infective endocarditis manoj kuduvalli. definition bacterial or fungal infection within the heart...

INFECTIVE INFECTIVE ENDOCARDITISENDOCARDITIS

Manoj KuduvalliManoj Kuduvalli

DefinitionDefinition

Bacterial or Fungal infection Bacterial or Fungal infection within the heart (although within the heart (although chlamydial and rickettsial chlamydial and rickettsial

infections are known) ; the role infections are known) ; the role of viruses is unknownof viruses is unknown

ORIGINAL ORIGINAL CLASSIFICATIONCLASSIFICATION

(Prior to Antibiotic era)(Prior to Antibiotic era)

AcuteVirulent O rganisms

Norm al ValveDeath < 6 w eeks

SubacuteRelatively avirulent organisms

Abnorm al valveIndolent course

Infective Endocarditis

Current Criteria for ClassificationCurrent Criteria for Classification

Underlying Anatomy:Underlying Anatomy:

› › Native Valve EndocarditisNative Valve Endocarditis

› › Prosthetic Valve EndocarditisProsthetic Valve Endocarditis

Infecting OrganismInfecting Organism

› › Serves as basis for therapy and Serves as basis for therapy and prognosis prognosis

Native Valve EndocarditisNative Valve EndocarditisUnderlying Predisposing ConditionsUnderlying Predisposing Conditions

›› ›› 60 - 80% of non IV Drug abusers have a 60 - 80% of non IV Drug abusers have a

predisposing conditionpredisposing condition

› › Mitral Valve Prolapse Mitral Valve Prolapse 30 - 50%30 - 50%

› › Rheumatic Heart Disease Rheumatic Heart Disease 20 - 40%20 - 40%

› › Degenerative Aortic and Degenerative Aortic and 20 - 30%20 - 30%

Mitral valve diseaseMitral valve disease

› › Congenital Heart Disease Congenital Heart Disease 10 - 20%10 - 20%

Native Valve EndocarditisNative Valve EndocarditisMicrobiologyMicrobiology

›› ›› StreptococciStreptococci 50 - 70%50 - 70%Viridans Streptococci Viridans Streptococci (50% of all Strep)(50% of all Strep)

›› ›› StaphylococciStaphylococci ~ 25% ~ 25%Mostly Coagulase +ve Staph. AureusMostly Coagulase +ve Staph. Aureus

Staph. EpidermidisStaph. Epidermidis

›› ›› EnterococciEnterococci ~ 10% ~ 10%


Viridans Viridans StreptococciStreptococci

Infect primarily abnormal Infect primarily abnormal valvesvalves

Indolent clinical courseIndolent clinical course Highly sensitive to PenicillinsHighly sensitive to Penicillins

Staph. aureusStaph. aureus Infect normal and abnormal Infect normal and abnormal

valvesvalves Fulminant course with rapid Fulminant course with rapid

destruction of valves and destruction of valves and multiple metastatic abscessesmultiple metastatic abscesses

Mostly resistant to Penicillins Mostly resistant to Penicillins and sensitive to penicillinase and sensitive to penicillinase resistant ß-lactamsresistant ß-lactams

Common with soft tissue Common with soft tissue infections, and infected IV infections, and infected IV catheterscatheters


Staph. EpidermidisStaph. Epidermidis Indolent CourseIndolent Course Affects abnormal valvesAffects abnormal valves

EnterococciEnterococci Normally affects Normally affects

damaged valvesdamaged valves Recent history of Recent history of

genitourinary or genitourinary or gastrointestinal gastrointestinal manipulation, disease or manipulation, disease or traumatrauma

Usually sensitive to Usually sensitive to Penicllin+GentamicinPenicllin+Gentamicin

Resistant strains Resistant strains prevalentprevalent

Prosthetic valve endocarditisProsthetic valve endocarditis

5 - 15% of all Infective Endocarditis5 - 15% of all Infective Endocarditis

Overall incidence 1 - 4%Overall incidence 1 - 4%

Risk of PVE peaks at 15 days postop. , Risk of PVE peaks at 15 days postop. , then rapidly declines by 150 daysthen rapidly declines by 150 days

