Infective endocarditis

PROF PM KOLO,
DEPARTMENT OF MEDICINE, FCS
COLLEGE OF HEALTH SCIENCES
UNIVERSITY OF ILORIN
 Outline
• Introduction
• Classifications
• Pathophysiology
• Clinical features
• Modified Dukes criteria
• Investigations
• Management
• Guidelines
• Indications for surgical intervention
• Complications
• Indications for prophylaxis
 Introduction
• Infective endocarditis (IE) is a life threatening infection
of the endocardial surfaces of the heart
• Usually of 1 or more cardiac valves; to a lesser
degree the mural endocardium; or a septal defect.
• IE may lead to severe valvular insufficiency, intractable
congestive heart failure, and myocardial abscesses.
• The signs and symptoms vary
widely including infected and sterile emboli and a
variety of immunological pathways.
• If its diagnosis is unduly delayed or treatment is
inadequate, IE inevitably is fatal
 Classification
• In infective endocarditis, size matters: risk of
embolism and indications for surgical
intervention depends size of the vegetations
• Endocarditis can be classified according to
temporal evolution of the disease, site of
infection, the cause, or the predisposing factors.
• A cute endocarditis is a febrile illness that rapidly
damages cardiac structures, seeds extracardiac
sites and if untreated, may progress to death
 Classification
• Acute bacteria endocarditis
• Much more aggressive disease
– Rapid onset of high grade fever, chills & rigour
– Rapid onset of heart failure
– Hx of antecedent procedure or illicit drug use
• Subacute bacteria endocarditis
• Hx of indolent process xtized by fever, fatigue,
anorexia, back pain and weight loss
 Classification

• The majority of subacute disease caused by S viridans

infection is related to dental disease.
• Most cases are not caused by dental procedures but by
transient bacteremias secondary to gingivitis.
• In 85% of patients, symptoms of endocarditis appear
within 2 weeks of dental or other procedures.
• The interval between the onset of disease and
diagnosis averages approximately 6 weeks.
• The fact that less than 50% of patients have previously
diagnosed underlying valvular disease significantly
limits the effectiveness of antibiotic prophylaxis
 Classification

• The distinction between these 2 polar types of IE has

become less clear.
• Intermittent use of antibiotics aimed at treating
misdiagnosed endocarditis can suppress bacterial
growth within the valvular thrombus, giving rise to the
state of muted IE.
• This often it the case in NIE (also referred to as
healthcare-associated IE [HCIE]), which commonly
manifests with elements of a sepsis syndrome
(ie,hypotension, metabolic acidosis, fever, leukocytosis,
and multiple organ failure).
 Types
• In developed world, incidence ranges from 4-7
cases per 100 000 population per year.
• While cong heart dx remains constant, the
etiology has shifted from RHDx to illicit IV drug
use, degenerative valve disease and intracardiac
devices in developed world. RHDx is still common
in developing world.
• Native valve endocarditis (NVE)
• Prosthetic valve endocarditis (PVE)
• Endocarditis involving cardio-vascular
implantable electronic devices (CIEDs)
 Aetiology & Pathogenesis of IE
• Undamaged endothelium is resistant to most
bacteria and thrombus formation
• Endothelial injury due to impact of high-
velocity blood jets or on the low-pressure side
of a cardiac structural lesion
• Direct invasion by virulent organisms or devpt
of a platelet-fibrin thrombus causing
nonbacterial thrombotic endocarditis (NBTE)
 Aetiology & Pathogenesis of IE
• Thrombus serves as site of bacteria
attachment during transient bacteremia
• Organisms that cause endocarditis enter the
blood stream from mucosal surfaces, skin or
site of focal infection
• Many of these organisms have surface adhesin
molecules collectively called microbial surface
components recognizing adhesin matrix
molecules (MSCRAMMs)
 Aetiology & Pathogenesis of IE
• Organisms
• Streptococcus viridians
• Staphylococcus aureus
• Fastidious gram-negative coccobacilli (HACEK
group)-Haemophilus species, Aggregatibacter
species, Cardiobacterium hominis, Eikenella
corrodens and Kingella kingae)
• Pseudomonas aerugenosa
 Pseudomonas aeroginosa

