INFECTIVE

ENDOCARDITIS

Elena Samohvalov
Doctor of medicine

A small number of
diseases present such
serious difficulties of
diagnosis than
malignant endocarditis,
difficulties that in many
cases are
insurmountable.
Gulstonian Lectures on
Malignant Endocarditis
W. Osler 1885

Infective endocarditis is a
microbial endovascular infection
of cardiovascular structures
(native valves, ventricular or
atrial endocardium), including
endarteritis of large intrathoracic
vessels (in arterio-venous shunts,
in aortarctia, in patent ductus
arteriosus), or foreign
intracardiac bodies (prosthetic
valves, pacemaker or intracardiac
European Guidelines for
defibrillator)
reflected
inand
the
Prevention,
Diagnosis

The early lesion

characteristic for
IE is vegetation of
various sizes
(composed of
fibrin, platelets,
red cells,
inflammatory cells
and
microorganisms),
while the
destruction,
ulceration or
abcesses are
alterations that

European Guidelines
for Prevention,
Diagnosis and
Treatment of IE, 2009

Mortality - 20-25%

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100.
ESC guidelines,
Cardiovascular Medicine,
2011

In the last 4-5 decades,

the pattern of the disease
has changed significantly,
particularly in the
Western countries

Netzer R, Zolinger E., Seiler C., Cerny A.

Infective endocarditis: clinical spectrum, prezentation and outcome.
An analisis of 212 cases 1980-1995.// Cardiovascular Medicine 2000.//
Heart 2000; 84: 25-30

IE, paternal change

The patients age
With the increase of life
expectancy, the age of
patients has grown. Patients
over 65 years old constitute
more than 30% of cases of
IE.
John L.Brusch, Wesley W.Emmons, Fransisco Talavera, Tomas M.Kerkering,
Eleftherios Mylonakis, Burke A Cunha.
Infective endocarditis. eMedicine, December 2007

IE, patient profile = 408

IE, the age of patients =

408

The average
age is
450,6 years

Favoring conditions

IE, paternal change

Degenerative valvular diseases,
valvular prostheses,
the prolapse of mitral valve
have replaced
the rheumatical chronic heart
diseases, which were the most spread
cardiac predisposal in the past
Prendergast B.D.
The changing face of infective endocarditis
Heart 2006;92:879-885

Risk factors

IE, paternal change

New risk factors have emerged : intravenous
drug use and a wide spectrum of invasive
diagnostic and therapeutic procedures:
valvular prosthesis
intravenous catheters
hemodialysis
pacemaker implants
intracardiac defibrillator implants
M.Heiro,
H.Helenius,
S.Makila, T.Savunen,E.Engblom, J.Nikoskelainen, P.Kotilainen.
Infective endocarditis in a Finish teaching hospital: a study on 326 episodes treated during
1980-2004 //Heart 2006;92: 1.457-1.462

IE, predisposing cardiac conditions

IE, the morbid circumstances that

ensured the bacteriemia

infections
dental care
optimization
respiratory tract

interventions

dental care (dental extractions)

heart

UDIV
hemodialysis

The
change
of
The change of
Predisposin
g factors

Risk
factors

Etiological spectrum
spectrum
Etiological
ofStaphyloco
IE
of
IE
Streptoco

cci
Bacilli Gr.-

Co-morbidities
Diabetes
mellitus

Cirrhosis

Cancer

Alcoholism

Kidney failure

Pulmonary
diseases

IE, associated diseases, 113 pts

35
30
25
20
15
10
5
0

2
33

28

16

16

10

1
2

Etiology
The pathogenic agent

Streptococcus viridans
Enterococci

(%)

30-40

5-10

Other streptococci

10-25

Staphylococcus aureus

10-27

coagulaso-negative Staphylococi
Gram-negative Bacilli
Fungi
Other pathogenic agents
negative Cultures"

