Infective Endocarditis
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Infective endocarditis Assoc.Prof.Dr.Zurkurnai Yusof USM
Who gets infective endocarditis Incidence: appr. 1.7 – 6.2 cases per 100000 patient years Rates higher in at risk cohorts such as iv drug users Men > women (2:1) Incidence progressively increases with age Underlying degenerative aortic and mitral predominate esp in the West
What is the underlying pathophysiology Ulceration on the valvular endothelial surface promotes bacterial adherence: Direct contact between blood and subendothelial components results in production of coagulum or small clot Local inflammation promotes cells to express transmembrane proteins that bind fibronectin
How do patients present? Fever 90% Poor appetide and weight loss Heart murmurs 80% Vasculitic phenomenon such as splinter h’rhage, Roth spots, and GN remain common Emboli to brain, lung, or spleen in 30% of patients Mycotic aneurysm Osler’s nodes and Janeway lesions uncommon Atypical presentation common in elderly or immunocompromised
Osler’s node
Purpuric lesions
How to investigate endocarditis Blood cultures 3 sets drawn one hour apart No evidence to take at temperature peaks
Micro‐organisms responsible for native valve and prosthetic valve endocarditis in recent European survey
What to do when the cultures are negative Blood cultures negative in 14%, delaying diagnosis and the start of treatment Commonly related to previous antibiotics administration Fastidiuos pathogens: Legionella, Coxiella, the HACEK gp(Haemophilus sp., Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae) Fungi: Candida, Histoplasma, and Aspergillus sp.
What to do when the cultures are negative Serological testing‐ possibility of Coxiella burnetti and Bartonella infection Histological techniques Polymerase chain reaction, to detect fastidious and non‐culturable agents
Echocardiography Transthoracic Transesophageal Ix potential Cx: mechanism of significant valvular regurg perivalvular abscesses
Diagnostic criteria Von Ryen criteria: published in early 1980’s Duke criteria: 1990s Modified Duke criteria: in the latest guidelines from ESC
Modified Duke criteria Pathological criteria Positive histology or microbiology of pathological material obtained at autopsy or cardiac surgery Major criteria Two positive blood cultures showing typical organisms consistent with infective endocarditis, such as Streptococcus viridans and the HACEK group OR Persistent bacteraemia from 2 blood cultures taken > 12 hours apart or 3 or more positive blood cultures where the pathogen is less specific, such as Staphylococcus aureus and Stap epidermidis OR Positive serology for Coxiella burnetti, Bartonella species, or Chlamydia psittaci OR Positive molecular assays for specific gene targets
Antimicrobial treatment Choice and length of treatment dictated by pathogen isolated from cultures require collaboration of microbiologist and physician Factors to consider for empirical treatment: patient related risk factors local bacterial resistance pattern Switch to appropriate antibiotic as soon as cultures and sensitivites are available Treatment duration: 4 to 6 weeks
Special subgroups Prosthetic valves Incidence: 0.1 to 2.3% per year 10‐15% of the cases TOE almost always indicated Classifications: Early Late Early onset: Staphylococci predominate Late onset: mirrors that of native valve endocarditis Complications: common aortic root abscess
Special subgroups Prosthetic valves Treatment: difficult prolonged antibiotics surgery when needed, is technically demanding Overall mortality: 40‐50% Specialist care mandatory
Special subgroups Intravenous drug users Incidence: 1‐5% a year rising in UK Equal frequency on right sided and left sided Most common pathogen: Staph aureus Problems: Management difficulties recurrence high cardiac surgeons reluctancy to operate mortality high
Who needs surgery Surgery‐ potentially life saving Outcome related to: valvular regurgitation abscess formation heart failure embolic complications Rarely vegetations cause valve obstruction Overall, surgery is needed in appr. 50% of the cases Careful timing essential for good outcome
Who needs surgery Urgent surgery should be considered: Haemodynamic compromise due to valve destruction Persistent fever despite appropriate antibiotic treatment Development of abscesses or fistulae due to perivalvular spread of infection Involvement of highly resistant organisms PVE (particularly in the early postoperative phase) Large vegetations with high embolic potential (> 10 mm or on the mitral valve
