INFECTIVE ENDOCARDITIS

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INFECTIVE ENDOCARDITIS Michael Sales 20/02/13

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INFECTIVE ENDOCARDITIS. Michael Sales 20/02/13. Infective Endocarditis. Colonisation or invasion of heart valves or mural endocardium by microbes Formation of vegetations composed of thrombotic debris & organisms Often associated with destruction of underlying cardiac tissue - PowerPoint PPT Presentation

Transcript of INFECTIVE ENDOCARDITIS

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INFECTIVE ENDOCARDITIS

Michael Sales20/02/13

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Infective Endocarditis• Colonisation or invasion of heart valves or mural endocardium

by microbes

• Formation of vegetations composed of thrombotic debris & organisms

• Often associated with destruction of underlying cardiac tissue

• Aorta, aneurysmal sacs, other blood vessels & prosthetic devices can be involved

• Most cases bacterial

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Acute IE• Infection of previously normal heart valve by a highly virulent

organism that produces necrotising, ulcerative, destructive lesions

• Difficult to cure with Abx & usually require Sx

• Death can occur within days to weeks despite Rx

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Subcute IE• Organisms are usually of lower virulence

• Cause insidious infections of deformed (native) valves that are less destructive

• Can take prolonged course: weeks to months

• More amenable to treatment with antibiotics

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Aetiology & Pathogenesis• Incidence 1.7-7.2 cases per 100 000

• Female to male 1:2

• Median age has increased from 30-40 to 47-69 yrs

• Rheumatic HD is no longer the major risk factor in Western countries

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Aetiology & Pathogenesis• More common causes now:

• Mitral valve prolapse

• Degenerative calcific valvular stenosis

• Bicuspid aortic valve

• Prosthetic valves

• Congenital defects

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Aetiology & Pathogenesis• Majority of cases of IE are caused by gram +ve bacteria

• Staphylococcus aureus is now more common (31-54%) than oral Streptococci

• MSSA is more frequent in community-acquired IE, infects mainly native valves & is associated with bacteraemia of unknown origin

• MRSA is more related to nosocomial infection, wound infection, permanent IV catheters or surgery in previous 6/12

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Aetiology & Pathogenesis• Strep viridans is now less common (12-26%) but difficult to

isolate & confers partial resistance to ABx

• Coag -ve Staph were main cause of prosthetic valve endocarditits in the past, esp within first 6-12/12 after valve surgery, MRSA is now more common

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Aetiology & Pathogenesis• Enterococci

• HACEK group:

• Haemophilus group

• Actinobacillus group

• Cardiobacterium hominis• Eikenella corrodens• Kingella kingae

• All commensals in the oral cavity

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Other Causes• Candida & Aspergillus species cause the majority of fungal IE

(1-3% of IE)

• Patients with IVDU, prosthetic valve & long-term CVC are more likely to have fungal IE: needs to be considered in presence of bulky vegetations, metastatic infection, perivalvular invasion, or embolisation to large blood vessels despite -ve BC

• In 10-15% of all cases of endocarditis no organism can be isolated from BC (“culture-negative” endocarditis)

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Other Causes• Whenever BC -ve IE is suspected other organisms such as

Coxiella burnetti, Legionella spp, Brucella spp, Bartonella spp &, Chlamydiae spp, must be considered

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Aetiology & Pathogenesis• The most common factors predisposing to IE are those that cause

bacteraemia:

• Dental/surgical procedures

• Needle sharing amongst IVDU

• Breaks in skin

• The risk in those with predisposing factors (eg valve abnormalities) can be lowered by using prophylactic Abx however the use of prophylactic Abx is no longer recommended (discussed further later)

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Morphology• Presence of friable, bulky, potentially destructive vegetations

containing fibrin, inflammatory cells & infective organism (ie bacteria, fungi) on heart valves

• Aortic & mitral most common sites

• Right heart more common in IVDU

• Vegetations can be single or multiple & may involve more than one valve

• Vegetations can erode into underlying myocardium producing abscesses (ring abscess)

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Morphology• Emboli can break off vegetations causing abscesses at distant

sites where they lodge leading to sequelae such as septic infarcts or mycotic aneurysms

• Vegetations of subacute endocarditis are associated with less valvular destruction than acute endocarditis

• Gram +ve bacteria are particularly resistant to pts innate antibacterial activity (eg complement) which facilitates the adhesion & formation of vegetations

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Morphology• When the left heart is involved vegetations most often develop

on the ventricular aspect of the aortic valve & atrial surface of mitral valve, usually along the valve leaflets

