Infective Endocarditis Ie

INFECTIVE
ENDOCARDITIS (IE)
Dr. Raveendra K R
Asst . Prof of Medicine
BMCRI
Definition
Its
a medical emergency
characterized by the infection of the
cardiac endothelium, macroscopically
seen as vegetations
-----------------------------------------------------Virtually fatal if untreated

Mortality
25%
rate even with treatment is
Classifications of IE
Acute
IE : fatal in < 6 weeks

SBE
: fatal between 6 weeks- 6
months
Chronic IE: persists > 6 months
----------------------------------------------------Native valve endocarditis
Prosthetic valve endocarditis
Endocarditis in I.V. drug users
Culture negative endocarditis
Predisposing factors
CHD
20%
RHD 30%
VHD
IHD
MVP 10-33%
Prosthetic valves 10-20%
IV drug abuse
Unknown 20-40%
Symptoms of IE
Fever
(specially on cardiac patient)

but absent in elderly/ uremia/
Fatigue
Weight loss
Malaise
Night sweats
Muscular Pains
Sudden onset of CCF
Physical signs
Progressive
pallor
Petechiae (20-40%) frequently on
conjunctiva, palate, buccal mucosa,
upper extremities.
Splinter hemorrhages (10-30%)
sub-ungual, linear dark red streaks
(DD trauma)
Oslers nodes- small tender nodules
on fingers/ toe pads for hours-days
Physical signs
Janeway
lesions(<5%) small
hemorrhagic nodules over palms &
soles non tender
Clubbing (10-20%)
Roths spots (<5%) oval retinal
hemorrhages with clear pale centre
Spleenomegaly ( 25-60%)
Arterial embolism - femoral in fungal
endocarditis, pulmonary embolism in
drug abusers
Physical signs
Cardiac
manifestations CCF 55%

patients, mitral followed by aortic
valve & tricuspid
Appearance
of a new murmur or
changing of an existing murmursuspect IE
Neurological
manifestations- cerebral
emboli 20%, meningitis/ brain
abscess
< 5%
Native valve endocarditis

Commonest
organism streptococcus
viridans, later S.sanguis, S. mutans,
staphylococci, enterococci, etc.
Streptococci
25%
HACEK
60-80% and staphylococci
group 3% - (Haemophilus,
Actinobacillus, Cardiobacterium,
Eikenella & Kingella) gram ve
organisms, sometimes more
commensals in URT
Native valve endocarditis

Fungal
endocarditis candida ,
aspergillus
More
Most
in males, more in elderly
common valve Mitral then

Aortic
(on RHD)
IE in drug abusers
More
in young males, source through
skin
Organisms S. aureus 50%, streptococci
15%, fungi (candida) & gram ve
(pseudomonas) 10-15%
Valve affected Tricuspid 50%, Aortic
25%, mitral 20%
Acute onset/ multiple organisms common
Septic pul. Emboli causing pneumoniacommon
Any
Prosthetic valve
endocarditis
intra vascular/ intra cardiac

device predisposes for IE
Accounts
for 10-20% of all IE
Risk
is similar in mechanical &

bioprosthesis
Highest
risk <6 m , < 2m virtually

nosocomial
Intra
Prosthetic valve
endocarditis
vascular sutures, pacemaker

lines, teflon silastic tubes act as foci
of infection
Aortic
valve > mitral valve prosthesis
Fungi
account for 10-15 %, has high

mortality
Organisms
S.epidermidis, S. aureus,
gram ve bacteria, fungi, etc
Non bacterial Endocarditis

(NBE)
Culture
negative endocarditis 10%

usually by fastidious organismsfungi, HACEK group, anerobes,
legionella, chlamydia, coxiella
brunetti, Libmans Salk, anti
phospholipid syndrome, infections
after previous antibiotics
Late
diagnosis, difficult to treat,

sometimes poor prognosis
Pathogenesis
Pathogenesis
Diagnosis of IE
Suspicion
of IE
- fever with predisposing
factors
- PUO
- acute CCF
- appearance of a new murmur
- changing murmurs
Investigations
Routine
blood
increased WBC,
decreased Platelet count,
increased ESR
Blood
culture 3 sets of cultures at

3 different venepuncture before
antibiotic use, for aerobic/anerobic/
fungal cultures
Investigations
ECG-
non specific, MI. tachycardia
Chest-
X ray acute CCF, pleural

effusion , infiltrates
2D
ECHO- vegetations,abscess, etc

identify, localise &
characterise
Duke criteria
Major
positive blood culture

evidence of endocardial involvement
- + ve ECHO finding
- new valvular regurgitations
Minor
criteria predisposing factors

- fever >38 C
-vascular phenomenon
- microbiological phenomenon
-ECHO
Management of IE
Medical
emergency- hospitalization ICU
Antibiotic
( broad spectrum) drug of
choice
penicillin G
12-18million U/24 hr x 4 weeks
ceftriaxone
2gm daily iv
x 4 weeks
GM1 mg/ kg iv tid
x 2 weeks
vancomycin 30 mg/d bid
x 4 weeks
Procedure
Usually
Or
pen + GM x 4 weeks
ceftriaxone+ GM
x 4 weeks
Broad
spectrum penicillin
Or third generation cephalosporins used
After
sensitivity report the antibiotics

may be changed appropriately
Anti-
fungal for fungal IE
Surgery in IE
Uncontrolled
CCF (valve
dysfunction)
Fungal IE
Large vegetations
Myocardial/ valve abscess/ fistula
Unstable prosthetic valves
Culture ve endocarditis
Worst prognostic features

Non
streptococcal group
Age > 70 years
Aortic valve involvement
Fungal IE
Large vegetations
Culture ve endocarditis
Prosthetic valve endocarditis
Development of CCF only
Complications of IE
Acute
CCF
death
Abscess ( pericadial/ aortic/
myocardial)
Coronary embolism
Valve regurgitation/ stenosis
Septal perforation ( VSA)
Systemic embolism
( kidney/spleen/brain/ lungs/retina/
limbs)
Mycotic anneurysm
Thank you

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INFECTIVE

-----------------------------------------------------Virtually fatal if untreated

rate even with treatment is

IE : fatal in < 6 weeks

(specially on cardiac patient)

manifestations CCF 55%

Native valve endocarditis

60-80% and staphylococci

Native valve endocarditis

in males, more in elderly

common valve Mitral then

in young males, source through

intra vascular/ intra cardiac

for 10-20% of all IE

is similar in mechanical &

risk <6 m , < 2m virtually

vascular sutures, pacemaker

valve > mitral valve prosthesis

account for 10-15 %, has high

Non bacterial Endocarditis

negative endocarditis 10%

diagnosis, difficult to treat,

culture 3 sets of cultures at

non specific, MI. tachycardia

X ray acute CCF, pleural

ECHO- vegetations,abscess, etc

positive blood culture

criteria predisposing factors

emergency- hospitalization ICU

( broad spectrum) drug of

sensitivity report the antibiotics

fungal for fungal IE

Worst prognostic features

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