ENDOCARDITIS The Etiology and the Laboratory Studies Reşat Özaras, MD, Professor, Infectious Diseases Dept.

Definition Endocarditis: it is an inflammation of the inner layer of the heart, the endocardium.

Clinical Features Whom to consider IE –Injection drug users –Prostethic heart valve –Prior IE –Bacteremia –Hemodialysis –HIV infection

Clinical Features Wide spectrum of signs&symptoms –Fatigue –Anorexia –Weight loss –Prolonged fever –Dizziness –Dyspnea –…..

PE Murmur Splenomegaly Findings of complications (emboli etc..)

IE: Clinical Classification Acute IE Main etiology: S. aureus Mortality (untreated) : < 2 months, 100% Subacute—chronic IE Main etiology: Viridans streptococci Mortality (untreated) : < 1 year, 100%

Classification According to the Valve Native Valve Endocarditis Prosthetic Valve Endocarditis

Clinical criteria Using specific definitions : –2 major criteria OR –1 major and 3 minor criteria OR –5 minor criteria Possible IE 1 major criterion and 1 minor criterion OR 3 minor criteria

Major Diagnostic Criteria Positive blood culture for typical infective endocarditis Echocardiography findings –with oscillating intracardiac mass – abscess

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Minor Diagnostic Criteria Predisposing heart condition or intravenous drug use Temp > 38.0° C Vascular phenomena: arterial emboli, pulmonary infarcts, mycotic aneurysms, intracranial bleed, conjunctival hemorrhages, Janeway lesions Immunologic phenomena: glomerulonephritis, Osler nodes, Roth spots, rheumatoid factor Microbiological evidence: positive blood culture but does not meet a major criterion Echocardiographic findings: consistent with endocarditis but do not meet a major criterion

Clinical criteria Using specific definitions : –2 major criteria OR –1 major and 3 minor criteria OR –5 minor criteria Possible IE 1 major criterion and 1 minor criterion OR 3 minor criteria

IE: Etiology NV PV 1-Streptococci: ~%50 ~40% 2-S. aureus: 3-Enterococci: 4-Coagulase-neg Staph: ~%5 ~70% 5-Gram-Neg Bacilli: 6-Fungus (Candida): 7-Diphteroids: 8-Polymicrobial: 9-Culture-neg./HACEK:

Our cases with IE 1-Viridans streptococci (8) (40%) 2-S. aureus (MSSA) (4) (20%) 3-Enterococci (2) (10%) 4-MSSE (1) (5%) 5-Anaerobs (1) 6-S. typhi (1) 7-Brucella (1) 8-Culture-negative (2)

IE: Streptococci Viridans streptococci (  -hemolytic) (the most frequent ones) 1-S. sanguis 2-S. mutans 3-S. mitis S. bovis (non-hemolytic)

Staphylococci S. aureus S. epidermidis

Diagnostics Clinical Samples Blood Serum (for serology) Embolus, abscess, or removed infected valve (for microbiological and histolgical studies)

IE: S. aureus Fever+S.aureus: consider IE (echo.) Fever+S.aureus in injection drug user: consider right side (tricuspid) IE (echo.)

Culture-negative IE Failure to yield any m.o. with automated blood culture systems within 7 days ~5% Use of antibiotics Coxiella burnetii and Bartonella

IE: Serology 1-Brucella 2-Coxiella burnetii 3-Bartonella

Treatment Antibiotics Surgery may be needed

IE: Mortality is ~30 Major systemic emboli Heart Failure Septic shock

Complications Cardiac Septic Embolic Neurologic Musculoskeletal Renal Associated with medical treatment

Complications Embolic (eg, cerebral infarct) Local spread of infection (eg, heart valve destruction) Metastatic infection (eg, vertebral osteomyelitis) Immune-mediated damage (eg, glomerulonephritis