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LIKHILA ABRAHAM
Definition
Infective endocarditis (IE) is defined as an
infection of the endocardial surface of the
heart, which may include one or more
heart valves, the mural endocardium, or a
septal defect. Its intracardiac effects
include severe valvular insufficiency,
which may lead to intractable congestive
heart failure and myocardial abscesses. If
left untreated, IE is generally
fatal.(medscape)
Infective endocarditis (IE) is a
microbial infection of the
endothelial surface of the heart
or iatrogenic foreign bodies
like prosthetic valves or other
intracardiac devices
Types
Native valve endocarditis
(NVE), acute and subacute
Prosthetic valve endocarditis
(PVE),[10] early and late
Intravenous drug abuse
(IVDA) endocarditis
•Risk factors
•Structural heart disease
–Rheumatic, congenital, aging
–Prosthetic heart valves
•Injected drug use
•Invasive procedures (Intracardiac
pacemaker, ICD , AV Fistula)
•Indwelling vascular devices
•Other infection with bacteremia (e.g.
pneumonia, meningitis)
•Immunocompromised states
•History of infective endocarditis
Bacterial
Staphylococcus aureus followed
by Streptococci of the viridans group
and Coagulase negativ
Staphylococci are the three most
common organisms responsible for
infective endocarditis.
Other Streptococci and Enterococci ar
e also a frequent cause of infective
endocarditis.
Fungal and Viral
Candida albicans, a yeast, is
associated with endocarditis in IV
drug users
and immunocompromised patients.
Other fungi demonstrated to cause
endocarditis are Histoplasma
capsulatum and Aspergillus
HACEK organisms
Hemophilus,
Actinobacillus,
Cardiobacterium,
Eikenella, Kingella
Infective endocarditis
Nonbacterial Thrombotic
Endocarditis
Endothelial injury
Hypercoagulable state
Lesions seen at coaptation points
of valves
Atrial surface mitral/tricuspid
Ventricular surface
aortic/pulmonic
Clinical features
•Symptoms
–Fever, sweats, chills
–Anorexia, malaise, weight loss
•Signs
–Anemia (normochromic, normocytic)
–Splenomegaly
–Microscopic hematuria, proteinuria
–New or changing heart murmur, CHF
–Embolic or immunologic dermatologic
signs
–Hypergammaglobulinemia, elevated
ESR, CRP, RF
Cardiac Pathologic Changes
 Vegetations on valve closure lines
 Destruction and perforation of valve leaflet
 Rupture of chordae tendinae, intraventricular
septum, papillary muscles
 Valve ring abscess
 Myocardial abscess
 Conduction abnormalities
Infective endocarditis
S. Aureus mitral valve vegetation, anterior leaflet
 Pathologic Changes
 Kidney
◦ Immune complex glomerulonephritis
◦ Emboli with infarction, abscess
 Aortic mycotic aneurysms
Pathologic Changes
 Splenic enlargement, infarction
 Septic or bland pulmonary embolism
 Skin
◦ Petechiae
◦ Osler nodes: diffuse infiltrate of neutrophils,
and monocytes in the dermal vessels with
immune complex deposition. Tender and
erythematous
◦ Janeway lesions: septic emboli with bacteria,
neutrophils and S/C hemorrhage and necrosis.
Blanching and non-tender. Palms and soles
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
Roth spots
Infective endocarditis
Modified Duke Criteria
Two major criteria,
OR
One major and three minor criteria,
OR
Five minor criteria allows a clinical
diagnosis of definite endocarditis.
