2. Case
32 year old male, a k/c/o RHD, who has
undergone mitral valve repair, presented
to emergency department with complaints
of fever (101 f), with chills and
rigor, myalgia and shortness of breath.
On examination patient was
normotensive with tachycardia and was
febrile. Systemic examination revealed
PSM with thrill in mitral area, and
splenomegaly. Head to foot examination
showed splinter hemorrhages in nails and
red tender lesion over pulp of left middle
3. Pathogenesis
◦ Endothelial injury
High velocity jet striking endothelium
Flow from a high pressure to a low pressure
chamber
Flow across a narrow orifice at a high
velocity
◦ Hypercoagulable state
◦ Virulent organisms may seed the
injured site directly
◦ Bacteremia seeds the sterile NBTE
4. Vegetations - Hallmark of IE
“…variably sized
amorphous mass of
platelets and fibrin
with abundant
enmeshed
microorganisms and
moderate
inflammatory cells…”
5. Native Valve Endocarditis
Acute NVE Subacute NVE
Site Normal/
damaged valves
Damaged valves
Course of
disease
Days to weeks
(aggressive)
Weeks to months
(Indolent)
Microbiology Staph. aureus
(MC)
Group B
streptococci
Viridans streptococci,
Enterococci,
Coagulase-negative
staphylococci,
Gram-negative
coccobacilli
Metastatic
infection
Often Rarely
6. Intravenous Drug Abusers
Tricuspid valve (46 to 78%) MC involved
Risk factor for recurrent NVE.
Staph. aureus (>50% of IE occurring in IV
drug abusers overall)
Streptococci, Enterococci, Pseudomona
s aeruginosa (Infection of right- and left-sided
heart valves)
Fungi - left-sided heart valves
Corynebacterium
species, Lactobacillus, Bacillus cereus
nonpathogenic Neisseria species
7. Prosthetic Valve Endocarditis
Constitutes 10% to 30% of all cases of IE
in developed countries.
Early
◦ Symptoms begin within 60 days of valve
surgery.
◦ Mostly due to complication of valve surgery.
◦ MC organism involved CoNS
Late
◦ Onset thereafter
◦ Usually from later infection, most likely to be
community acquired
◦ MC organism Streptococci
8. Health Care – Associated
Endocarditis
Includes..
◦ Nosocomial IE (54%)
◦ Arising in the community after a recent
hospitalization (44%)
◦ As a direct consequence of long-term
indwelling devices (such as central
venous lines and hemodialysis catheters).
9. Clinical Features
Fever – almost universal
Dyspnea, cough, and chest pain -
common with intravenous drug users.
Cardiac murmurs
10. Classic peripheral
manifestations of IE
Petechiae (most common)
found on the palpebral
conjunctiva, the buccal
and palatal
mucosa, and the
extremities.
Splinter or subungual
hemorrhages are dark
red, linear, or
occasionally flame-
shaped streaks in the
proximal nailbed.
11. Classic peripheral manifestations
of IE – Contd…
Osler nodes are small, tender
subcutaneous nodules in the pulp of the
digits, or occasionally more proximal, that
persist for hours to several days.
Janeway lesions are small
erythematous or hemorrhagic macular
nontender lesions on the palms and soles
and are the consequence of septic embolic
events.
12.
13. Embolic
infarcts in the
digits (common
in left-sided S.
aureus IE.)
Roth
spots, oval
retinal
hemorrhages
with pale
centers.
14. Splenic abscess (3 to
5 %) – indicated by
persistent fever and
progressive
enlargement of lesion
during therapy
Mycotic aneurysm (2
to 10%) – located
mostly in the territory
of MCA. Anticoagtn
therapy should be
avoided in those with
persistent mycotic
aneurysm
15. Musculoskeletal symptoms
◦ Arthralgias and myalgias
◦ Occasional true arthritis
Renal insufficiency
◦ Immune complex–mediated
glomeruonephritis (occurs in less than
15%)
◦ Embolic renal infarcts
Congestive Cardiac Failure
17. Chest X ray PA view showing septic emboli in
left lung fields in a patient with infective
endocarditis involving right heart valves
18. Work Up
◦ Complete hemogram
◦ CRP/ ESR
◦ BLOOD CULTURE
◦ Renal function tests
◦ Culture form the sites of septic emboli
◦ Electrocardiogram
◦ Echocardiogram
◦ Multislice CT with contrast
◦ Chest xray
19. Obtaining Blood Culture
Three separate sets of
blood cultures, each
from a separate
venipuncture, after
proper aseptic
precautions, obtained
during 24 hours, are
recommended to
evaluate patients with
suspected endocarditis.
