Infective Infective EndocarditisEndocarditis

DEFINITIONDEFINITION

Infection or colonization of Infection or colonization of endocardium , heart valves and endocardium , heart valves and congenital heart defects by bacteria congenital heart defects by bacteria , rickettsiae and fungi , rickettsiae and fungi

.. Low grade persistent Low grade persistent

bacteraemiabacteraemia

IMPORTANCEIMPORTANCE

Serious disease Serious disease mortality : 30 %mortality : 30 % Damage of heart or other organsDamage of heart or other organs Follow dental procedures ( tooth Follow dental procedures ( tooth

extraction)extraction) Rheumatic heart disease Rheumatic heart disease Congenital heart diseaseCongenital heart disease

ETIOLOGYETIOLOGY

SUSCEPTIBLE PATIENTSUSCEPTIBLE PATIENT

BACTEREMIABACTEREMIA

FACTORES AFFECTING FACTORES AFFECTING SEVERITY AND SEVERITY AND

OUTCOMEOUTCOME

BACTERIAL FACTORSBACTERIAL FACTORS VIRULENCEVIRULENCE

N umber of BACTERIA IN THE N umber of BACTERIA IN THE BLOODBLOOD

HOST FACTORS HOST FACTORS : : . FACTORS INCREASING SUSCEPTIBILITY. FACTORS INCREASING SUSCEPTIBILITY

LOCALLOCAL CONGINITALOR RHEUMATIC HEART DISEASECONGINITALOR RHEUMATIC HEART DISEASE PROSTHETIC HEART VALVESPROSTHETIC HEART VALVES OTHER CARDIOVASCULAR DISEASEOTHER CARDIOVASCULAR DISEASE HEART SURGERYHEART SURGERY

GENIRALGENIRAL UNDERLYING DISEASE ( DIABETES.M )UNDERLYING DISEASE ( DIABETES.M )

DRUGSDRUGS IATROGENIC:IATROGENIC:

IMMUNOSUPPRESSIVE TREATMENTIMMUNOSUPPRESSIVE TREATMENT CYTOTOXIC AGENTSCYTOTOXIC AGENTS

SELF- INFLICTEDSELF- INFLICTED ALCOHOLISMALCOHOLISM ADDICTION (INJECTED DRUGS )ADDICTION (INJECTED DRUGS )

PROTECTIVE FACTORSPROTECTIVE FACTORS ANTIMICROBIAL CHEMOTHERAPYANTIMICROBIAL CHEMOTHERAPY

SOURCES OF SOURCES OF INFECTIONINFECTION

Dental extraction and other dental Dental extraction and other dental proceduresprocedures

Cardiac surgery ( prosthetic valves)Cardiac surgery ( prosthetic valves) Intravenous medicationIntravenous medication Intravenous. Drug addictionIntravenous. Drug addiction Intracardiac or intravenous cathetersIntracardiac or intravenous catheters Obstetric or gynaecologic procedures Obstetric or gynaecologic procedures Urogenital manuplationsUrogenital manuplations

PREDISPOSING PREDISPOSING FACTORSFACTORS

A- cardiac lesionsA- cardiac lesions Chronic rheumatic valvular disease Chronic rheumatic valvular disease Congenital heart disease and defects Congenital heart disease and defects AtherosclerosisAtherosclerosis Prosthetic valves Prosthetic valves

ImmediateImmediate DelayedDelayed

Distorted shape causes stasis of blood flow Distorted shape causes stasis of blood flow and settee of bacteria on the endocardium and settee of bacteria on the endocardium Virulent bacteria`, staph. aureus and Virulent bacteria`, staph. aureus and strept. Pneumoniae can infect normal strept. Pneumoniae can infect normal heart heart

B. systemic factorsB. systemic factors Immunosuppressive treatmentImmunosuppressive treatment Immune defects ( disease)Immune defects ( disease) AlcoholismAlcoholism Iv. Drug abuse Iv. Drug abuse

PORTAL OF ENTRYPORTAL OF ENTRY Dental extraction bleeding Dental extraction bleeding

bacteraemia bacteraemia Rocking the tooth in the socket Rocking the tooth in the socket pumping effect on the vessels of pumping effect on the vessels of periodontal ligament , forces bacteria periodontal ligament , forces bacteria from gingival pockets into blood stream from gingival pockets into blood stream 40 – 80 % bacteraemia 40 – 80 % bacteraemia

Sensitivity of blood culture techniquesSensitivity of blood culture techniques

Severity of gingival infectionSeverity of gingival infection

Oral irrigation deviceOral irrigation device

NOTENOTE Bacteraemia may follow scaling , Bacteraemia may follow scaling ,

tooth brushing, endodontic therapy .tooth brushing, endodontic therapy . Lack of clinical effect of many Lack of clinical effect of many

bacteraemia is due to small number or bacteraemia is due to small number or low virulence low virulence

They are rapidly cleared by normal They are rapidly cleared by normal body defence ( leucocytes )body defence ( leucocytes )

Strept. Faecalis may cause endocarditis Strept. Faecalis may cause endocarditis after genitourinary or gut procedures after genitourinary or gut procedures