Prosthetic Valve EndocarditisProsthetic Valve EndocarditisClassificationClassification

Early ( < 60 days )Early ( < 60 days )

Reflects perioperative Reflects perioperative contaminationcontamination

Incidence around 1%Incidence around 1% MicrobiologyMicrobiology

– Staph (45 - 50%)Staph (45 - 50%)

» Staph. Epiderm (~ 30%)Staph. Epiderm (~ 30%)

» Staph. Aureus (~ 20%)Staph. Aureus (~ 20%)

– Gram -ve aerobes (~20%)Gram -ve aerobes (~20%)

– Fungi (~ 10%)Fungi (~ 10%)

– Strep and Entero (5-10%)Strep and Entero (5-10%)

Late ( > 60 days)Late ( > 60 days)

After endothelializationAfter endothelialization Incidence 0.2 -0.5 % / pt. yearIncidence 0.2 -0.5 % / pt. year Transient bacteraemia from Transient bacteraemia from

dental, GI or GUdental, GI or GU MicrobiologyMicrobiology

– resembles native valve resembles native valve endocarditisendocarditis

IE in IV Drug AbusersIE in IV Drug Abusers

Right sided predilectionRight sided predilection

Tricuspid ValveTricuspid Valve ~ 55%~ 55%

Aortic ValveAortic Valve ~ 25%~ 25%

Mitral ValveMitral Valve ~ 20%~ 20%

Pulmonary ValvePulmonary Valve 1 - 1.5% 1 - 1.5%

Mixed Rt. And Lt. SideMixed Rt. And Lt. Side 5 - 6%5 - 6%

IE in IV Drug AbusersIE in IV Drug Abusers

Skin most predominant source of infectionSkin most predominant source of infection Also contamination of drugs and paraphernaliaAlso contamination of drugs and paraphernalia 70 - 100% of Rt. sided IE results in pneumonia 70 - 100% of Rt. sided IE results in pneumonia

and septic emboliand septic emboli MicrobiologyMicrobiology

– Staph aureusStaph aureus ~60%~60%

– Streptococci and EnterococciStreptococci and Enterococci ~20%~20%

– Gram -ve bacilliGram -ve bacilli ~10%~10%

– Fungi (Candida and AspergillusFungi (Candida and Aspergillus ~5%~5%

IE in adults with congenital IE in adults with congenital heart diseaseheart diseaseCommon defectsCommon defects

VSD PDAVSD PDA

Bicuspid AV PSBicuspid AV PS

Coarctation of AortaCoarctation of Aorta

Occurs in defects withOccurs in defects with --mild or no hemodynamic consequences --mild or no hemodynamic consequences

--high gradients --high gradients

--high velocity jets impinging on endocardium--high velocity jets impinging on endocardium

Microbiology very important since Microbiology very important since virulence of the infecting organism virulence of the infecting organism

is a significant factor in is a significant factor in determining the success rates of determining the success rates of

both medical and surgical both medical and surgical treatmenttreatment

PathogenesisPathogenesis

Requires interaction betweenRequires interaction between

› › Host vascular endotheliumHost vascular endothelium

› › Host haemostatic responseHost haemostatic response

› › Adventitiously circulating Adventitiously circulating organisms organisms

Pathogenesis of VegetationsPathogenesis of Vegetations

Hemodynamic factors Hemodynamic factors predisposing to Infective predisposing to Infective

EndocarditisEndocarditis

High velocity abnormal jet streamHigh velocity abnormal jet stream Flow from high to low pressure Flow from high to low pressure

chamberchamber Narrow orifice between two Narrow orifice between two

chambers creating pressure gradientchambers creating pressure gradient

Local intracardiacinfectious process

Em bolization

Im m une com plexassociated disease

Pathology

PathologyPathology

Leafletperforation

Rupture ofchordae

VSD Conductionabnorm alities

Fistu lae Aneurysm ofS inus of Valsalva

Burrowingabscesses

Purulentpericard ial effusions

Valve ringabscesses

Intracardiacinfections

Common sites of origin of extravalvular spreadCommon sites of origin of extravalvular spread