• Septic embolism has usually occurred before diagnosis

• Up to 30% of patients have renal or splenic infarcts at the time of diagnosis

• Septic emboli can also occur in the heart, brain, intestine & other large organs

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Diagnosis• The modified Duke criteria based on clinical, microbiological

& echo findings providing high sensitivity & specificity (~80%) for diagnosis of IE when applied to patients with native valve IE with +ve BC

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Modified Duke CriteriaMajor Criteria:•Posititive blood cultures Positive echocardiogram for IE defined as Oscillating intracardiac mass Intracardiac abscess New partial dehiscence of prosthetic valve

Minor Criteria:•Predisposition such as a heart condition or IV drug use•Fever•Vascular phenomena or immunological phenomena such as major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial haemorrhage, conjunctival haemorrhage, & Janeway lesions•Other microbial evidence such as PCR, serological tests, or a positive blood cuture but does not meet a major criterion

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Diagnosis• The dx is confirmed in presence of 2 major criteria, 1 major + 2

minor or 5 minor criteria

• IE considered in presence of 1 major + 1 minor or 3 minor

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Clinical Features & Diagnosis

• The modified Duke criteria have low sensitivity when BC -ve, infection affecting prosthetic valve/pacing system & when IE effects right heart

• It’s not always useful for rapid diagnosis: one of its major criteria includes +ve blood cultures

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Clinical Features• Fever, chills, weakness, lethargy, weight loss, flu-like illness

(not always present)

• Longstanding IE (rarely seen now with earlier diagnosis): splinter haemorrhages, Janeway lesions, Osler nodes, Roth spots

• Murmurs are present in 90% of patients with left sided IE

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Splinter Haemorrhages

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Janeway Lesions

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Osler Nodes

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Roth Spots

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Clinical Features• In IVDU right sided IE usually affect the tricuspid valve &

occasionally the pulmonary valve, instead of systemic issues pulmonary embolism is the most important complication which can evolve into:

• Pulmonary infarction

• Pulmonary abscess

• Bilateral pneumothoraces

• Pleural effusion

• Empyema

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Clinical Features• The severity of valvular destruction depends on virulence of

infecting organism & infection duration

• Heart failure can be the initial presentation

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Micro• +ve BC still the best method for identifying the causative

agent: considered a major diagnostic criteria

• BC are +ve in ~80% of cases

• BC -ve in cases of intracellular or fastidious pathogens or after prior Abx treatment

• BC are important in suspected IE (eg T > 38, new regurgative murmur, hx of valvular disease, IVDU): in cases where Abx have been commenced prior to BC the recovery rate is only ~ 35-40%

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Micro• It is recommended to draw 3 sets of cultures

• Culture -ve IE delays diagnosis + initiation of treatment/correct treatment

• Using PCR has been proposed in these cases

• PCR of excised valve tissue or embolic material should be performed in culture -ve IE (in cases of valve surgery or embolectomy)

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Echo• Important non-invasive technique for diagnosis & management

• Sensitivity of TTE ranges from 45-60%

• TOE offers better quality & sensitivity ranges from 90-100%, it is necessary whenever perivalvular complications or mitral valve involvement is suspected

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Echo• Findings:

• Vegetation (hallmark lesion of IE): mobile echodense mass attached to valvular leaflets or mural endocardium. Sensitivity TTE 75% TOE 90%

• Periannular abscess

• New dehiscence of valvular prosthesis

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Echo Findings• ~10% of IE involves right side of heart: most commonly the

triscupid valve alone (98%), although the pulmonary valve & Eustachian valve (junction of IVC & RA) can be involved

• Isolated right sided involvement is well detected by TTE & in those cases a TOE isn’t necessary

• However ~15% IVDU associated IE affects left-sided valves & a TOE should be considered

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Echo Findings• An abscess usually affects the aortic root & presents as a

perivalvular zone of reduced echo density without blood flow. TTE (45-50%) TOE (>90%)

• Important because the diagnosis of an abscess is an indication for early surgery

• Aortic/mitral regurg is secondary to valvular necrosis, perforation or prolapse

• ~50-60% of pts with IE develop HF secondary to valvular destruction & require early surgery (mortality without surgery ~80%)

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Echo Findings• Vegetation size & mobility is important

• Stroke complicates 20-40% of left-sided IE & is the second most common cause of death

• *Vegetation > 10mm &/or high vegetation mobility are associated with increased embolic risk, & early surgery (within 1/52 of dx) is associated with improved long-term outcomes through reduction in systemic embolic events*

