ENDOCARDITIS

CLASSIFICATION OF ENDOCARDITIS

CATEGORIES OF ENDOCARDITIS n Native valve n Prosthetic valve n IVDA

AETIOLOGY OF NATIVE VALVE ENDOCARDITIS n Streptococci55% n Staphylococci30% n Enterococci6% n Gram negative bacillirare n Fungirare

EPIDEMIOLOGY OF NATIVE VALVE ENDOCARDITIS n Male n Age > 50 yrs n Mitral valve > aortic valve >>> tricuspid n Predisposing Factors –mitral valve prolapse –congential heart disease

PROSTHETIC VALVE ENDOCARDITIS n Early onset - symptoms within 60 days of surgery –usually valve contaminated during surgery –S. epidermidis –S. aureus –Gram-negative bacilli n Late onset - symptoms occur > 60 days after surgery –usually due to Streptococci

INTRAVENOUS DRUG ABUSERS Tricupsid (50%) > aortic (25%) > mitral (20%) n S. aureus>50% n Streptococci20% n Enterococci20% n Gram negative bacilli 5% n Fungi 5%

CLINICAL MANIFESTATIONS OF ENDOCARDITIS SymptomsPercentage Fever80 Chills/Weakness/Dyspnoea40 Cough/Anorexia/Wt loss25 Skin lesions/Stroke/N/V/HA20 Myalgia/Arthralgia/Oedema/CP15 Delirium/Haemoptysis/Back pain10

CLINICAL MANIFESTATIONS OF ENDOCARDITIS Physical FindingsPercentage Fever90 Heart murmur85 Embolic phemomenom>50 Skin manifestations18-50 Splenomegaly20-57 Septic complications20 Clubbing12-52

CLINICAL INVESTIGATIONS n FBC U+E Cr LFT n Multiple Blood Cultures (At least 3 from 2 different sites) n ESR CRP n TTE  TOE n CT/MRI (embolic phenomena)

CRITERIA FOR DIAGNOSIS OF ENDOCARDITIS n Definite –Pathologic criteria –Clinical criteria n 2 major or 1 major and 3 minor or 5 minor n Possible if not definite or rejected n Rejected –Alternate diagnosis –No evidence at surgery or resolution of endocarditis with < 4 days of abx therapy

MAJOR CRITERIA FOR IE n Positive blood culture for IE –Typical organism from 2 separate blood cultures or –Persistently positive blood cultures n Evidence of endocardial involvement –Positive echocardiogram –New valvular regurgitation

MINOR CRITERIA FOR IE n Predisposition n Fever n Vascular phenomena n Immunologic phenomena n Echocardiogram n Microbiologic evidence

INDICATIONS FOR SURGERY NVE PVE 5 or more points suggest the need for valve replacement

VIRIDANS STREPTOCOCCI n S. sanguis n S. mutans n S. mitis n S. milleri n S. bovis n Normal inhabitants of the oropharynx

RARE ORGANISMS n Corynebacterium n Listeria n Bartonella Species n Coxiella Burnetti (Q fever)

NATIVE VALVE ENDOCARDITIS DUE TO PENICILLIN SUSCEPTIBLE VIRIDANS STREPTOCOCCI (MIC 0.1 µg/ml) JAMA 1995;274:

NATIVE VALVE ENDOCARDITIS DUE TO VIRIDANS STREPTOCOCCI (MIC 0.1 AND < 0.5 µg/ml) JAMA 1995;274:

ENTEROCOCCI ENDOCARDITIS JAMA 1995;274:

STAPHYLOCOCCUS ENDOCARDITIS IN THE ABSENCE OF PROSTHETIC VALVE JAMA 1995;274:

STAPHYLOCOCCAL ENDOCARDITIS IN THE PRESENCE OF A PROSTHETIC VALVE JAMA 1995;274:

HACEK ORGANISMS n Haemophilus parainfluenzae n Haemophilis aphrophilus n Actinobacillus actinomycetemcomitans n Cardiobacterium hominis n Eikenella corrodens n Kingella kingae

ENDOCARDITIS DUE TO HACEK ORGANISMS JAMA 1995;274:

CARDIAC CONDITIONS ENDOCARDITIS PROPHYLAXIS RECOMMENDED n High Risk Conditions –Prosthetic valves –Previous bacterial endocarditis –Complex congenital heart disease –Surgically constructed pulmonic shunts n Moderate Risk Conditions –Most other Coronary Heart Diseases –Mitral prolapse with regurgitation –Hypertrophic cardiac myopathy

CARDIAC CONDITIONS ENDOCARDITIS PROPHYLAXIS NOT RECOMMENDED n Cardiac pacemakers and implanted defibrillators n Rheumatic fever without valve dysfunction n Physiologic, functional heart murmurs n Mitral valve prolapse without MI n Previous CABG n Atrial septal defect

DENTAL AND OTHER PROCEDURES FOR ENDOCARDITIS PROPHYLAXIS n Dental - extractions, periodontal procedures, implants, root canal n Respiratory - T&A, rigid bronchoscopy n GI - ERCP with biliary obstruction, Sclerotherapy of esophageal varices, dilation of esophageal n Biliary tract surgery, surgery on/through intestinal mucosa n GU - prostate surgery, cystoscopy, urethral dilatation

PROCEDURES ENDOCARDITIS PROPHYLAXIS IS NOT RECOMMENDED n Dental - filling cavities, orthodontic adjustments, dental x-rays n Respiratory - Intubation, flexible bronchoscopy n GI - transoesophageal echo n GU - vaginal hysterectomy, vaginal delivery, C- section, insert/remove IUD, foley catheter n Other - cardiac catheter, balloon angioplasty, implanted pacemaker, defibrillators, circumcision, skin biopsy, coronary stents

PROPHYLACTIC REGIMENS FOR GU/GI PROCEDURES

PROPHYLACTIC FOR DENTAL, ORAL, RESPIRATORY OR OESOPHAGEAL

FAILURE TO RESPOND TO TREATMENT n Abscess formation - paravalvar - metastatic n Low cardiac output - flail mitral valve or perforation - coronary embolism - free aortic regurgitation n Wrong diagnosis - lymphoma- SLE- TB - sarcoidosis- AIDS n Major Immune Activation - renal failure- emboli - vasulitis