Pathology

Initially affects

Valve leaflets in native valve endocarditis

Can extend into annulus

Annulus in prosthetic valve endocarditis

Due to presence of sewing rim

Pathology -Pathology - Embolic PhenomenaEmbolic Phenomena IncidenceIncidence

– ClinicallyClinically 15 - 45%15 - 45%

– PathologicallyPathologically 45 - 65%45 - 65%

More with large mobile vegetationsMore with large mobile vegetations– Fungi (Candida and Aspergillus)Fungi (Candida and Aspergillus)

– Group B and G StreptococciGroup B and G Streptococci

– Staph aureusStaph aureus

Result in Result in – InfarctsInfarcts

– AbscessesAbscesses

– Mycotic aneurysmsMycotic aneurysms

PathologyPathology Immune Complex AssociatedImmune Complex Associated

GlomerulonephritisGlomerulonephritis

ArthritisArthritis

Osler’s nodesOsler’s nodes

Clinical FeaturesClinical Features Onset usually within 2 weeks of infectionOnset usually within 2 weeks of infection

› › Indolent courseIndolent course

- Malaise- Malaise

- Fatigue- Fatigue

- Night sweats- Night sweats

- Anorexia- Anorexia

- Weight loss- Weight loss

› › Explosive courseExplosive course

- CCF- CCF

- S/o severe systemic sepsis- S/o severe systemic sepsis

Clinical featuresClinical features› › FeverFever

- Usually < 39 °C, remittent- Usually < 39 °C, remittent

- May be absent in - May be absent in

- elderly- elderly

- severe debility- severe debility

- CCF- CCF

- Already on antibiotics- Already on antibiotics

› › MurmursMurmurs

- Appearance of new murmur or true - Appearance of new murmur or true

change in existent murmur indicates change in existent murmur indicates

infection with virulent organisminfection with virulent organism

Other Clinical FeaturesOther Clinical Features SplenomegalySplenomegaly ~ 30%~ 30% PetechiaePetechiae 20 - 40%20 - 40%

– ConjunctivaeConjunctivae– Buccal mucosaBuccal mucosa– palatepalate– skin in supraclavicular regionsskin in supraclavicular regions

Osler’s NodesOsler’s Nodes 10 - 25%10 - 25% Splinter HaemorrhagesSplinter Haemorrhages 5 - 10%5 - 10% Roth SpotsRoth Spots ~ 5%~ 5% Musculoskeletal (arthritis)Musculoskeletal (arthritis)

ComplicationsComplications

Congestive Cardiac Failure Congestive Cardiac Failure (Commonest (Commonest complication)complication)

» Valve DestructionValve Destruction

» Myocarditis Myocarditis

» Coronary artery embolism and MICoronary artery embolism and MI

» Myocardial AbscessesMyocardial Abscesses

Neurological Manifestations (1/3 cases)Neurological Manifestations (1/3 cases)» Major embolism to MCA territory Major embolism to MCA territory ~25% ~25%

» Mycotic AneurysmsMycotic Aneurysms 2 - 10% 2 - 10%

ComplicationsComplications

Metastatic infectionsMetastatic infections

– Rt. Sided vegetationsRt. Sided vegetations» Lung abscessesLung abscesses

» Pyothorax / PyopneumothoraxPyothorax / Pyopneumothorax

– Lt. Sided vegetationsLt. Sided vegetations» Pyogenic MeningitisPyogenic Meningitis

» Splenic AbscessesSplenic Abscesses

» PyelonephritisPyelonephritis

» OsteomyelitisOsteomyelitis

Renal impairment d/t GlomerulonephritisRenal impairment d/t Glomerulonephritis

DiagnosisDiagnosis Blood CulturesBlood Cultures

– Positive in 95% casesPositive in 95% cases

Other Laboratory ParametersOther Laboratory Parameters– AnaemiaAnaemia

– Leucocytosis (WCC may be normal in indolent Leucocytosis (WCC may be normal in indolent infection)infection)