• If vegetations are small or have already embolised, echo can provide false -ve results in ~15%. When suspicion is high a TOE can be repeated in 7-10 days

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Echo• In the emergency department bedside USS is starting to be used

in patients suspected of IE to help speed up diagnosis: it has its limitations (should be used to rule in IE not rule out) & must be followed up with a formal USS

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Prophylaxis• 2008 National Institute of Clinical Excellence (NICE)

produced guidelines re: antimicrobial prophylaxis for IE in pts undergoing interventional procedures

• The guidelines suggest there is weak evidence to support routine preop Abx for pts at risk of IE

• They state risk of allergic reaction, cost & resistance implications from Abx overuse

• Therefore the routine use of Abx prophylaxis is no longer recommended

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Prophylaxis• However in the case of infection at the operative site, Abx

prophylaxis is still recommended in high-risk patients eg:

• Acquired valvular HD

• Previous valve replacement

• Structural congenital HD (excluding repaired ASD, VSD or PDA)

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Antibiotics• Empirical treatment; flucloxacillin & gentamicin are the usual

first line

• Adjusted according to MCS

• Vancomycin is used in pts with intracardiac prosthetic material or suspected MRSA

• Benzylpenicillin is the first choice for Streptococcus or Enterococcus penicillin-susceptible strains

• For vanc-resistant MRSA: teicoplanin, lipopeptide daptomycin or oxazilidones (linezolid) is recommended

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Fungal IE• Usually requires surgery

• Amphotericin B doesn’t penetrate well into vegetations however is used successfully against Candida endocarditis

• Fluconazole is a fungistatic & only active against Candida spp

• Caspofungin is usually fungicidal for Candida spp but its penetration into vegetations is unknown

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Treatment Course• IV Abx is normally continued for 4-6 weeks, with the aim of

sterilising the vegetations

• ID should be involved in BC -ve IE

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Surgery• Antimicrobial therapy can only offer curative treatment in

~50%

• The other 50% require surgery

• The surgical goal is valve repair but most require valve replacement

• Pts with IE + large vegetations, intracardiac abscess (9-14%) or persisting infection (9-11%) almost always require surgery

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Surgery• Anaesthetic can be complicated secondary to haemodynamic

instability

• Mitral or aortic regurg particularly challenging

• Induction often complicated by hypotension despite hyerdynamic left ventricle & hypoxaemia secondary to severe pulmonary oedema

• Some pts may develop acute RV dysfunction & severe tricuspid regurg

• These pts require arterial pressure & CVP monitoring & may require inotropes/vasopressors

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Surgery• Pts with peri-annular abscess have higher risk of para-valvular

regurgitation & valve dehiscence after OT

• Current IE perioperative mortality is 5-15%

• If sepsis is under control the mortality is similar to non-infected valve replacement

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Surgery• Most common complications:

• Persistent septic shock

• Coagulopathy

• Acute renal failure

• Stroke

• Refractory heart failure

• Conduction abnormalities

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Summary• Challenging diagnosis therefore diagnosis often delayed

• Need to have a high index of suspicion: esp high risk pts

• Clinical examination is still very important

• Cultures are extremely important for diagnosis/treatment

• The use of TTE/TOE is vital for Dx & Tx planning

• Bedside USS is now being used for rapid assessment in ED

• Treatment needs to be started early to reduce morbidity/mortality

• Many pts require surgical intervention

• Pts can be haemodynamically unstable peri-operatively

• ID involvement is useful esp in BC -ve IE

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References• Martinez, G., Valchanov, K., Infective Endocarditis, Continuing Education in

Anaesthesia, Critical Care & Pain, 2012; 12:3

• Kumar., Abbas., Fausto., Aster., Robbins and Cotran Pathological Basis of Disease, 8th Edition, 2010

• Deng, H., Ma, Y., Zhia, H., Miao, Q., Surgical valve repair of isolated pulmonary valve endocarditis, Interactive Cardiovascular and Thoracic Surgery, 2013; 16: 384-386

• Seif, D., Meeks, A., Mailhot, T., Perera, P., Emergency department diagnosis of infective endocarditis using bedside emergency ultrasound, Clinical Ultrasound Journal, 2013; 5:1

• Kang, D., Kim, s., Yun, S., Choo, S., Song, J., Sohn, D., Early Surgery versus conventional treatment for infective endocarditis, The New England Journal of Medicine, 2012; 366: 2466-73

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References• Wikipedia (images)

• Dermnet.nz (images)

• Beaulieu, A., Rehman, H., Janeway Lesions, Canadian Medical Association Journal, 2010; 182:10 (images)