INFECTIVE ENDOCARDITIS

- A REVIEW.Dr Hasan Mahmud Iqbal

NHFH&RI.

Definition:

IE is defined as infection of heart valve(native or prosthetic) , lining of a cardiac chamber or blood vessel or congenital anomaly (eg septal defect) and implanted devices caused by micro-organism that invariably fatal if untreated.

Population Groups At Greater Risk: •Congenital Heart Disease(Aortic valve-BAV,VSD,Tetralogy of Fallot, MVP, ASD primum)•Acquired heart disease(eg. AR, MR)•Hemodialysis•Previous History Of Endocarditis•Patients With Prosthetic Valves•IV Drug Users (30% Risk Within 2 Years)• No identifiable cause in 25-47 %

Infective endocarditis classifications: On the basis of heart valve 1.Native–valve endocarditis: associated with congenital heart disease and chronic rheumatic heart disease. NVE infection is largely confined to leaflets. 2.Prosthetic-valve endocarditis: Incidence 10-30%, Commonly extends beyond valve ring into annulus or periannular tissue.(Ring abscesses, Septal abscesses, Fistulae, Prosthetic dehiscence.) (a)Early-PVE: infection within 2 months to 1 year of surgery (b) Late -PVE: infection after 1 year of surgery

On the basis of culture:Culture positive IE : - up to 80%

Culture negative IE : -Upto 20%, highly fastidious organism, inadequate culture technique, non bacterial pathogen, previous antibiotics therapy,non infectious endocarditis like Libman sac(APS),marantic endocarditis(malignancy).

On the basis micro-organism: Bacterial- (predominant)- Staph Aureus is single most common cause Non-bacterial- Fungi -common in drug abuser, immunosuppressed, cardiac surgery. -Large, friable vegetation. -High mortality(survival< 20%) -Rickettsia, Chlamydia(Others)

Mode of clinical presentationAcute: -Toxic presentation, Progressive valve destruction & metastatic infection developing in days to weeks. -Most commonly caused by S. aureus,Complications more.Subacute: Presentation over weeks to months, Rarely leads to metastatic infection - Most commonly S. viridans or enterococcus.

Causative agents:

●Staphylococci-S.aureus,S.albus●Streptococci-S.vridians,S.faecalis,S.mutans,S.bovis●Enterococci●Coxiella burnetii-H/O Contract with farm animals -Aortic valve affected mainly -Hepatitis,pneumonia,purpura -Life long antibiotic therapy

●HACEK group(Haemophillus,Actinobacillus actinomycetem-comitans,Cardiobacterium hominis,Eikenella) - Detected after prolonged culture - Resistant to penicillin● Brucella -H/O contact with goats or cattle -Affect mainly aortic valve●Yeast & fungi -Candida -Aspergillus

DIAGNOSIS

Modified Major Diagnostic Criteria –According to ESC 2015 Guideline: No :1

■Modified Major Diagnostic Criteria –According to ESC 2015 Guideline: No:2.

Nail Fold Infarction:

MANAGEMENT APPROACH:

DIET: No special diet ,If CCF – Salt restriction is necessary

Oxygen therapy –If necessary. 3 Sets of blood for culture& we have to

start empirical antibiotic therapy. If ALVF & CCF : Appro. Medical

management. Surgery – Carefully case selection.

Acutely I'll – Native Valve – Empirical Rx

Acutely I'll – Prosthetic Valve – Empirical Rx

Native Valve –Staphylococcal Infection

Native Valve: Penicillin Allergic -Staphylococcal

Prosthetic Valve –Staphylococcal Infection

Streptococcus- penicillin sensitive

Streptococcus- penicillin sensitive:

Streptococcus- penicillin allergic pt.

Treatment in Culture Negatives:

Indications for Surgery….

Chemoprophylaxis

Chemoprophylaxis:

Key Messages

Antibiotics are the mainstay of treatment for infective endocarditis (IE).

Goals to maximize treatment success are early diagnosis, accurate microorganism identification, reliable susceptibility testing, prolonged intravenous (IV) administration of bactericidal antimicrobial agents, proper monitoring of potentially toxic antimicrobial regimens, and aggressive surgical management of correctable mechanical complications.