– ThrombocytopeniaThrombocytopenia ESR (may be absent in CCF and renal failure)ESR (may be absent in CCF and renal failure)

– Urine - Microscopic hematuria / proteinuriaUrine - Microscopic hematuria / proteinuria

EchocardiographyEchocardiography Can demonstrate lesion / vegetation in 60 - Can demonstrate lesion / vegetation in 60 -

80% of cases80% of cases Difficult in prosthetic valve endocarditisDifficult in prosthetic valve endocarditis TOETOE better than better than TTETTE Can demonstrateCan demonstrate

– Morphology of valveMorphology of valve

– Annular abscessesAnnular abscesses

– Hemodynamics of the valvesHemodynamics of the valves

Serial observations can contribute to decision Serial observations can contribute to decision for surgeryfor surgery

Treatment

Medical Surgical

Principles of Medical Principles of Medical ManagementManagement

Sterilization of Vegetations with antibioticsSterilization of Vegetations with antibiotics

- prolonged- prolongedSlowly metabolising bacteriaSlowly metabolising bacteria

due to high density, hence due to high density, hence sensitivitysensitivity

- high dose- high doseBacteria deep inside Bacteria deep inside

vegetationsvegetations

-bactericidal-bactericidal

Principles of Medical Principles of Medical ManagementManagement

Acute onset, fulminantAcute onset, fulminant-Within two to three hours of-Within two to three hours of

clinical diagnosis. clinical diagnosis.

-Take cultures, but do not wait -Take cultures, but do not wait

for resultsfor results

Timing of TherapyTiming of TherapySubacute onset, or havingSubacute onset, or having

received recent antibioticreceived recent antibiotic-Within two to three days.-Within two to three days.-Can wait for culture reports-Can wait for culture reports

Principles of Medical ManagementPrinciples of Medical Management Isolation of organisms very importantIsolation of organisms very important

Therapy before isolation of organismTherapy before isolation of organism» Native valve endocarditis and in IV drug Native valve endocarditis and in IV drug

abusersabusers Directed against Staph aureusDirected against Staph aureus

» Prosthetic valve endocarditisProsthetic valve endocarditis Broad spectrum antibiotics directed against Broad spectrum antibiotics directed against

– Staph aureusStaph aureus– Staph epidermidisStaph epidermidis– Gram –ve bacilliGram –ve bacilli

Indications for SurgeryIndications for SurgeryLeft sided native valve endocarditisLeft sided native valve endocarditis

Valvular disruption leading to severe Valvular disruption leading to severe insufficiency and CCFinsufficiency and CCF

Extravalvar extensionExtravalvar extension Embolization of vegetationsEmbolization of vegetations Failure of medical managementFailure of medical management

Positive blood culture and systemic signs of Positive blood culture and systemic signs of infection after “adequate” antibiotic therapyinfection after “adequate” antibiotic therapy

Resistant organisms Resistant organisms such as MRSA, Fungi , Pseudomonassuch as MRSA, Fungi , Pseudomonas

Echo detected vegetation > 1 cm ??Echo detected vegetation > 1 cm ??

Indications for SurgeryIndications for SurgeryRight sided native valve endocarditisRight sided native valve endocarditis

Indications differ because:Indications differ because:

- Consequences of valve disruption and emboli are less- Consequences of valve disruption and emboli are less

- Success with antibiotics seems to be better - Success with antibiotics seems to be better

--Failure of medical treatment--Failure of medical treatment

--CCF, with its complications --CCF, with its complications

IndicationsIndications (elective) (elective)

--Recurrent pulmonary emboli --Recurrent pulmonary emboli

with complicationswith complications

--Extravalvar spread (rare)--Extravalvar spread (rare)

