valve cusps.
Heart failure, Arrhythmias
microscopic hematuria, gross hematuria, immune complex GN.
6) Renal manifestations:
emboli, cerebral abcesses, mycotic aneurysm, Hge. (staph).
8) Pulmonary & other systemic emboli:
rare except with fungal disease
Predisposing conditions e.g. dental procedure.
Embolic vascular signs
Immune complex phenomena (glomerulonephritis, arthritis, rheumatoid factor, osler nodes)
Single positive blood culture or serologic evidence of infection.
ECHO signs not meeting the major criteria.
The following minor criteria are added:
newly diagnosed clubbing.
high C-reactive protein
the presence of microscopic hematuria.
Modified Duke Criteria
For most patients:
Oral Amoxicillin (50mg/Kg) 1 hour before the procedure.
If unable to take oral:
IM or IV Ampicillin (50mg/Kg) 30 min before the procedure.
In penicillin allergic patients:
oral Clindamycin (20mg/kg) 1 hour before the procedure.
In penicillin allergic patients unable to take oral:
IV Clindamycin (20mg/kg) 30 min before the procedure.
GIT and Gentourinary tract surgery and instrumentation: ( No oral)
IM or IV
(1.5 mg/kg) 1/2 hour before the procedure.
6 hours later, IM or IV Ampicillin (25mg/kg).
If penicillin allergic replace ampicillin with
Mortality rate is 20- 25%.
due to toxic myocarditis , myocardial abscesses, aortic or mitral valve obstruction (by vegetation).
Systemic emboli infarction & abscesses:
CNS, lungs, kidneys.
Mycotic aneurysm in CNS :
Ruptured sinus of valsalva.
(abscess of the conduction system)
Prognosis & complications:
High-risk groups :
- Patients with congenital or rheumatic heart diseases, especially with lesions associated with a high velocity of blood
- Survivors of cardiac surgery.
- Patients with prosthetic material (valve conduit) and valves.
- Patients without pre-existing heart disease who have immune deficiency, chronic central venous catheters or who are intravenous drug abusers.