American Health Association

1-3
2-13
2-4
5
5-24

IE, negative hemocultures

Administration of antibiotics cures
before taking over the hemocultures
Pathogenic agents difficult to
diagnose ( Chlamydia, viruses,
rickettsia, fungi, etc.)
Low-cost microbiological laboratory
techniques

The hemoculture (HC)

The suspect presence of IE requires the collection

of 3 or more HC in the first 24 hours;
From every venous puncture must be obtained one
culture
Cultures must be separated at least 30-60 minutes
of each other to prove continuous bacteriemia;
If the initiation of antibiotic treatment is an
emergency will be collected at least 3 hemocultures
at the range of an hour
If the patient has taken antibiotics for a short period
of time, it will be expected at least 3 days after
treatment is completed before the new
hemocultures will be taken.

THE HEMOCULTURE

The hemocultures taken after a long treatment

with antibiotics may remain negative for 6-7
days
HC must be performed regularly during the
treatment, HC become negative after a few days
of therapy;
HC must be performed after 2 and 4 weeks from
the disruption of therapy, because it will be
detected the most majority of recurrences of IE.

THE HEMOCULTURE

For hemocultures are necessary two pots with

50 ml of environment for aerobic and anaerobic
cultures. It will be taken at least 5 ml (10 ml for
adults, 1 5 ml from children) of venous blood.
It has to be used both techniques, for anaerobic
and aerobic ones.
Insemination from the excised valves during
surgery and from septic emboli is compulsory;
The microorganisms depicted in positive HC
must be stored and kept for at least one year, for
comparison in cases of relapse or recurrence of
IE.

120

IE, period of determining the

diagnosis
96 93

100
80
60

58

51

41

40

26

18

20

2
12

4
3

8
6

10
8

12

14

16

11 12

13 months
14

Months

The average period 1,7 months

Stirbul A., Grejdieru A, Mazur M, et al. "Infective endocarditis: clinical profile, presentation
and development (study on a group of 408 patients in the retrospective of 16 years - 19922007)," Bulletin of the Academy of Sciences , 4 (18), Chisinau 2008..

IE, late diagnosis

Deficient use of the key investigations
(blood culture and EcoCG)
The unjustified administration of
antibiotics for febrile cardiac patients,
prior taking the hemocultures
lack of specific signs, patognomonical,
clinical and laboratory.
Tornos P, Iung B. Permanyel-Miralda G. Baron G, Delahaye F.,
et.al.
Infective endocarditis in Europe: lessons from the Euro heart
survey.

IE, regional differences

IN

Socio-economic
factors
WHICH Race differences
HABITATE

Life style
Bacterial
environment

POPULATIO
N
Cabell CH, Jollis JG, Peterson GE, Corey GR, Anderson DJ, Sexton DJ,

Woods CW, Reller LB, Ryan T, Fowler VG Jr.

Changing patient characteristics and the effect on mortality in endocarditis.
Arch Intern Med. 2002; 162: 9094.

CLASSIFICATION OF IE
By evolution:
Acute form
Subacute form

By the origin:
Primary
on intact valve
Secondary on native valve:

rheumatic heart disease

congenital heart disease
degenerative heart disease

IEDV
Infectious Endocarditis of denture
valve (IEDV) early :
valvular dentures infection up to 1 year after the
valve surgery
Infectious Endocarditis of denture
valve (IEDV) tardy:
valvular dentures infection over 1 year after the
valve surgery

CLASSIFICATION OF IE

After activity:
Active form
Treated form
Recurrent form
(after the eradication of the infection)
Persistent form
(the infection has never been
permanently eliminated)

CLASSIFICATION OF IE
The First episode
Recurrence
Relapse
Reinfection
The National Clinical
Protocol Reinfection
Infectious Endocarditis in
adults ' refreshed 2011

The active infective endocarditis

IE with persistent fever and

Positive hemocultures or
Active inflammatory
morphology found at surgery or
patient that is still under
antibiotic treatment
Or histopathology enable of IE

THE CURED INFECTIOUS ENDOCARDITIS

iradicatin of infection
normal body temperature
VSH in normal ranges
Negative hemocultures within a
year after finishing the term of
treatment

Appelant Infectious Endocarditis

Relapse
repeating the episode of IE with the same
micro-organism < 6 months after the
initial episode.
reinfection
infection with a different microorganisms or
repeating the episode of IE with the same
micro-organism < 6 months from the
initial episode.