Indications for surgeryIndications for surgeryProsthetic valve endocarditisProsthetic valve endocarditis

Early infection almost always require Early infection almost always require surgerysurgery

Late infectionLate infectionAntibiotic therapy succeeds more often with Antibiotic therapy succeeds more often with Bioprosthesis compared to mechanical valvesBioprosthesis compared to mechanical valves

CCF due to CCF due to prosthesis prosthesis dysfunctiondysfunction

IndicationsIndications Multiple emboli Multiple emboli

Persistent infectionPersistent infection

Indications for SurgeryIndications for SurgerySpecial situationsSpecial situations

AIDSAIDS

Not usually indicated since life Not usually indicated since life expectancy due to AIDS very poorexpectancy due to AIDS very poor

HIV +ve patient without AIDS HIV +ve patient without AIDS

IV Drug AbusersIV Drug Abusers

No change in indications since enough No change in indications since enough number survive > 10 yearsnumber survive > 10 years

When to operate ?When to operate ?As soon as there is a major indicationAs soon as there is a major indication

Valid reasons for delayValid reasons for delay

Acute CNS injuryAcute CNS injury

----Hemorrhagic infarct (Wait for Hemorrhagic infarct (Wait for 10 days to allow healing) 10 days to allow healing)

--Coma (very poor prognosis )--Coma (very poor prognosis )

Renal failure due to Glom’nephritisRenal failure due to Glom’nephritis

Follow through the acute phaseFollow through the acute phase

(Prerenal failure -- early operation)(Prerenal failure -- early operation)

Principles of operationPrinciples of operation

Repair or Replacement ?Repair or Replacement ?(More important with mitral valves)(More important with mitral valves)

Repair contemplated only if:Repair contemplated only if:

--Infection well controlled--Infection well controlled

--Repair structurally feasible after --Repair structurally feasible after involved tissue excised involved tissue excised


Early operation Early operation once indicatedonce indicated Preop. knowledgePreop. knowledge of morphology of valveof morphology of valve Good exposureGood exposure (may be difficult in (may be difficult in

mitrals)mitrals) Excision and debridement Excision and debridement of all infected of all infected

or involved tissue even if extensive or involved tissue even if extensive reconstruction or permanent pacing reconstruction or permanent pacing requiredrequired


LookLook for extravalvar extensionfor extravalvar extension If present,If present, evacuate abscess cavity and evacuate abscess cavity and

repairrepair with biological material such as with biological material such as autologous or bovine pericardiumautologous or bovine pericardium

SutureSuture valve onto clean and relatively valve onto clean and relatively strong tissuestrong tissue

Temporary Temporary pacing leadspacing leads

Which Prosthesis?

MechanicalStented Bioprosthesis

Stentless Bioprosthesis Homograft

Choice of prosthesisChoice of prosthesisImportant factor is location of infectionImportant factor is location of infection

-- Infection of cusps only:-- Infection of cusps only:

Choice does not matter, since all infected Choice does not matter, since all infected tissue is usually excisedtissue is usually excised

-- -- Perivalvar extension:Perivalvar extension:

No choice between mechanical and stented No choice between mechanical and stented bioprosthesis (both with cloth sewing rims)bioprosthesis (both with cloth sewing rims)

Homograft, maybe stentless bioprosthesis Homograft, maybe stentless bioprosthesis have lesser incidence of infectionhave lesser incidence of infection

Choice of prosthesisChoice of prosthesisMechanical v/s BioprostheticMechanical v/s Bioprosthetic

No difference in linearized rates for recurrent No difference in linearized rates for recurrent or residual infection (~1-2% per patient year)or residual infection (~1-2% per patient year)

No difference in operative mortality and No difference in operative mortality and complication free survivalcomplication free survival

Infected bioprosthesis more easily sterilized Infected bioprosthesis more easily sterilized (since infection initially involves leaflets)(since infection initially involves leaflets)

However, infection in bioprosthesis may hasten However, infection in bioprosthesis may hasten SVD due to damage to leafletsSVD due to damage to leaflets

