INFECTIVE ENDOCARDITIS Dr. Muayad AL-Qaisy

Infective Endocarditis A microbial infection of the endothelial surface of the heart or valves Usually is near congenital or acquired cardiac defects Designated by the causative organism Also classified as NVE or PVE Like “staph endocarditis” or “strep endocarditis” or native valve endocarditis or prosthetic valve endocarditis

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

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

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

PNEUMATOCELE

Epidemiology Incidence <1% Of General Population

Epidemiology Rheumatic Fever History Hemodialysis Population Groups At Greater Risk: Rheumatic Fever History Hemodialysis Previous History Of Endocarditis Patients With Prosthetic Valves IV Drug Users (30% Risk Within 2 Years)

Predisposing Conditions Mitral valve prolapse Aortic valve disease Congenital heart disease Prosthetic valve Intravenous drug use No identifiable cause in 25-47%

Epidemiology More Common In Men Median Age 50 Years Acute Cases Increasing Streptococcal Cases  Slightly; Fungal And Gram Negative Cases Increasing

Epidemiology Incidence Increases With Age, Probably Due To Increased Cardiac Disease And Decreased Immunity Prosthetic Heart Valve Infections Are Increasing

Dentistry And Endocarditis Streptococcus viridans: Usual Etiologic Agent Usually Is Not Acute (Subacute) (That Is Why It Is Referred To As “SBE”) Incubation Period Approximately Two Weeks The most recent AHA information stresses the impact of daily living activities and importance of immaculate oral hygiene to prevent endocarditis in susceptible patients. Many patients will have bacteremias of oral origin periodically due to risk factors such as periodontal disease. Research indicates very few cases of endocarditis probably result from actual dental procedures performed in a dental office.

Epidemiology Mitral Valve Prolapse: Only 1/4 Of MVP Patients Have Mitral Insufficiency (Regurgitation Or Murmur) - This Results In The Very Slight Increased Risk For Endocarditis

MVP Mitral valve prolapse accounts for 25-30% of adult cases of native valve endocarditis MVP is now the most common underlying condition among patients who develop infective endocarditis

Aortic Valve Disease Accounts for 12-30% of IE cases

3 Types Of Endocarditis Lesions Cardiac Lesions Embolic Lesions: Friable Cardiac Lesions That Break Away General Lesions

Cardiac Lesions Usually Valvular Most Often Mitral Valve May Cover The Entire Valve Mass Of Platelets, Fibrin And Bacteria Sterile Vegetations May Occur In 50% Of Lupus Patients

Embolic Lesions Osler’s Nodes: Are Small, Painful Petechiae In Extremities

Janeway Lesions Pathognomonic of IE Non-tender dermal abscesses

Splinter Hemorrhages Late-appearing symptom in endocarditis These represent damage to capillaries May also appear due to nail trauma

General Lesions Enlarged Spleen Arthritis Clubbing Of Fingers Cardiac Failure Conduction Abnormalities Stroke Renal Failure

Mortality Overall Rate About 40% Death Usually Due To Heart Failure Resulting From Valve Dysfunction Highest Death Rate Is In Early Prosthetic Valve Endocarditis

Classic Triad - But May Not Always Be Present 1. Fever 2. Positive Blood Culture 3. Heart Murmur Sometimes Insidious Onset “Flu-Like” Symptoms

Lab Findings +Culture In 95% Of BE Strep viridans Most Commonly Causes SBE Staph aureus Most Commonly Causes ABE Electrocardiography: Will Determine If Infection Progresses To Myocardium

Lab Findings Echocardiography - As Important As A Positive Blood Culture Are Results Which Show Vegetations, Abscesses, Etc.

Major Diagnostic Criteria Positive Blood Culture Echocardiogram Findings Of Endocardial Involvement New Valvular Regurgitation

Minor Diagnostic Criteria Predisposing Heart Conditions IV Drug Use Vascular Emboli Osler Nodes Aneurysm Roth Spots Of The Eye Splinter Hemorrhages

Treatment Treat It Early! Culture Use Bactericidal Agents PCN G; Cefatriaxone; PCN G + Gentamicin; Nafcillin; Vancomycin

Antibiotics Empirical treatment; flucloxacillin & gentamicin are the usual first line 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

Treatment Use Adequate Dosage Parenteral Route Sufficient Duration: 4-6 Weeks Or Longer

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

Antibiotic Prophylaxis Regimen Designed For Alpha-hemolytic Strep (S. viridans) No Clinical Trials Available To Show This Works! (Actually Prevents BE In Humans) 25-50% Hospital Antibiotic Usage Is For Prophylaxis Effective For Patients With Prosthetic Valves And Previous Endocarditis History

Antibiotic Prophylaxis Complications: Resistant Bacteria, Toxicity, Allergies, Suprainfections, Costs Will Not Prevent All Cases

American Heart Association Guidelines Not Intended To Be A Standard Of Care Not A Substitute For Clinical Judgment Must Be Considered If You Receive A Medical Opinion That Conflicts With The Guidelines (You Are Responsible For The Outcome Of Your Patient’s Dental Treatment)

American Heart Association Guidelines Can Still Develop Endocarditis Even When Using Guidelines

Prophylaxis Myths Most Cases Of BE Of Oral Origin Are Caused By Dental Procedures AHA Regimens Give Almost Total Protection Against Endocarditis After Dental Procedures

Prophylaxis Myths If A Patient Is Taking Antibiotics For An Infection Before The Dental Procedure, You Do Not Need To Change The Patient To Another Antibiotic Before The Dental Procedure

Prophylaxis Myths The Risk Of Endocarditis Is Greater Than The Risk Of Toxic Effects Of The Antibiotic

Dental Procedures For Which Prophylaxis Is Recommended All procedures involving manipulation of gingival tissue or the periapical region of teeth or perforation of oral mucosa Excluded procedures: Routine anesthetic injections through noninfected tissue Radiographs Placement of removable prosthodontic or orthodontic appliances Adjustment of orthodontic appliances Shedding of primary teeth and bleeding from trauma to lips or oral mucosa

Nonvalvular Cardiovascular Devices Such as coronary artery stents, hemodialysis grafts Routine antibiotic prophylaxis for dental procedures is not recommended However, prophylaxis is recommended if an abscess is going to be incised & drained, Or, if there is leakage present after the device is placed