1. INFECTIVE ENDOCARDITIS
Dr. Muayad AL-Qaisy

2. 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

3. 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

5. 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

6. 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

7. PNEUMATOCELE

8. Epidemiology
Incidence <1% Of General Population

9. 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)

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

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

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

13. 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.

14. 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

15. 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

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

17. 3 Types Of Endocarditis Lesions
Cardiac Lesions
Embolic Lesions: Friable Cardiac Lesions That Break Away
General Lesions

18. 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

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

20. Janeway Lesions
Pathognomonic of IE
Non-tender dermal abscesses

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

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

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

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

25. 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

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

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

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

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

30. 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

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

32. 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

33. 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

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

37. 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)

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

39. 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

40. 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

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

42. 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

43. 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