Choice of prosthesisChoice of prosthesisHomograft v/s othersHomograft v/s others

Hazard function for recurrent Hazard function for recurrent endocarditis has only low constant phase endocarditis has only low constant phase and has no high early hazard phase like and has no high early hazard phase like other prosthesisother prosthesis

Homograft best choice if valved conduit Homograft best choice if valved conduit is required for root replacement is required for root replacement ( > 50% ( > 50% annular dehiscence or aortoventricular annular dehiscence or aortoventricular discontinuity)discontinuity)

Postoperative AntibioticsPostoperative AntibioticsTo continue for 6 weeks ifTo continue for 6 weeks if

› › Operated for --Operated for --Acute fulminant infectionAcute fulminant infection

--Failure of medical therapy--Failure of medical therapy

--Resistant organisms--Resistant organisms

› › Excised valve yields positive culturesExcised valve yields positive cultures

›› Periannular involvementPeriannular involvement

›› Valve culture –ve, but organisms seen on Valve culture –ve, but organisms seen on

histologyhistology

› › PositivePositive blood cultures 3 – 4 days postop. blood cultures 3 – 4 days postop.

Results of TreatmentResults of TreatmentNative valve endocarditisNative valve endocarditis

Medical ManagementMedical ManagementMortality 10 – 60 %Mortality 10 – 60 %

Risk FactorsRisk FactorsVirulent organisms s/a MRSA, G-ve bacilli, fungiVirulent organisms s/a MRSA, G-ve bacilli, fungi

CCFCCF

Persistence of systemic sepsisPersistence of systemic sepsis

Major septic embolusMajor septic embolus

Extravalvar extensionExtravalvar extension

Acute renal failureAcute renal failure


Surgical ManagementSurgical Management

Hospital Mortality 5 – 20%Hospital Mortality 5 – 20%

Risk factorsRisk factors

Virulent organismsVirulent organisms

Perivalvar extensionPerivalvar extension

Intractable CCFIntractable CCF

Renal and multiorgan failureRenal and multiorgan failure



Recurrent Endocarditis ~ 2%Recurrent Endocarditis ~ 2%Most occurs within 2 months post op.Most occurs within 2 months post op.

Same organismSame organism

No fresh source of infectionNo fresh source of infection

Perivalvar leaks 3-7%Perivalvar leaks 3-7%

Results of TreatmentResults of TreatmentProsthetic valve endocarditisProsthetic valve endocarditis

Medical ManagementMedical Management

Mortality ~ 70%Mortality ~ 70%

Risk factorsRisk factorsValve incompetence or perivalvar leakValve incompetence or perivalvar leak

Early postoperative onset Early postoperative onset

Virulent organismVirulent organism



Hospital Mortality 0 –22%Hospital Mortality 0 –22%

Risk factorsRisk factorsEarly postoperative infectionEarly postoperative infection

Virulent organismVirulent organism

Perivalvar extensionPerivalvar extension

Delay in operationDelay in operation



Long term results differ from valve Long term results differ from valve replacement for NVE or other lesionsreplacement for NVE or other lesions

Have comparatively unfavourable rates Have comparatively unfavourable rates of late death, recurrence of infection and of late death, recurrence of infection and reoperationreoperation

Antibiotic ProphylaxisAntibiotic Prophylaxis

Protocol usually followed recommended by Dajani et al in Protocol usually followed recommended by Dajani et al in JAMA 1990JAMA 1990

Recommended in following conditionsRecommended in following conditionsProsthetic valvesProsthetic valves

Previous history of infective endocarditis (even without Previous history of infective endocarditis (even without underlying heart disease) underlying heart disease)

Most congenital heart diseasesMost congenital heart diseases

Rheumatic or other acquired valve diseaseRheumatic or other acquired valve disease

IHSSIHSS

MVP with MRMVP with MR

Thank you!

infective endocarditis manoj kuduvalli. definition bacterial or fungal infection within the heart...

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