• Infection with P aeruginosa has a high rate of

neurologic involvement, with 2 distinctive
features: (1)mycotic aneurysms with a higher-
than-average rate of rupture and (2)
panophthalmitis (10% of patients). The course
of infection with P aeruginosa is much slower
than that of S aureus
 Clinical features
• FEATURE FREQUENCY%
• Fever 80-90
• Chill & sweats 40-75
• Anorexia, weight loss, malaise 25-50
• Myalgias, athralgias 15-30
• Back pain 7-15
• Heart murmurs 80-85
• New onset regurgitant murmur 20-50
• Arterial emboli 20-50
• Splenomegaly 15-50
• Cubbing 10-20
• Neurological manifestations 20-40
• Peripheral manifestations 2-15
• Petechiae 10-40
 Laboratory manifestations
• FEATURE FREQUENCY %
• Anemia 70-90
• Leukocytosis 20-30
• Microscopic haematuria 30-50
• Elevated ESR 60-90
• Elevated CRP >90
• Rheumatoid factor 50
• Circulating immune complexes 65-100
• Decreased serum complement 5-40
 Diagnosis
• High index of suspicion
• Approximately 5-8% of febrile individuals who
abuse IV drugs have underlying IE. Many users
of illicit drugs may lose their fever within a few
hours of hospitalization. This phenomenon,
termed cotton wool fever, is probably caused
by the presence of adulterants contained
within the injected drugs
Infective endocarditis
Infective endocarditis
Diagnostic criteria of IE
Indications for Echo
 Differential diagnosis

• COVID-19 with or without concurrent IE

• Thrombotic nonbacterial endocarditis

• Vasculitis

• Temporal arteritis

• Marantic endocarditis

• Connective tissue disease (Libman Salk endocarditis)

• Fever of unknown origin

• Intra-abdominal infections

• Septic pulmonary infarction

 Differential diagnosis
• Antiphospholipid Syndrome

• Atrial Myxoma

• COVID-19 Reinfections

• COVID-19 Vaccines

• Lyme Disease

• Polymyalgia Rheumatica

• Primary Cardiac Neoplasms

• Reactive Arthritis
 Management
The major goals of therapy for IE are to
eradicate the infectious agent from the
thrombus and to address the intra and
extacardiac complications of valvular
infection.
The latter includes both the intracardiac and
extracardiac consequences of IE. Some of the
effects of IE require surgical intervention
 Emergency care

• Emergent care should focus on making the correct

diagnosis and stabilizing the patient.
• General measures include the following:

• Treatment of congestive heart failure

• Supplemental oxygenation if required

• Hemodialysis may be necessary in the setting of severe

renal failure
 Guidelines

• Antibiotics are the mainstay of treatment for infective

endocarditis (IE).
• Goals to achieve to maximize clinical outcomes are
early diagnosis, accurate microorganism identification,
reliable susceptibility testing, prolonged intravenous
(IV) administration of bactericidal antimicrobial agents,
proper monitoring of potentially toxic antimicrobial
regimens
• Aggressive surgical management of correctable
mechanical complications.
Controversies on infective endocarditis
prophylaxis
• Cardiologists and microbiologists controversies
on effectiveness of the prophylaxis in the
prevention of infective endocarditis
• Reference:
• Ibrahim AM, Siddique MS. Subacute bacterial
endocarditis prophylaxis. Updated 2022, May 15,
In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2022Jan. Available at:
https://www.ncbi.nlm.nih.gov/books/NBK532983
/
 References
• Harrison Principles of Internal Medicine 20th
Edition: Infective Endocarditis: pg 921.
• Ibrahim AM, Siddique MS. Subacute bacterial
endocarditis prophylaxis. Updated 2022, May
15, In: StatPearls [Internet]. Treasure Island
(FL): StatPearls Publishing; 2022Jan. Available
at:https://www.ncbi.nlm.nih.gov/books/NBK5
32983
 References
• Gilbert Habib, Patrizio Lancellotti, Manuel J Antunes, Maria Grazia
Bongiorni, Jean-Paul Casalta, Francesco Del Zotti, Raluca Dulgheru,
Gebrine El Khoury, Paola Anna Erba, Bernard Iung, Jose M Miro,
Barbara J Mulder, Edyta Plonska-Gosciniak, Susanna Price, Jolien
Roos-Hesselink, Ulrika Snygg-Martin, Franck Thuny, Pilar Tornos
Mas, Isidre Vilacosta, Jose Luis Zamorano, ESC Scientific Document
Group, 2015 ESC Guidelines for the management of infective
endocarditis: The Task Force for the Management of Infective
Endocarditis of the European Society of Cardiology (ESC)
Endorsed by: European Association for Cardio-Thoracic Surgery
(EACTS), the European Association of Nuclear Medicine
(EANM), European Heart Journal, Volume 36, Issue 44, 21
November 2015, Pages 3075–
3128, https://doi.org/10.1093/eurheartj/ehv319