Infective Endocarditis (IE) PDF

INFECTIVE ENDOCARDITIS Infective Endocarditis (IE) is one of the most important topics that links internal medicine and dentistry. Understanding this disease is essential for healthcare professionals in both fields, as it involves the interplay of systemic health and oral hygiene...

INFECTIVE ENDOCARDITIS Infective Endocarditis (IE) is one of the most important topics that links internal medicine and dentistry. Understanding this disease is essential for healthcare professionals in both fields, as it involves the interplay of systemic health and oral hygiene. Hanna K. AL-Makhamreh, MD FACC Written by: Mohammad Abushehab Associate Professor in Cardiology Corrected by:Yazeed Al-jammal University of Jordan-Faculty of Medicine EPIDEMIOLOGY Untreated IE → 100 % fatal! IE is a relatively rare but serious disease with high mortality despite the improvement in diagnosis and therapy. Estimated annual incidence 3-10/100 000. The profile of patients and pathogens has changed over time (rheumatic fever x PM/ICD). (In the past, they suffered from rheumatic fever, but they now have a permanent pacemaker or an intracardiac defibrillator). Predisposing factors: ❑prosthetic valves. ❑elderly patients with degenerated valves. ❑i.v. drug users (In Western countries, tricuspid valve involvement is commonly associated with intravenous drug abuse) ❑ Intravenous catheters, hemodialysis, pacemaker electrodes, and other implantable devices have led to a new era of infections, following the decline of rheumatic fever as a dominant cause. CLASSIFICATION 1. NVE - native valve endocarditis 2. PVE - prosthetic valve endocarditis 3. IVDU - intravenous drug users 4. IE (infective endocarditis) on PM / ICD electrodes pacemaker Implantable Cardioverter-Defibrillator CLASSIFICATION 5. Relapse - repeat IE within 6 months and proven Identical pathogen 6. Reinfection - involves either a new microorganism or the same species, which is very rare but can occur more than 6 months after the initial infection. 7. Early PVE - Within one year of the operation, infections are usually aggressive nosocomial infections involving the sewing material. 8. Late PVE - > 1 year after surgery/implantation ‘Relapse’ - suggests an incompletely treated primary episode, leading to the re-emergence of the original microorganism from a protected source, such as a deep-tissue infection or seeded prosthetic hardware. ‘Reinfection’ - on the other hand, typically refers to infection caused by a new microorganism. An episode of infective endocarditis (IE) caused by the same species within 6 months of the initial episode is classified as a relapse, whereas IE caused by the same species more than 6 months after treatment of the initial episode is considered reinfection (historically termed 'recurrent IE'). PATHOPHYSIOLOGY Infective endocarditis (IE) is rare in healthy individuals, despite the common occurrence of bacteremia encountered daily. This has led to changes in the guidelines regarding prophylaxis. Scientists have observed that bacteremia can occur during activities such as dental procedures, tooth brushing, flossing, and even chewing gum. Any injury to the endocardial surface, including iatrogenic factors such as degenerative changes, the impact of catheters, electrodes, and prosthetic materials, can result in endocardial damage. This damage exposes the extracellular matrix, leading to the activation of factor III, platelet activation, and the formation of fibrin-platelet (sterile) vegetation. These changes increase the risk of bacterial seeding. Additionally, congenital factors such as shunts, ventricular septal defects, and atrial septal defects, as well as degenerative processes like valve stenosis and regurgitation, can also lead to endocardial injury. NVE Rheumatic valvular disease – usually mitral valve followed by the aortic valve. Congenital heart disease - patent ductus arteriosus, ventricular septal defect, tetralogy of Fallot (TOF), any native or surgical high-flow lesion. Mitral valve prolapse with MR (mitral regurgitation) Degenerative heart disease aortic stenosis in elderly, bicuspid valve, Marfan syndrome mitral regurgitation CLINICAL PRESENTATION Variable! Fever (95%) (most common), signs of systemic disease (nausea, weight loss….) Heart murmur (85%) Septic embolization (20-50%) - brain, kidneys, spleen - Pulmonary Peripheral microembolization less common  DIAGNOSTIC TESTING Blood cultures 3 sets (aerobe + anaerobe) at different times + from diff. sites (85-90% of cases are identified from the first two sets of samples) 85-90% → streptococci, staphylococci, enterococci 10% culture negative (usually due to previous antibiotic therapy) less commonly HACEK (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella ) Fungi – Candida, Aspergillus Intracellular pathogens: Coxiella, Bartonella  DIAGNOSTIC TESTING Echocardiography - **TTE (Trans-thoracic echocardiogram)** : Low sensitivity (40-60%). The probe is placed across the chest wall. - **TEE (Trans-esophageal echocardiogram)** : Sensitivity of 90-100%, with higher sensitivity and specificity than TTE for diagnosing and visualizing vegetations. The probe is passed through