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Internal medicine

Lecture 5

:INFECTIVE ENDOCARDITIS

As the name suggest infective ( there is an infection) endocarditis (of the


.endocardium, the inner lining of the heart chamber , or blood vessels or heart valve )

Abnormal valve or endothelium make infection more easy , but infective endocarditis
can involve normal valves and endothelium specially if the organism is highly
.virulent

infective endocarditis can be divided into acute and sub-acute according to the
severity and acuteness of symptoms ( really this reflect how virulent the
.microorganism is )

It can also be divided according to valve involved , causative organism or whether it


is associated with medical procedures ( nosocomial endocarditis) or not (community
.acquired endocarditis)

, coagulation When there is a disturbed endothelium as far as the platelets think it


factors will follow this and form a fibrin , microorganisms, which found a difficulty
in invading normal epithelium , will be excited to join the party forming a vegetation
. ( which is abnormal mass formed from platelets , fibrin and microorganisms)

This vegetation which is attached in abnormal , almost always moving endothelium ,


may break and travel with bloodstream to more distant areas leading to embolic
. manifestations of the disease

It's also resemble a challenge to the immune system , which will attack aggressively
.leading to immunologic manifestations of the disease

Sub-acute infective endocarditis is more common among elderly patients , mitral


.valve are the most commonly involved valve , followed by aortic valve

Pulmonary valve is a rare site for infective endocarditis , while tricuspid valve is
usually involved in intravenous drug users and the case is often acute rather than sub-
.acute infective endocarditis

Staph. aureus is the most common cause of acute infective endocarditis , especially
.in intravenous drug users

Viridans group of streptococci (from the upper respiratory tract or gums) and

enterococci (from the gut or urinary tract) are the most common cause of subacute
infective endocarditis.
Staph. epidermidis, ( post-operative endocarditis) (after cardiac surgery), Gram-
negative HACEK group (Haemophilus spp., Actinobacillus actinomycetemcomitans,
Cardiobacterium hominis, Eikenella spp. And Kingella kingae), Coxiella burnetii (Q
fever) , Brucella , Yeasts and fungi all can cause infective endocarditis

abnormal valve lesion or congenital heart disease , insertion of a foreign bodies into
the blood stream ( like catheters ) or a procedure which may induce bacteremia can
increase risk of infective endocarditis.
Prosthetic valve are prone to infection , in the first two month after operation by high
virulent microorganisms (like staph. aureus ) resembling acute infective endocarditis ,
After two months , low virulent organisms( coagulase negative staph or viridans
group) are more common leading to subacute infective endocarditis .

Clinical features :

First lets agree that when a valve is damaged the first thing to be affected is its closure
(regurgitation).
To simplify this imagine a well fitted door , if you hit this door strong enough to
cause damage or if you add a peace of wood to the door , its opening will not or will
be affected much less than its closure , cardiac valve is this door .
The two typical and expected signs of infective endocarditis are :
Fever (90%)..(its an infection)
Murmur (85%) ..(the abnormal sound heard when the blood passes through an
abnormal valve).. when we whistle ,we narrowed the opening of the mouth , this is
the same concept , the blood pass through narrow opening which remains due to
abnormal valve closure.
how acute and sever the symptoms and systemic manifestations ( embolic or
immunologic )depends on the virulence of the microorganism :
in acute infective endocarditis the fever is high grade , valve damage and heart
murmur is more obvious and septic emboli (like cerebral septic emboli or osler nodes
–which is painful subcutaneous nodules on the distal pads of the fingers or toes- may
occur.

In sub-acute infective endocarditis the course of the disease is more indolent , the
usual story is development of fever , sweating mainly at night , malaise and a new
valvular murmur in a patient with known congenital or valvular (including prosthetic
valves)heart disease , there may be a backache , joint pain and embolic and immune
complex mediated manifestations *( Osler’s nodes (painful, subcutaneous nodules on
the distal pads of the fingers or toes, Janeway’s lesions (hemorrhagic, nonpainful
macules on the palms and soles) and Roth’s spots(retinal hemorrhages with small
central clearing. Also the immune complexes may invade kidney causing interstitial
nephritis or glomerulonephritis or even renal failure.

Post-operative endocarditis: Should be considered in any patient who develops an


unexplained fever after heart valve surgery. The pattern may resemble subacute or
acute endocarditis, depending on the virulence of the organism. Morbidity and
mortality are high and redo surgery is often required.
Diagnosis:
To diagnose infective endocarditis , we should collect findings , to simplify this Duke
s criteria were suggested .
The idea is that features "specific" to infective endocarditis plotted as a major criteria ,
those features that are less specific are called minor criteria.
We understand the main pathologic feature is vegetation so observing a vegetation in
echocardiography is a major criteria (echo can be transthoracic , this means that it is
done through chest wall or transesophageal , this means that the examiner insert the
probe through esophagus of the patient to make it as near to the heart as possible).

Also infective endocarditis can change or initiate a heart murmur so finding a new
heart murmur or change already known murmur is a major criteria.

Infective endocarditis is an infection in the bloodstream so as one can expect it should


make a positive blood culture( with typical organisms and at least two samples) so
positive blood culture is a major criteria .
Fever , immunologic or embolic manifestations are all considered a minor criteria as
positive blood culture that don’t meet the typical criteria .

Treatment :
For treating infective endocarditis we should put in mind :
1. there is no role for oral antibiotics
2.Any source of infection (e.g. dental abscess) should be removed as
soon as possible.
3. the vegetation provide a shield to microorganisms so treatment duration should be
prolonged ( 4 to 6 weeks except in uncomplicated right sided native valve
endocarditis due to Methicillin sensitive bacteria , which can be treated for 2 weeks)
4. we should choose bactericidal antibiotics.
5. in patients with normal cardiovascular function ,awaiting culture results is
reasonable , in those with poor cardiovascular function empirical antibiotics should be
started while awaiting culture results and the following are a reasonable approach

6. in high risk patients or in failure of medical treatment surgery is indicated and as


follow:
Idications for surgery (débridement of infected material, valve replacement) include :
heart failure, abscess formation, failure of antibiotic therapy and large vegetations on
left-sided heart valves (high risk of systemic emboli) also dehiscence of prosthetic
valve or infection of prosthetic valve with staph. aureus.

Prevention

Provide prophylaxis for IE only in patients with the highest risk, including those with:
• prosthetic cardiac valve
• history of IE
• unrepaired cyanotic congenital heart disease
• repaired congenital heart defect with prosthesis or shunt (≤6 months post-procedure)
or residual defect
• valvulopathy following cardiac transplantation

Prophylaxis is only indicated for the highest-risk procedures:

• dental procedures that involve mucosal bleeding


• procedures that involve incision or biopsy of the respiratory mucosa
• procedures in patients with ongoing GI or GU tract infection.

ANTIBIOTIC REGIMENS FOR PROPHYLAXIS :

A. Standard oral regimen


Amoxicillin : 2g PO 1 h before procedure

ß. Inability to take oral medication


Ampicillin : 2g IV or 1M within 1 h before procedure
C. Penicillin allergy
1 . Clarithromycin or azithromycin : 500 mg PO 1 h before procedure
2. Cephalexin': 2g PO 1 h before procedure
3. Clindamycin : 600 mg PO 1 h before procedure

D. Penicillin allergy, inability to take oral medication


1 . ceftriaxone': 1g IV or 1 M 30 min before procedure
2. Clindamycin : 600 mg IV or 1M 1 h before procedure

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