20. Each set should include
a bottle containing an
aerobic medium and
one containing
thioglycollate broth
(anaerobic medium); at
least 10 mL of blood
should be placed into
each bottle.
21. Echocardiography
Aims
Determine the presence, location and
size of vegetations
Assess the damage to the valve
apparatus and determine the
haemodynamic effects.
The dimensions and function of the
ventricles.
Identify any abscess formation
Need for surgical intervention.
22. Above: TEE shows a large mitral
vegetation (broken arrow) and a
perforation of anterior mitral
leaflet (arrowhead). LA, left
atrium; LV, left ventricle; RV, right
ventricle.
Below: TTE shows a large mitra
vegetation
23. TTE vs TEE
TTE TEE
Resoulution Poor Better
Minimum size of
vegetation seen
> 2mm <2mm
Sensitivity NVE 45% - 65% 85% - 95%
PVE 42% - 60% 82% - 96%
Indications for TEE
•Prosthetic valve endocarditis
•Poor trans thoracic views
•Continuing sepsis in spite of adequate antibiotic therapy
•New PR prolongation
•No signs of endocarditis on trans thoracic
echocardiography, but high clinical suspicion.
24.
25. Making the Diagnosis
Pelletier and Petersdorf criteria (1977)
Von Reyn criteria (1981)
Duke criteria (1994)
27. Major Criteria
◦ Positive Blood Culture
Typical organism for IE from two separate
cultures (viridans strep, Strep bovis, HACEK
group or Staph aureus or community acquired
enterococci in the absence of primary focus) OR
Persistently positive blood culture –
recovery of microorganism consistent with IE from
- Blood culture (>2) drawn more than 12
hrs apart OR
- All of the three or a majority of four or
more separate blood culture , with the first and the
last drawn at least one hr apart
Single positive blood culture for Coxiella burnetti
or anti phase IgG antibody titer > 1:800
28. Major Criteria Contd…
◦ Evidence of Endocardial
Involvement
Positive Echocardiogram
Oscillating intracardiac mass,
On valve or supporting structures
In the path of regurgitant jets
Implanted material , in the absence of an
alternative anatomic explanation
OR
Abscess
OR
New partial dehiscence of prosthetic valve
OR
New valvular regurgitation
29. Minor Criteria
Predisposition – predisposing heart
condition or IV drug use
Fever (>100.4 F)
Vascular phenomena
◦ Major arterial emboli
◦ Septic pulmonary infarcts
◦ Mycotic aneurysm
◦ Intracranial hemorrhage
◦ Conjunctival hemorrhage
◦ Janeway lesions
30. Minor Criteria - Contd
Immunologic Phenomena
◦ Glomerulonephritis
◦ Osler Nodes
◦ Roth Spots
◦ Rheumatoid factor
Microbiological Evidence
◦ Positive blood culture, but not meeting the
major criterion OR
◦ Serological evidence of active infection
with organism consistent with IE
31. Definitive Infective
Endocarditis
Pathologic Criteria
◦ Micro-organisms
demonstrated by culture or histology in a
vegetation OR
in a vegetation that has embolized OR
In an intracardiac abscess
OR
◦ Pathologic Lesions
Vegetations or intracardiac abscess present
confirmed by histology showing active
endocarditis
32. Definitive Infective Endocarditis –
contd..