the esophageal wall to better visualize the heart. - **Vegetations** : Highly mobile tissues growing on valves, shunt segments, electrodes, or abscesses, or indicative of new prosthetic valve dehiscence (where the valve is "rocking" because the sutures aren't properly fixed to the wall). This is a specific finding. - **New regurgitation** : Can result from damage to the valve, particularly the leaflet, or obstruction caused by growing vegetation. **This echocardiogram shows the mitral valve, with obvious tissue growth on both edges and thickening of both the anterior and posterior leaflets. **TEE, mitral endocarditis **Please refer back to the lecture to assess the mobility of these tissues DUKE CRITERIA (There are five minor criteria that help establish solid evidence) DUKE CRITERIA We take three samples from three different sites at three different times, then apply the criteria below: When dealing with intracellular pathogens such as Coxiella, one sample is sufficient.  Osler nodes and Janeway lesions are similar, but Osler's Splinter hemorrhage nodes are tender and of immunologic origin. are Flame-shaped Osler nodes are Painful nodules at the pulps of the lesions under the fingers. nails. Roth's spots are retinal hemorrhages with Janeway lesions are painless, small white or pale centers, typically caused by erythematous or hemorrhagic macular or immune complex-mediated vasculitis, often nodular micro abscesses caused by septic resulting from bacterial endocarditis. emboli. Janeway lesions are Flat, painless, Roth's spots are Retinal hemorrhages macular red lesions. with white or pale centers.  TREATMENT ATB therapy (antibiotic therapy) Surgery - performed in high-risk patients Age/comorbidities/PVE/DM Complicated IE (heart failure, shock…) High-risk agents (S.aureus, fungi…), ATB failure TTE/TEE high-risk morphology parameters – risk of embolization (due to large-size vegetations) ANTIBIOTICS Antibiotics are usually administered as a combination of multiple agents, as we are dealing with a very aggressive disease in a critical location. Any damage can lead to significant mortality and morbidity. beta-lactam (penicillin, cefalosporin) glycopeptide (vancomycin) aminoglycosides (gentamicin) rifampicin in PVE Fungi – ATB centre expert consult  ANTIBIOTICS Streptococci: Use Penicillin (PEN) or Ceftriaxone (CEF) combined with Gentamicin (GENTA). Vancomycin (VANCO) is used if there is resistance or in the presence of fever. Enterococci: Similar to streptococci, Empiric therapy: Should focus on Penicillin (PEN) resistance is common, so covering Staphylococcus aureus as the Vancomycin (VANCO) is preferred, often most common causative pathogen. combined with Gentamicin (GENTA). HACEK organisms, early prosthetic Staphylococci: For methicillin-sensitive valve endocarditis (PVE), or fungal strains, use Methicillin (MET) or Oxacillin infections: These require consultation (OXA) along with Gentamicin (GENTA). with an expert in antibiotics. If the staphylococcus is resistant to Methicillin/Oxacillin, then use Prosthetic valve endocarditis (PVE): Vancomycin (VANCO) combined with Requires prolonged intravenous antibiotics Gentamicin (GENTA). (minimum 6 weeks), with Rifampin (RIFAMPIN) added for prosthetic valve infections.  SURGERY progressive heart failure (emergency in shock) signs of ATB th. failure - continuous fever, abscess, vegetation, valve dehiscence… embolization potential (> 10 mm) In this echocardiogram, the arrows indicate the aortic valve, which has developed vegetation extending as a strand-like formation toward the ventricular side. TEE (Transesophageal Echocardiogram), PLAX (Parasternal Long Axis), and aortic views show destruction of the non-coronary cusp, resulting in severe regurgitation. TEE (Transesophageal Echocardiogram) in the aortic view shows a small vegetation on the 'left' coronary cusp of the bioprosthetic valve. The arrow indicates the site of infection. Permanent Pacemaker (PPM) / Implantable Cardioverter Defibrillator (ICD) in Infective Endocarditis (IE): IE on or near electrodes. Staphylococcus aureus is the most likely causative pathogen. Electrode withdrawal may be necessary if infection is present (embolization during withdrawal is common but rarely clinically significant). TEE (Transesophageal Echocardiogram) shows vegetation on the electrode. IV DRUG ABUSER IT IS A MULTIFACTORIAL AND MULTI-ORGANISM DISEASE BECAUSE INTRAVENOUS DRUG ABUSERS OFTEN USE CONTAMINATED NEEDLES, LEADING TO VERY AGGRESSIVE INFECTIONS. Tricuspid valve is most commonly affected, as the veins drain back into the right side of the heart. S. aureus, pseudomonas, G-, fungi, polymicrobial Fever, septic pulmonary embolisation (cough, hemoptysis, pulmonary abscesses, …) Mortality is less than 10%, which is lower than for the left side, but there is a high likelihood of recurrence, and surgery is commonly required. PREVENTION (PROPHYLAXIS SHOULD BE GIVEN, ESPECIALLY FOR HIGH-RISK PATIENTS) High risk patients only Prosthetic valve implant Previous IE Congenital Heart Disease patients High-risk procedures (dental) Practice may differ from the recommended guidelines. Practice may differ from the recommended guidelines.