CAUSATIVE ORGANISMSCAUSATIVE ORGANISMS

Viridans streptococciViridans streptococci Most common cause of sub- acute Most common cause of sub- acute

bacterial endocarditis (SBE)bacterial endocarditis (SBE) Produce glucagons adhere to Produce glucagons adhere to

endocardiumendocardium E.g : E.g :

Streptococcus mutansStreptococcus mutans Streptococcus sanguisStreptococcus sanguis

Streptococcus faecalis[after urogenital Streptococcus faecalis[after urogenital manoulation]manoulation]

Streptococcus faeciumStreptococcus faecium Streptococcus pneumoniaeStreptococcus pneumoniae Staphylococcus aureus Staphylococcus aureus

Acute endocarditisAcute endocarditis Staphylococcus epidermidis Staphylococcus epidermidis

Prosthetic heart valvesProsthetic heart valves Brucella species Brucella species Actinobacillus actinomycetes comitansActinobacillus actinomycetes comitans RickettisaeRickettisae FungiFungi Coxiella burneti [Q fever cases]Coxiella burneti [Q fever cases] Candida albicansCandida albicans

PATHOGENESISPATHOGENESIS Formation of vegetations Formation of vegetations

Fibrin , platelets (thrombi) , bacteria colonies Fibrin , platelets (thrombi) , bacteria colonies Attached to heart valves Attached to heart valves

Break off infected emboli Break off infected emboli distant organs ( kidney , brain )distant organs ( kidney , brain )

Immune complex formation causes Immune complex formation causes glomerular damage haematuria glomerular damage haematuria

Valves infection destruction Valves infection destruction heart failure .heart failure .

Drug addicts tricuspid,pulmonary Drug addicts tricuspid,pulmonary valves of right side of heart lung valves of right side of heart lung emboli pneumoniaemboli pneumonia

CLINICAL FEATURESCLINICAL FEATURES

Onset is insidious ( SBE) – 3 weeks after extractionOnset is insidious ( SBE) – 3 weeks after extractionFever ( mild and prolonged )Fever ( mild and prolonged )Malaise , weight loss , weaknessMalaise , weight loss , weaknessChanging murmurs due tovalve involvement]Changing murmurs due tovalve involvement]Anaemia , leucocytosis Anaemia , leucocytosis Microscopic haematuria Microscopic haematuria Petechiae Petechiae Spleenomegaly Spleenomegaly Splinter haemorrhage [nails]Splinter haemorrhage [nails]Hypergammaglobulinaemia Hypergammaglobulinaemia Age young , elderly Age young , elderly

MORTALITYMORTALITY

With antibiotic treatment With antibiotic treatment 30%30%

High mortality High mortality Virulance of organism or severe infectionVirulance of organism or severe infection Presence of underlying disease Presence of underlying disease ElderlyElderly Inadequate treatmentInadequate treatment

poor prognosispoor prognosis CandidalCandidal StaphylococcusStaphylococcus Gram-negativeGram-negative

LABORATORY LABORATORY DIAGNOSISDIAGNOSIS

A – serial blood cultureA – serial blood culture ( 2-3 sets ( 2-3 sets before antibiotic therapy )before antibiotic therapy )

Aerobic Aerobic Anaerobic Anaerobic

B- serological testsB- serological tests CFT ( coxiella burniti )CFT ( coxiella burniti )

C- sensitivity testC- sensitivity test

TREATMENTTREATMENT

Disk diffusion test ( not sufficient )Disk diffusion test ( not sufficient ) MIC [minimum inhibitory MIC [minimum inhibitory

concetration], MBC concetration], MBC Criteria of antibioticCriteria of antibiotic

Bactericidal Bactericidal Parenteral Parenteral High doseHigh dose Prolonged Prolonged

Viridans streptococciViridans streptococci –Benzyl penicillin –Benzyl penicillin I.VI.V

4 MU I.V. every 4 hrs for 4 weeks4 MU I.V. every 4 hrs for 4 weeks oror penicillin + gentamicinpenicillin + gentamicin

Streptococcus faecalis Streptococcus faecalis ampicillin + gentamicin I.V ampicillin + gentamicin I.V

Recurrence after cure is common in:Recurrence after cure is common in: drug addictsdrug addicts immunodeficient patientsimmunodeficient patients

Antimicrobial prophylaxisAntimicrobial prophylaxis(prevention)(prevention)

For susceptible patients For susceptible patients Rheumatic valvular or congenital heart Rheumatic valvular or congenital heart

diseasedisease Before tooth extraction , deep Before tooth extraction , deep

scalingscaling , , other operationsother operations Benzyl-penicillin 2M– I.M 30 mint. Benzyl-penicillin 2M– I.M 30 mint.

before 500mg penicillin V before 500mg penicillin V oral – 6 hourly for 2 days afterwards oral – 6 hourly for 2 days afterwards

If patient is allergic to penicillin :If patient is allergic to penicillin : Vancomycin or Erythromycin Vancomycin or Erythromycin

lactobionate Ig I.V. 30 minutes befor lactobionate Ig I.V. 30 minutes befor operation.operation.

Genitourinary procedures:mainly by Genitourinary procedures:mainly by Enterococcus feacalisEnterococcus feacalis gentamicin +ampicillin I.Vgentamicin +ampicillin I.V

30 minutes before operation30 minutes before operation