Infective endocarditis

Assoc prof Ruxandra Jurcut

IUBCV “Prof.dr.C.C.Iliescu”
 Infective endocarditis
Definition
• infection of the endocardial surface of the heart –
valvular/m. rare mural endocardium
• Representative - vegetations
- platelets, fibrin, microorganisms,
inflammatory cells
• Endarteritis – persistent arterial duct

Mortality rate – 20-25%

 Infective endocarditis
• 70 -75% - pre-existing lesions
- rheumatic/ degenerative valvulopathy
- congenital heart diseases (not ASD)
- prosthesis, intracardiac devices (PM)
• 20 - 25% - normal heart valves

• IV drugs
 Pathophysiology
• Endothelial injury

• Regurgitations > stenosis; high turbulence zone

• vegetations tend to develop at sites where blood travels from an area of high pressure
through a narrow orifice into an area of lower pressure
• atrial face of the mitral valve; ventricular face of the aortic valve; right side of VSD
Pathophysiology

• transient bacteraemia
• microorganisms adherence
• invasion of the valvular
endocardial surface

Bashmore et al. Curr Probl Cardiol 2006

 Infective endocarditis
• Location
• IE of left chambers
- IE on native valves
- IE on prosthesis
• IE of right chambers
• Way of appearing
• IE associated with medical assistance (nosocomial or non~)
• Community- acquired IE
• IV drugs
• Recurrence
• Relapse: iteration of the same microorganism < 6 months
• Reinfection:
— different microorganism
— iteration of the same microorganism > 6 months
 Infective endocarditis
• NATIVE VALVES
- Streptococcus (viridans) – more species
- Staphylococcus – aureus, white (epidermidis)
- Streptococcus bovis (gallolyticus) - ! GI tract
- Enterococcus species
- HACEK
- GNB, ricketsia (Coxiella), chlamidia, fungi, Legionella
- 2-30% - negative hemocultures
 Infective endocarditis

• PROSTHESIS
- Early < 1 y
- Stphylococcus species –white (epidermidis),
aureus
- fungi
- GNB
- Late > 1 y
- the same as native valves
 Infective endocarditis

• IV drugs
- Staphylococcus – aureus
- GNB , fungi, polymicrobial infections

• Intracardiac devices
- Staphylococcus – white, aureus
 Basis of clinical changes

• Vegetations
- Valve distruction
- Interference with normal function
- Local intracardiac complications
• Embolization from cardiac vegetations
• Sustained bacteriaemia
• Immunological manifestations
*

*
Brush J. emedicine. 2012
 Clinical presentation

• Variable
• Fever ~95%
• new or change of heart murmur ~ 80%
- Signs of congestive heart failure
- Not of the right chambers
- Signs of systemic emboli ~ 30%
 Clinical presentation
• Peripheral lesions

• Subungual (splinter) hemorrhages

• Osler nodes

• Janeway lesions

• Roth spots

Mylonakis. NEJM 2001

 Clinical presentation
• Splenomegaly
• Petechiae, Conjunctival hemorrhage
• Digital clubbing
• Embolic manifestations
• Neurological
• Peripheral ischaemia, infarctions (visceral, coronary)
• Systemic septic emboli
 Lynfield. NEJM 2002
Clinical presentation Matsumoto, AnnThorac Surg 1998

• Mycotic aneurysms

- septic embolization of vasa vasorum

- CNS / Valsalva sinuses/ coronary arteries etc
- dilatation/ rupture
 Intracardiac complications
• Regurgitations
• Valvular obstructions
• Periannular abscesses
• Fistulas
• Conduction disturbances

E-heart.org
Andresen. Heart 2005
 Laboratory

• Inflammatory syndrome
- ESR, fibrinogen, CRP
- Nchromic, Ncytic anaemie, leucocytes ↑, platelets ↑→↓
• Procalcitonine +-
• Renal function– GN / abscesses/ stroke/ toxicity
• Urinalysis– grade of hematuria, proteins
• rheumatoid factor +
• Serum complement ↓
 Hemocultures
• Minimum of 3 sets – different veins, optimal t ∆ >30 min
• Each probe must contain 10 ml of blood
• Harvesting from peripheral vein (ideal not central catheter)
• Aerobic/anaerobic
• Incubation ~ 14 days
• +- special media for growth, fungi, serological tests

• Previous antibiotic treatment!