Clinical Criteria
◦ Two Major Criteria
OR
◦ One Major and Three Minor Criteria
OR
◦ Five Minor Criteria
34. Rejected
Firm alternative diagnosis for
manifestations of endocarditis
OR
Sustained resolution of manifestations
of endocarditis, with antibiotic therapy
for 4 days or less
OR
No pathologic evidence of IE at
surgery or autopsy after antibiotic
therapy for 4 days or less
36. Treatment
Intiation
In Acute IE and for those with
hemodynamic decompensation – Start
empirical therapy
In hemodynamically stable patients -
delay of antibiotic therapy briefly
pending the results of the initial blood
cultures.
39. Antibiotic Dosage and Route[†] Duration
Aqueous
penicillin G
12-18 million units/24 hr IV either continuously or
every 4 hr in six equally divided doses
4 weeks
Or
Ceftriaxone 2 g once daily IV or IM 4 weeks
Aqueous
penicillin G
12-18 million units/24 hr IV either continuously or
every 4 hr in six equally divided doses
2 weeks
Or
Ceftriaxone 2 g once daily IV or IM 2 weeks
Plus
Gentamicin 3 mg/kg/day IM or IV as a single daily dose or divided
in equal doses every 8 hr
2 weeks
Vancomycin 30 mg/kg/24 hr IV in two equally divided doses, not to
exceed 2 g/24 hr unless serum levels are monitored
4 weeks
Treatment of Native Valve Endocarditis Caused by
Penicillin-Susceptible Viridans Streptococci and
Streptococcus gallolyticus (bovis)
40. Antibiotic Dosage and route[†] Duration
Aqueous
penicillin G
24 million units/24 hr IV either
continuously or every 4 hr in six equally
divided doses
4 weeks
or
Ceftriaxone 2 g once daily IV or IM 2 weeks
plus
Gentamicin 3 mg/kg/day IM or IV as a single daily
dose or divided in equal doses every 8 hr
2 weeks
Vancomycin 30 mg/kg/24 hr IV in two equally divided
doses, not to exceed 2 g/24 hr unless
serum levels are monitored
4 weeks
Treatment of Native Valve Endocarditis Caused by
Strains of Viridans Streptococci and Streptococcus
gallolyticus (bovis) Relatively Resistant to Penicillin G
41. Streptococcus Pyogenes, Streptococcus
Pneumoniae, and Group B, C, and G
Streptococci
Refractory to antibiotic therapy or associated
with extensive valvular damage.
Dosage and Route Duration
Group A
streptococca
l
endocarditis
Penicillin G in a dose of 3 million
units intravenously every 4 hours
4 weeks
Gentamycin i/m First 2 weeks
Early cardiac Surgery
42. Dosage and Route
Pneumococci
(with or without
concomittant
meningitis)
Penicillin G 4 million units
intravenously every 4 hours
Ceftriaxone 2 g intravenously every
12 hours OR
Cefotaxime 4 g intravenously every 6
hours
In the absence of meningitis, these regimens are
effective for IE caused by pneumococci that are
relatively penicillin resistant
43. Antibiotic Dosage and route[†] Duration
Aqueous
penicillin G
18-30 million units/24 hr IV given
continuously or every 4 hr in six equally
divided doses
4-6 weeks
plus
Gentamicin 1 mg/kg IM or IV every 8 hr 4-6 weeks
Ampicillin 12 g/24 hr IV given continuously or every 4 hr
in six equally divided doses
4-6 weeks
plus
Gentamicin 1 mg/kg IM or IV every 8 hr 4-6 weeks
Vancomycin 30 mg/kg/24 hr IV in two equally divided
doses not to exceed 2 g/24 hr unless serum
levels are monitored
4-6 weeks
plus
Gentamicin 1 mg/kg IM or IV every 8 hr 4-6 weeks
Standard Therapy for Endocarditis
Caused by Enterococci*
44. Antibiotic Dosage and route* Duration
Methicillin-susceptible staphylococci†
Nafcillin or
oxacillin
2 g IV every 4 hr 4-6 weeks
or
Cefazolin 2 g IV every 8 hr 4-6 weeks
or
