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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