Definition
Infective endocarditis is an
inflammation of the endocardium (a thin connective tissue layer that lines the
heart along with the valves ), which is caused by pathogens such as bacteria or
fungi and despite the optimal therapy it's associated with a high mortality
rate (20-30%).
Epidemiology
The latest incidence of IE is
approximately ( 2 to 5 cases per 100,000 inhabitants annually). Men
are affected about twice as often. Although rarely are the patients younger
than 60 years.
Classification
Depending on the course
- The foudroyant acute septic endocarditis
- subacute endocarditis (endocarditis lenta)
Depending on valves
- Native valves endocarditis
- Prosthetic valves endocarditis : If the endocarditis occurs within one year after a valve replacement, one speaks of early prosthetic valve endocarditis, then of a late prosthetic valve endocarditis.
Also
- Significantly more frequent left ventricular endocarditis involving the mitral or aortic valve
- prognostically it's better classified when right-sided endocarditis (Risk Factor: i.v.-Drug Abuse, central venous catheter) which is usually associated with the invasion of the tricuspid valve
Pathogenesis
In the area of endocardial lesions,
which occur in particular on mechanically stressed structures (especially those
affected by the mitral and aortic valve), the deposition of sterile thrombotic
vegetation forms an ideal ground for pathogens. In the case of transient
bacteremia (eg iatrogenic or in infectious diseases) colonization of the
initially germ-free thrombotic deposition with permanent bacteremia is possible.
Symptoms
1. General: fever, chills, fatigue, paleness, tachycardia
2. Cardiac:
- heart murmur or aggravation of a pre-existing heart murmur
- Heart failure (valve insufficiency(
- Valve perforation and rupture with acute decompensation (pulmonary edema(
3. Extracardially
I. Central nervous system
- Septic-embolic encephalitis (often multiple ischemia(
- Septic sinus vein thrombosis
- Mycotic aneurysms with risk of subarachnoid hemorrhage
II. Cutaneous
- Petechiae
- Janeway Lesions: Painless hemorrhages on palms and soles
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Janeway Lesions |
- Osler nodules: painful, nodular bleeding on fingers and toes, embolic or in immune complex vasculitis
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Osler nodules |
- Splinter hemorrhages: bleeding in the nail bed as a result of immune complex deposits or micro thrombosis; esp. in subacute forms
III. Kidney
- kidney infarcts
- Focal or diffuse immune complex glomerulonephritis
IV. Spleen
Spleen enlargement and septic
embolisms in the spleen
V. Eyes
- Retinal embolism and conjunctival hemorrhage
- Roth's spots (retinal bleeding(
- Staphylococcus aureus (45-65%): most common causative agent of endocarditis acuta
- Streptococcus viridans (30%): most common causative agent of endocarditis lenta
- Staphylococcus epidermidis: most common germ transmitted via infected venous indwelling catheters
- Enterococcus faecalis (<10%): Multiple antibiotic resistance: Always resistance on penicillin G and cephalosporins
- Streptococcus bovis: detection of Streptococcus bovis must be thought of as colon carcinoma; accordingly, a colonoscopy is mandatory in the course
- HACEK group: group of gram-negative pathogens from the mouth and throat, responsible for about 3%.
- H - Haemophilus aphrophilus and Haemophilus paraphrophilus
- A - Aggregatibacter actinomycetemcomitans (formerly Actinobacillus actinomycetemcomitans)
- C - Cardiobacterium hominis
- E - Eikenella corrodens
- K - Kingella kingae
- Fungi (Aspergillus, Candida): in immunosuppression (e.g., HIV, renal transplant state(
Diagnosis
Blood cultures for pathogen
detection
- blood collection before the start of antibiotic therapy (continuous bacteremia(
- at least 3-5 separate blood culture couples
- the collected blood must be transported to the laboratory within 2 hours
- Antibiogram to detect possible resistances at an early stage
Imaging: TT, TEE: Vegetations and
paravalvular abscesses as well as valve status
Cross-sectional imaging: CT and
nuclear medicine imaging (PET: Positron emission tomography, SPECT /CT:
Single-photon emission computed tomography(
Duke criteria (simplified) with
additional criteria of the European Society of Cardiology (ESC(
Diagnosis is made using the Duke
criteria. The presence of two main criteria, one major criteria and three minor criteria or five minor
criteria verifies the diagnosis.
The major criteria
- Positive blood cultures: Two separate positive blood cultures with typical pathogen detection
- Evidence of endocardial involvement in imaging: transesophageal echocardiography: heart valve vegetation, abscesses, (pseudo) aneurysms, fistulas, perforations and /or dehiscences of a valve prosthesis
- Cross-sectional imaging: consequences of perivalvular lesions, including pseudoaneurysms and abscesses
Additional main criteria according to European Society of Cardiology (ESC) 2015
Evidence of paravalvular lesions in cardiac CT
Evidence of abnormal activity around a valve replacement in PET/CT or SPECT/CT
Minor criteria
- Predisposition due to cardiac disease or i.v. drug abuse
- Fever ≥38 ° C
- Vascular changes: Arterial embolism, septic infarction, ICB
- Immunological Disorder: Glomerulonephritis, Osler nodules, Roth's spots, pos. RF
- Microbiology: Positive blood culture that does not fall under the main criteria
- Additional incidental criterion after ESC 2015: Detection of (septic) embolic events (e.g., of the CNS) or infectious aneurysms in imaging
Therapy Principles
- antibiotic therapy
- For complicated cases : surgical therapy
Antibiotic therapy
- Initially calculated(empirical ) antibiotic therapy
- Adjust in the course according to the antibiogram
Duration of treatment:
- Native valve infection: 2-6 weeks
- Valve prosthesis infection: at least 6 weeks
Empirical antibiotic therapy of
endocarditis (pathogen unknown)
All native valves and valve
prosthesis> 12 months after surgery
- ampicillin
- And (flu) cloxacillin
- And gentamicin
In case of intolerance of β-lactam antibiotics
- vancomycin
- and gentamicin
Valve prosthesis <12 months after surgery
- vancomycin
- And gentamicin
- And rifampicin
Prophylaxis
High-risk groups (where antibiotic prophylaxis is recommended)
- Patients with valve replacement (mechanical and biological)
- Patients with endocarditis
- Patients with congenital heart disease (cyanotic heart disease, All operatively or interventional using prosthetic material-treated heart defect (6 months after surgery))
Situations in which antibiotic prophylaxis should take place
- Interventions in oropharyngeal cavity (mainly dental treatments with manipulation of the gingiva, the periapical tooth region or perforation of the oral mucosa)
- Respiratory, gastrointestinal and urogenital infections as well as skin and soft tissue infections: here, the local pathogens, which are probably responsible, must be considered primarily in the choice of Antibiotic
- biopsies
- Vascular surgery involving the introduction of foreign material (including pacemakers or defibrillators)
Antibiotic prophylaxis
- Intervention area: Oropharyngeal cavity (in particular dental risk interventions): Aminopenicillins: Amoxicillin (p.o.) or Ampicillin (i.v.), alternative (in case of allergy): Clindamycin
- Intervention area: Respiratory tract: aminopenicillin + beta-lactamase inhibitor or cefazolin, alternative (in case of allergy): clindamycin
- Intervention area: Skin: Oxacillin or Flucloxacillin, alternative (in case of allergy): Clindamycin
- Intervention area: Gastrointestinal and urogenital tract: ampicillin or piperacillin, alternative (in case of allergy): vancomycin
Proofreading: Amany Altabba
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