Infective Endocarditis

DEFINITION Infection or colonization of endocardium, heart valves and congenital heart defects by bacteria, rickettsiae and fungi Infection or colonization of endocardium, heart valves and congenital heart defects by bacteria, rickettsiae and fungi. Low grade persistent bacteraemia Low grade persistent bacteraemia

IMPORTANCE Serious disease Serious disease mortality : 30 % mortality : 30 % Damage of heart or other organs Damage of heart or other organs Follow dental procedures ( tooth extraction) Follow dental procedures ( tooth extraction) Rheumatic heart disease Rheumatic heart disease Congenital heart disease Congenital heart disease

ETIOLOGY SUSCEPTIBLE PATIENT SUSCEPTIBLE PATIENT BACTEREMIA BACTEREMIA

FACTORES AFFECTING SEVERITY AND OUTCOME BACTERIAL FACTORS BACTERIAL FACTORS VIRULENCE VIRULENCE N umber of BACTERIA IN THE BLOOD N umber of BACTERIA IN THE BLOOD

HOST FACTORS : HOST FACTORS :. FACTORS INCREASING SUSCEPTIBILITY. FACTORS INCREASING SUSCEPTIBILITY LOCAL LOCAL CONGINITALOR RHEUMATIC HEART DISEASE CONGINITALOR RHEUMATIC HEART DISEASE PROSTHETIC HEART VALVES PROSTHETIC HEART VALVES OTHER CARDIOVASCULAR DISEASE OTHER CARDIOVASCULAR DISEASE HEART SURGERY HEART SURGERY GENIRAL GENIRAL UNDERLYING DISEASE ( DIABETES.M ) UNDERLYING DISEASE ( DIABETES.M ) DRUGS DRUGS IATROGENIC: IATROGENIC: IMMUNOSUPPRESSIVE TREATMENT IMMUNOSUPPRESSIVE TREATMENT CYTOTOXIC AGENTS CYTOTOXIC AGENTS SELF- INFLICTED SELF- INFLICTED ALCOHOLISM ALCOHOLISM ADDICTION (INJECTED DRUGS ) ADDICTION (INJECTED DRUGS ) PROTECTIVE FACTORS PROTECTIVE FACTORS ANTIMICROBIAL CHEMOTHERAPY ANTIMICROBIAL CHEMOTHERAPY

SOURCES OF INFECTION Dental extraction and other dental procedures Dental extraction and other dental procedures Cardiac surgery ( prosthetic valves) Cardiac surgery ( prosthetic valves) Intravenous medication Intravenous medication Intravenous. Drug addiction Intravenous. Drug addiction Intracardiac or intravenous catheters Intracardiac or intravenous catheters Obstetric or gynaecologic procedures Obstetric or gynaecologic procedures Urogenital manuplations Urogenital manuplations

PREDISPOSING FACTORS A- cardiac lesions A- cardiac lesions Chronic rheumatic valvular disease Chronic rheumatic valvular disease Congenital heart disease and defects Congenital heart disease and defects Atherosclerosis Atherosclerosis Prosthetic valves Prosthetic valves Immediate Immediate Delayed Delayed Distorted shape causes stasis of blood flow and settee of bacteria on the endocardium Virulent bacteria`, staph. aureus and strept. Pneumoniae can infect normal heart

B. systemic factors B. systemic factors Immunosuppressive treatment Immunosuppressive treatment Immune defects ( disease) Immune defects ( disease) Alcoholism Alcoholism Iv. Drug abuse Iv. Drug abuse

PORTAL OF ENTRY Dental extraction bleeding bacteraemia Dental extraction bleeding bacteraemia Rocking the tooth in the socket pumping effect on the vessels of periodontal ligament, forces bacteria from gingival pockets into blood stream 40 – 80 % bacteraemia Rocking the tooth in the socket pumping effect on the vessels of periodontal ligament, forces bacteria from gingival pockets into blood stream 40 – 80 % bacteraemia Sensitivity of blood culture techniques Sensitivity of blood culture techniques Severity of gingival infection Severity of gingival infection Oral irrigation device Oral irrigation device

NOTE  Bacteraemia may follow scaling, tooth brushing, endodontic therapy.  Lack of clinical effect of many bacteraemia is due to small number or low virulence  They are rapidly cleared by normal body defence ( leucocytes )  Strept. Faecalis may cause endocarditis after genitourinary or gut procedures