Blood culture - negative endocarditis (BCNE)

 Ethiological agent could not be identified on standard general purpose media

 31% of IE forms have (–) blood cultures
 Causes:
 Atypical bacteria, intracellular and fungi that require special media; in general- slow
growth
 Inappropriate antibiotic treatment
 Serology for Coxiella Burnetii, Bartonella spp,  Aspergillus spp,
Mycoplasma pneumonia, Brucella spp. and Legionella pneumophila is
recommended
Investigation of rare causes of BCNE

When all the microbiological tests

are negative, diagnosis of non-
infectious endocarditis will be
taken into consideration:
 ANA
 Ac anti-cardiolipina (IgG)
 Ac anti-β2-glicoproteina (IgG
sau IgM)
 Electrocardiogram

• Sinus tachycardia
• Conduction disturbances
• AV block, different grades NONSPECIFIC
• Bundle brach block etc
• Ventricular arrhytmias
• MI (embolic)
Imaging techniques

 Imaging, especially echocardiography, plays an essential role

in the diagnosis and management of IE.
 Echocardiography provides:
 Initial evaluation
 Risk and prognosis stratification
 Treatment follow- up
 intra-
and postoperative evaluation (TEE).
The evaluation of patients with IE shouldn’t limit itself to
echocardiography and complementary imaging techniques
should be used whenever necessary (MSCT, IRM, PET-CT).
Echocardiography

 TTE/TEE – first line- imaging modality in suspicion of IE.

 Essential role in diagnosis, management and monitoring.
 S.aureus bacteriaemia – new indication of echocardiographic
evaluation justified by:
 Increased frequency of IE at this patients
 Virulence of the microorganism
 Substantial endocardial destruction in IE with this bacteria
Echocardiography criteria

 3 major echocardiographic criteria:

 Vegetations
 Abscesses or pseudoaneurysms
 Prosthetic dehiscence
 Diagnostic Sn for vegetations is 70% (native valves) and 50% (prosthesis) for TTE,
respectively 96% and 92% for TEE.
 Sp – 90% for both types of echocardiography.
Lower Sn when:
• valvular lesions (MVP, massive calcification of the valves)
• mechanical prosthesis
• small vegetations (2-3 mm) or absence of vegetations
• IE on intracardiac devices
Anatomical/ echo defining

Sb in abscesses detection is 50% for

TTE and 90% for TEE
Sp over 90% for both methods

3D TEE anables a better quantification of:

 vegetations dimensions (embolic risk)
 paravalvular extension of infection
 prosthetic dehiscence and valvular
perforation
Mitral valve
vegetation
Aortic valve
vegetation
Aortic annulus abcess
Other imaging modality

 CT angiography
 Coronary arteries evaluation (if it’s at high risk of embolization from vegetation or
hemodynamic degradation during coronarography).
 Identification of cerebral lesions
 MSCT – high Sb and Sp in diagnosing abscesses and peripheral complications of IE.
 MR imaging
 MRI permits a better characterization of the cerebral lesions in patients with neurological
symptoms and many times it allows the establishment of the diasnosis in unclear
situations.
 Nuclear imaging
 SPECT and PET/CT
Pseudo-aneurysm – mitro-aortic region
Aortic
periprothetic
annulus abcess
Duke modified diagnostic criteria
Diagnostic criteria
Major criteria
Diagnostic criteria
Diagnostic algorithm
Prognosis of IE

 “Highest risk”
Heart failure
S.aureus
Periannular abscess
Treatment
Medication principles – bactericidal AB, high doses, long duration

Habib G et al. EHJ 2015

Staphiloccocus sp.