Vancomycin 15 to 20 mg/kg actual body
weight, IV every 8 to 12 hr
4-6 weeks
Methicillin-resistant staphylococci‡
Vancomycin[?] 15 to 20 mg/kg actual body
weight, IV every 8 to 12 hr
4-6 weeks
Treatment of Staphylococcal Endocarditis
in the Absence of Prosthetic Material
45. Antibiotic Dosage and route* Duration
Regimen for methicillin-resistant staphylococci†
Vancomycin 15 to 20 mg/kg actual body weight, IV every 8
to 12 hr
≥6 weeks
Plus
Rifampin 300 mg PO every 8 hr ≥6 weeks
And
Gentamicin 1.0 mg/kg IM or IV every 8 hr 2 weeks
Regimen for methicillin-susceptible staphylococci
Nafcillin or
oxacillin
2 g IV every 4 hr ≥6 weeks
Plus
Rifampin 300 mg PO every 8 hr ≥6 6weeks
And
Gentamicin 1.0 mg/kg IM or IV every 8 hr 2 weeks
Treatment of Staphylococcal Endocarditis in the Presence of a
Prosthetic Valve or Other Prosthetic Material
46. Antibiotic Dosage and route[†] Duration
Ceftriaxone 2 g once daily IV or IM 4 weeks
or
Ampicillin-
sulbactam
12 g/24 hr IV given every
4 hr in six equally divided
doses
4 weeks
Treatment of Endocarditis Caused by
HACEK Microorganisms*
47. Organisms Drugs
Candida IE Amphotericin desoxycholate or liposomal amphotericin
formulation, at full doses, often combined with 5-
fluorocytosine. Surgical intervention shortly after
beginning of medical treatment is advised.
Sporadic
Candida PVE
and NVE
Caspofungin, with prolonged or indefinite oral azole therapy
has been advocated for patients treated either medically or
surgically.
Corynebacteria
(diphtheroids) IE
Penicillin combined with aminoglycosides OR
vancomycin
Corynebacterium
jeikeium IE
Often resistant to penicillin and aminoglycosides, is sensitive to
vancomycin.
Pseudomonas
aeruginosa IE
Tobramycin (8 mg/kg/day intravenously once daily plus
piperacillin, ceftazidime, or cefipime.
Coxiella burnetii
IE
Doxycycline (100 mg twice daily) combined with a quinolone
for at least 4 years. Treatment with doxycycline combined
with hydroxychloroquine for 18 to 48 months may be more
48. Culture-Negative Endocarditis
Recommended therapy
Suspected IE Received confounding antibiotic
therapy
NVE Ampicillin-sulbactam plus
gentamicin (3 mg/kg/day) or
vancomycin plus gentamicin and
ciprofloxacin
PVE Vancomycin plus gentamicin,
cefepime, and rifampin.
49. Anticoagulant therapy in IE
Patients with PVE involving devices that
necessitates maintenance
anticoagulation
Anticoagulant therapy in patients with
NVE is limited to patients for whom
there is a clear indication and no
increased risk for intracranial
hemorrhage.
50. Monitoring Therapy
~70% of patients with NVE or PVE are
afebrile, by one week of therapy
Blood cultures should be repeated
daily until sterile, and rechecked if
there is recrudescent fever and
performed again 4 – 6 weeks after
therapy.
51. Relapse and Recurrence
Relapse of IE usually occurs within 2
months of discontinuation of
antibiotic treatment.
IV drug abuse is now the most
common predisposing factor for
recurrent IE
52. Surgery in IE - Indications
Congestive Heart Failure
Unstable Prosthesis
Uncontrolled infection or unavailable
effective therapy
Staph aureus PVE
Perivalvular invasive infection
Left sided Staph aureus IE
Unresponsive culture negative IE
Large vegetations (>10mm)
53. Cardiac Conditions Associated with the Highest Risk of
Adverse Outcome from Endocarditis for Which
Prophylaxis with Dental Procedures Is Recommended
54. Regimens for Prophylaxis Against
Endocarditis: Use with Dental, Oral, and
Upper Respiratory Tract Procedures