CAUSATIVE ORGANISMS Viridans streptococci Viridans streptococci Most common cause of sub- acute bacterial endocarditis (SBE) Most common cause of sub- acute bacterial endocarditis (SBE) Produce glucagons adhere to endocardium Produce glucagons adhere to endocardium E.g : E.g : Streptococcus mutans Streptococcus mutans Streptococcus sanguis Streptococcus sanguis

Streptococcus faecalis[after urogenital manoulation] Streptococcus faecalis[after urogenital manoulation] Streptococcus faecium Streptococcus faecium Streptococcus pneumoniae Streptococcus pneumoniae Staphylococcus aureus Staphylococcus aureus Acute endocarditis Acute endocarditis Staphylococcus epidermidis Staphylococcus epidermidis Prosthetic heart valves Prosthetic heart valves Brucella species Brucella species Actinobacillus actinomycetes comitans Actinobacillus actinomycetes comitans Rickettisae Rickettisae Fungi Fungi Coxiella burneti [Q fever cases] Coxiella burneti [Q fever cases] Candida albicans Candida albicans

PATHOGENESIS Formation of vegetations Formation of vegetations  Fibrin, platelets (thrombi), bacteria colonies Attached to heart valves  Break off infected emboli distant organs ( kidney, brain )  Immune complex formation causes glomerular damage haematuria  Valves infection destruction heart failure.  Drug addicts tricuspid,pulmonary valves of right side of heart lung emboli pneumonia

CLINICAL FEATURES Onset is insidious ( SBE) – 3 weeks after extraction Fever ( mild and prolonged ) Malaise, weight loss, weakness Changing murmurs due tovalve involvement] Anaemia, leucocytosis Microscopic haematuria PetechiaeSpleenomegaly Splinter haemorrhage [nails] Hypergammaglobulinaemia Age young, elderly

MORTALITY With antibiotic treatment 30% 30% High mortality High mortality Virulance of organism or severe infection Virulance of organism or severe infection Presence of underlying disease Presence of underlying disease Elderly Elderly Inadequate treatment Inadequate treatment poor prognosis poor prognosis Candidal Candidal Staphylococcus Staphylococcus Gram-negative Gram-negative

LABORATORY DIAGNOSIS A – serial blood culture ( 2-3 sets before antibiotic therapy ) A – serial blood culture ( 2-3 sets before antibiotic therapy ) Aerobic Aerobic Anaerobic Anaerobic B- serological tests B- serological tests CFT ( coxiella burniti ) CFT ( coxiella burniti ) C- sensitivity test C- sensitivity test

TREATMENT Disk diffusion test ( not sufficient ) Disk diffusion test ( not sufficient ) MIC [minimum inhibitory concetration], MBC MIC [minimum inhibitory concetration], MBC Criteria of antibiotic Criteria of antibiotic Bactericidal Bactericidal Parenteral Parenteral High dose High dose Prolonged Prolonged

Viridans streptococci –Benzyl penicillin I.V Viridans streptococci –Benzyl penicillin I.V 4 MU I.V. every 4 hrs for 4 weeks 4 MU I.V. every 4 hrs for 4 weeks or or penicillin + gentamicin penicillin + gentamicin Streptococcus faecalis ampicillin + gentamicin I.V Streptococcus faecalis ampicillin + gentamicin I.V Recurrence after cure is common in: Recurrence after cure is common in:  drug addicts  immunodeficient patients

Antimicrobial prophylaxis (prevention) For susceptible patients For susceptible patients Rheumatic valvular or congenital heart disease Rheumatic valvular or congenital heart disease Before tooth extraction, deep scaling, other operations Before tooth extraction, deep scaling, other operations  Benzyl-penicillin 2M– I.M 30 mint. before 500mg penicillin V oral – 6 hourly for 2 days afterwards

If patient is allergic to penicillin : If patient is allergic to penicillin : Vancomycin or Erythromycin lactobionate Ig I.V. 30 minutes befor operation. Vancomycin or Erythromycin lactobionate Ig I.V. 30 minutes befor operation. Genitourinary procedures:mainly by Enterococcus feacalis Genitourinary procedures:mainly by Enterococcus feacalis gentamicin +ampicillin I.V gentamicin +ampicillin I.V 30 minutes before operation 30 minutes before operation