1. Infective Endocarditis
Hasan Al_Farhan
Prof. of cardiology
FACC,FICSM Cardiol,DIC.DM
7/98
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2. Pathogenesis
Disruption of the endocardial layer as a complication of abnormal blood flow associated with underlying cardiac defect
Bacterium-endothelium interaction with bacterial attachment and invasion of endothelial cells
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3. Epidemiology
Underlying valvular abnormality predisposing to infective endocarditis
rheumatic fever a common cause in the past
mitral valve prolapse currently represents the most common underlying cardiac abnormality
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4. mitral valve prolapse risk for infective ednocarditis is 5x-8x
mitral regurgitation increases the risk
leaflet redundancy with myxomatous degeneration is a frequent finding
age <20 , female predominate age >20 , male accounts for 60% age >50 , male accounts for 68%
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5. Causative Agents
1 .Streptococci Staphylococci Gram –negative bacilli Haemophillus Anaerobes Other : Rickettsia ,fungi
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6. Predisposing Factors Polymicrobial Infective Endocarditis
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7. Infective Endocarditis; clinical features
1. Clinical course
2.Clinical feature
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8. 7/98
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9. Diagnostic (Duke) Criteria
Definitive infective endocarditis
pathologic criteria
microorganisms or pathologic lesions: demonstrated by culture or histology in a vegetation, or in a vegetation that has embolized, or in an intracardiac abscess
clinical criteria (see below)
two major criteria, or one major and three minor criteria, or five minor criteria
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10. Diagnostic (Duke) Criteria
Possible infective endocarditis
findings consistent of IE that fall short of “definite”, but not “rejected”
Rejected
firm alternate Dx for manifestation of IE
resolution ofmanifestations of IE, with antibiotic therapy for  4 days
no pathologic evidence of IE at surgery or autopsy, after antibiotic therapy for  4 days
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11. Diagnostic (Duke) Criteria
Major criteria
positive blood culture for IE
evidence of endocardial involvement
Minor criteria
predisposition (heart condition or IV drug use)
fever of 38 c or higher
vascular or immunologic phenomena
microbiologic or echocardiographic evidence not meeting major criteria
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12. Duke’s Major Criteria positive blood culture for IE
typical microorganism (strep viridans, strep bovis, HACEK group, staph aureus or enterococci in the absence of a primary focus) for endocarditis from two separate blood cultures
persistently positive blood culture from:
blood cultures drawn more than 12 hr apart, or
all of 3 or more separate blood cultures,taken over more than 1 hr .
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13. Duke’s Major Criteria Evidence of endocardial involvement
positive echocardiogram for endocarditis
oscillating intracardiac mass on valve or supporting structure, or in the path of regurgitant jets, or on implanted material, in the absence of an alternate anatomic explanation
abscess
new partial dehiscence of prosthetic valve
new valvular regurgitation (increase or change in pre-existing murmur not sufficient)
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14. Duke’s Minor Criteria
predisposition (predisposing heart condition or iv drug use)
fever of F or higher
vascular phenomena (major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctive hemorrhages, Janeway lesions)
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15. Duke’s Minor Criteria
immunologic phenomena (glomerulonephritis, Osler’s nodes, Roth spots, rheumatoid factor)
microbiologic evidence (positive blood culture not meeting major criteria or serologic evidence of active infection with organism consistent with IE)
echocardiogram (consistent with IE but not meeting major criteria)
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16. Risk for Endocarditis High risk prosthetic cardiac valve
prior episodes of endocarditis
complex congenital cardiac defect
surgically constructed systemic-pulmonary shunts or conduits
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17. Risk for Endocarditis Moderate risk patent ductus arteriosus
VSD, primum ASD
coarctation of the aorta
bicuspid aortic valve
hypertrophic cardiomyopathy
acquired valvular dysfunction
MVP with mitral regurgitation
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18. Risk for Endocarditis Low risk isolated secundum atrial septal defect
ASD, VSD, or PDA >6 months past repair
“innocent” heart murmur by auscultation in the pediatric population
“innocent” heart murmur by echocardiography in adult patients
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19. Treatment
……………….??
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20. SBE Prophylaxis Standard general prophylaxis amoxicillin
Unable to take oral meds ampicillin
Allergic to penicilin clindamycin
cephalexin
azithromycin
clarithromycin
Allergic to penicillin and unable clindamycin
to take oral medications cefazolin
7/98
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