Prophylaxis
Who gets infective endocarditis Incidence: appr. 1.7 – 6.2 cases per 100000 patient years Rates higher in at risk cohorts such as iv drug users Men > women (2:1) Incidence progressively increases with age Underlying degenerative aortic and mitral predominate esp in the West
What is the underlying pathophysiology Ulceration on the valvular endothelial surface promotes bacterial adherence: Direct contact between blood and subendothelial components results in production of coagulum or small clot Local inflammation promotes cells to express transmembrane proteins that bind fibronectin
How do patients present? Fever 90% Poor appetide and weight loss Heart murmurs 80% Vasculitic phenomenon such as splinter h’rhage, Roth spots, and GN remain common Emboli to brain, lung, or spleen in 30% of patients Mycotic aneurysm Osler’s nodes and Janeway lesions uncommon Atypical presentation common in elderly or immunocompromised
Osler’s node
Purpuric lesions
How to investigate endocarditis Blood cultures 3 sets drawn one hour apart No evidence to take at temperature peaks
Micro‐organisms responsible for native valve and prosthetic valve endocarditis in recent European survey
What to do when the cultures are negative Blood cultures negative in 14%, delaying diagnosis and the start of treatment Commonly related to previous antibiotics administration Fastidiuos pathogens: Legionella, Coxiella, the HACEK gp(Haemophilus sp., Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae) Fungi: Candida, Histoplasma, and Aspergillus sp.
What to do when the cultures are negative Serological testing‐ possibility of Coxiella burnetti and Bartonella infection Histological techniques Polymerase chain reaction, to detect fastidious and non‐culturable agents
Echocardiography Transthoracic Transesophageal Ix potential Cx: mechanism of significant valvular regurg perivalvular abscesses
Diagnostic criteria Von Ryen criteria: published in early 1980’s Duke criteria: 1990s Modified Duke criteria: in the latest guidelines from ESC
Modified Duke criteria Pathological criteria Positive histology or microbiology of pathological material obtained at autopsy or cardiac surgery Major criteria Two positive blood cultures showing typical organisms consistent with infective endocarditis, such as Streptococcus viridans and the HACEK group OR Persistent bacteraemia from 2 blood cultures taken > 12 hours apart or 3 or more positive blood cultures where the pathogen is less specific, such as Staphylococcus aureus and Stap epidermidis OR Positive serology for Coxiella burnetti, Bartonella species, or Chlamydia psittaci OR Positive molecular assays for specific gene targets
Antimicrobial treatment Choice and length of treatment dictated by pathogen isolated from cultures require collaboration of microbiologist and physician Factors to consider for empirical treatment: patient related risk factors local bacterial resistance pattern Switch to appropriate antibiotic as soon as cultures and sensitivites are available Treatment duration: 4 to 6 weeks
Special subgroups Prosthetic valves Incidence: 0.1 to 2.3% per year 10‐15% of the cases TOE almost always indicated Classifications: Early Late Early onset: Staphylococci predominate Late onset: mirrors that of native valve endocarditis Complications: common aortic root abscess
Special subgroups Prosthetic valves Treatment: difficult prolonged antibiotics surgery when needed, is technically demanding Overall mortality: 40‐50% Specialist care mandatory
Special subgroups Intravenous drug users Incidence: 1‐5% a year rising in UK Equal frequency on right sided and left sided Most common pathogen: Staph aureus Problems: Management difficulties recurrence high cardiac surgeons reluctancy to operate mortality high
Who needs surgery Surgery‐ potentially life saving Outcome related to: valvular regurgitation abscess formation heart failure embolic complications Rarely vegetations cause valve obstruction Overall, surgery is needed in appr. 50% of the cases Careful timing essential for good outcome
Who needs surgery Urgent surgery should be considered: Haemodynamic compromise due to valve destruction Persistent fever despite appropriate antibiotic treatment Development of abscesses or fistulae due to perivalvular spread of infection Involvement of highly resistant organisms PVE (particularly in the early postoperative phase) Large vegetations with high embolic potential (> 10 mm or on the mitral valve
Prophylaxis
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