Habib G et al. EHJ 2015

Empirical therapy

Habib G et al. EHJ 2015

Normal response to treatment

• NORMAL
• No fever, blood cultures become negative~ 1 week
• PROBLEMS
• Persistent fever– uncontrolled infection,
medication, abscess, septic embolisation
• Renal function!!!
Surgical treatment
- Heart failure– especially refractory
- Uncontrolled infection
- Fever and blood cultures + after 7-10 days
- Abscesses, fistulas
- Fungi, resistant microorganisms
- Prevention of embolisation
- Optimal – after complete course of antibiotics
Surgical treatment

Emergency surgery:
surgery performed
within 24 h

Urgent surgery: within a

few days

Elective surgery: after at

least 1 – 2 weeks of
antibiotic Tx

Habib G et al. EHJ 2015

Prophylaxis of IE
 Guidelines 2003  2009  2015
- progressive reduction of indications

Preservation of antibiotic prophylaxis indications in high- risk patients

because:
 Exact estimation of the risk still remains unclear
 IE in this group of patients has a negative prognosis
 Lower number of high- risk patients than those with intermediate risk 
downsizing of the adverse effects
Patients with high- risk
1. Patients with prosthetic valves or materials (including the
percutaneous implantable ones)
2. Patients with personal history of IE
3. Patients with uncorrected congenital cyanogenic heart diseases
or with palliative shunts.

* Antibiotic prophylaxis is recommended only in the first 6 months after the

complete correction of the defects in patients with congenital heart diseases.
Non- specific prevention measures
 Strict dental and cutaneous hygiene (re-assessment at > 6 months for those at
high risk and annual for the rest of the population)
 Asepsis of wounds
 Eradication of chronic bacterial infections
 Curative antibiotic treatments for any infectious bacterial outbreak
 Avoiding self-medication
 Rigorous prophylaxis for any risk procedure
 Limiting the use of venous catheters and invasive procedures
 Discourage tattoos and piercings
 At risk procedures
 Dental interventions with gingival and periapical region handling
including oral mucosal injury.

 Procedures such as local anesthesia in uninfected tissue, simple caries

treatment, suture removal or handling of dental devices are excluded.

 * There is insufficient data on dental implants to contraindicate them in

patients at high risk.
Prophylaxis of dental interventions
 recommended only for patients at high risk  target are the streptococcus
species in the oral cavity

* alternatively, cephalexin 2 g iv for adults or 50 mg / kg iv for children may be

given; ceftriaxone / cefazolin 1 gr iv adults or 50 mg / kg iv children.
"Endocarditis Team" –
a multidisciplinary approach

 It may take different aspects depending on the first affected organ, the underlying
cardiac pathology, the presence or absence of complications and the characteristics
of the patient.

 The wide range of diagnostic and therapeutic methods make it necessary to

involve more specialists: cardiologists, microbiologists, cardiovascular surgeons,
neurologists, neurosurgeons.

 Class IB indication in the AHA / ACC 2014 guide.

Further reading
 https://academic.oup.com/eurheartj/article/36/44/3075/2293384
 www.uptodate.com
MCQ 1

1. The endocarditis lesions are all except:

a. Abcess
b. Vegetation
c. Stenosis
d. Pseudoaneurysm
MCQ 2

2. Patients at low or intermediate risk for endocarditis who

should not receive prophylaxis are:
a. patients with prosthetic valves
b. patients with personal history of IE
c. patients with severe aortic regurgitation
d. patients with uncorrected tetralogy of Fallot
Endocarditis - in special situations
Implantable devices

 Incidence of 1.9 / 1000 implanted devices/ year

 Increase in No of implants
 Age, comorbidities
 Location of the infection
 Probes, intracardiac elements
 Pocket infection: it is suspected in the presence of local elements (erythema,
fluctuation, suppuration, erosion)
 Mixed

 Underdiagnosed!
Implantable devices

 Risk factors
 CKD, CHF, DM
 Corticosteroid treatment
 Hematoma formation, anticoagulation therapy
 Microbiology
 60-80% Staphy, *coagulase negative
 Clinics - difficult
 Suspicion: inexplicable fever in patient with implantable device
 Echo: TTE/TEE/intracardiac
 Duke criteria difficult to apply (different? S.locale, pulmonary embolism)
Implantable devices

 Treatment
 AB according to the antibiogram: parenteral, minimum of 4
weeks
 Complete extraction of the lead
 Difficult, procedure death rate 0.1-0.6%
 Centres with neighbourhood and volume cardiac surgery
 Possible risk of pulmonary embolism
 Reimplantation according to the indications
Contralateral, min 72 h free interval
IE of the right chambers

 5-10% cases
 * tricuspid valve
 Special risk factors: iv drugs , devices, congenital heart diseases

 S.aureus 60-90%
 Clinical manifestations atypical; pulmonary embolism

 Death rate 7%