Other tests
 Electrocardiogram
◦ Conduction delays
◦ Ischemia or infarction
 Chest X-ray
◦ Septic emboli in right-sided IE
◦ Valve calcification
◦ CHF
Antimicrobial Therapy
 Blood culture become sterile within 2 days
 Fever resolves in 4 to 7 days
 If fever persists despite 7 days of antibiotics
evaluate for paravalvular or extracardiac
abscess
 Combination therapy most important for
◦ Shorter course regimens
◦ Enterococcal endocarditis
◦ Prosthetic valve infections
Streptococci susceptible to
pencillin
Infective endocarditis
Infective endocarditis
Infective endocarditis
NVE
 Fungal
◦ Amphotericin
◦ Fluconazole
◦ Caspofungin, little data
◦ Surgery usually necessary 1-2 weeks into treatment

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Infective endocarditis

  • 2. Definition Infective endocarditis (IE) is defined as an infection of the endocardial surface of the heart, which may include one or more heart valves, the mural endocardium, or a septal defect. Its intracardiac effects include severe valvular insufficiency, which may lead to intractable congestive heart failure and myocardial abscesses. If left untreated, IE is generally fatal.(medscape)
  • 3. Infective endocarditis (IE) is a microbial infection of the endothelial surface of the heart or iatrogenic foreign bodies like prosthetic valves or other intracardiac devices
  • 4. Types Native valve endocarditis (NVE), acute and subacute Prosthetic valve endocarditis (PVE),[10] early and late Intravenous drug abuse (IVDA) endocarditis
  • 5. •Risk factors •Structural heart disease –Rheumatic, congenital, aging –Prosthetic heart valves •Injected drug use •Invasive procedures (Intracardiac pacemaker, ICD , AV Fistula) •Indwelling vascular devices •Other infection with bacteremia (e.g. pneumonia, meningitis) •Immunocompromised states •History of infective endocarditis
  • 6. Bacterial Staphylococcus aureus followed by Streptococci of the viridans group and Coagulase negativ Staphylococci are the three most common organisms responsible for infective endocarditis. Other Streptococci and Enterococci ar e also a frequent cause of infective endocarditis.
  • 7. Fungal and Viral Candida albicans, a yeast, is associated with endocarditis in IV drug users and immunocompromised patients. Other fungi demonstrated to cause endocarditis are Histoplasma capsulatum and Aspergillus
  • 10. Nonbacterial Thrombotic Endocarditis Endothelial injury Hypercoagulable state Lesions seen at coaptation points of valves Atrial surface mitral/tricuspid Ventricular surface aortic/pulmonic
  • 11. Clinical features •Symptoms –Fever, sweats, chills –Anorexia, malaise, weight loss •Signs –Anemia (normochromic, normocytic) –Splenomegaly –Microscopic hematuria, proteinuria –New or changing heart murmur, CHF –Embolic or immunologic dermatologic signs –Hypergammaglobulinemia, elevated ESR, CRP, RF
  • 12. Cardiac Pathologic Changes  Vegetations on valve closure lines  Destruction and perforation of valve leaflet  Rupture of chordae tendinae, intraventricular septum, papillary muscles  Valve ring abscess  Myocardial abscess  Conduction abnormalities
  • 14. S. Aureus mitral valve vegetation, anterior leaflet
  • 15.  Pathologic Changes  Kidney ◦ Immune complex glomerulonephritis ◦ Emboli with infarction, abscess  Aortic mycotic aneurysms
  • 16. Pathologic Changes  Splenic enlargement, infarction  Septic or bland pulmonary embolism  Skin ◦ Petechiae ◦ Osler nodes: diffuse infiltrate of neutrophils, and monocytes in the dermal vessels with immune complex deposition. Tender and erythematous ◦ Janeway lesions: septic emboli with bacteria, neutrophils and S/C hemorrhage and necrosis. Blanching and non-tender. Palms and soles
  • 17. 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
  • 18. 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
  • 19. Janeway Lesions 1. More specific 2. Erythematous, blanching macules 3. Nonpainful 4. Located on palms and soles
  • 23. Two major criteria, OR One major and three minor criteria, OR Five minor criteria allows a clinical diagnosis of definite endocarditis.
  • 24. Other tests  Electrocardiogram ◦ Conduction delays ◦ Ischemia or infarction  Chest X-ray ◦ Septic emboli in right-sided IE ◦ Valve calcification ◦ CHF
  • 25. Antimicrobial Therapy  Blood culture become sterile within 2 days  Fever resolves in 4 to 7 days  If fever persists despite 7 days of antibiotics evaluate for paravalvular or extracardiac abscess  Combination therapy most important for ◦ Shorter course regimens ◦ Enterococcal endocarditis ◦ Prosthetic valve infections
  • 30. NVE  Fungal ◦ Amphotericin ◦ Fluconazole ◦ Caspofungin, little data ◦ Surgery usually necessary 1-2 weeks into treatment