IE, new clinical forms

IE at elderly
IE nozocomial
IEi Dentary
IE for pts subjected to hemodialysis

IE of right heart
IE at UDIV
IE at patients with DI

Cabell CH,
Jollis JG,
Peterson GE,
Corey J.,
Anderson D,
Sexton DJ,
Woods CW,
Reller LB,
Ryan T, Fowler
VG
Changing
patient
characteristics and the
effect on
mortality in
endocarditis.
Arch Intern
Med. 2002;
162: 9094

DUKE major criteria (Durack 1994)

I. Positive hemocultures from 2 separate
cultures:
virids Streptococci and gr. D
the golden Stafilococci
Enterococci
Germ from the group HACEK
Coxiela burnetti (HC single positive)
or an antibody IgG phase
I > 1:800

DUKE major criteria (Durack 1994)

II. EcoCG (evidence of endocardial involvement)
Vegetation (presence of oscillating masses
located on:
Heart valves
Support structures
in the path of Geta
Prosthetic materials
Ring abscess
New partial dehiscence of prosthetic valve
New appeared valvular Regurgity

DUKE minor criteria (Durack 1994)

Cardiac predisposing conditions and

UDIV

Fever > 38.0C

Vascular phenomena :

septic pulmonary embolisms

Septic pulmonary infarcts
mycotic aneurysms
intracranial bleeding
Conjunctively bleeding
Janeway injuries

DUKE minor criteria (Durack 1994)

imunological phenomena:

glomerulonephritis
Osler nodules
Roth stains
rheumatoid factor positive
microbiological Signs: positive blood culture in

a sample or other microorganisms

(diphteroizi, anaerobi baccili, cocci gr.+, etc.)
EcoCG sighs: that is not included in the
major criteria

IE, clinical picture

Fever

Chills

Fatigability

Sweats
Loss of weight

Dyspnea
Arthralgia

Palpitations
Arthritis

Myalgia

Embolic phenomena

The suspection of infectious endocarditis - the

temperature must be measured every 3 hours..
fever: hectic or ondulant, associated with
chills, night sweats;
subfeverishness (the elderly,
imunocompromised people, patients with
congestive heart failure, with renal failure);
Altered general state, headache, myalgia,
arthralgia, low back pain, fatigue,
inapetencia, weight loss;

Objective data
New spirit emerged, modification of the existing

Pallor of your skin

Palpitations
BP diastolica low

Janeway Injuries
Osler nodules
Hemorrhage in splinter

Extracardiac signs
Moderate splenomegaly
Ocular manifestation:
Roth spots (oval retinal hemorrhages with clear central,

pale)
Optic neuritis
Embolic episode:
Cerebral embolisms in IE caused by Staphylococci
aureus with vegetation on the aortic valve
Femoral artery emboli often the result of fungal IE
Pulmonary emboliin IE of right heart of UDIV
Renal manifestation:
Kidney failure due to
Renal emboli or
Glomerulonephritis with complex immune

IE, touvh of periferic

Eruption
Janeway injuries
Hemorrhage in splinter

Osler nodules
Hipocratic fingers
Roth spots

Eruptions

A. skinned
B. conjunctival
C. On lining of the oral
cavity

Osler nodules

Osler nodules are vasculits

The pacient T. 46
years,
Of small vesselsIE subacute streptococci etiology
mediated imunologically
with the affectation of VA(Va will
bicuspid)

Leziuni Janeway
Janeway
injuries :
Septic
vasculitis
characteristic
for acute
staphilococic
IE
(Staphylococci
. aureus)
Patient L. 42
years

Linear
hemorrhages
in splinter,
With localization
On the nail bed
In hands and
feet
The patient O. 24
years, IE
acute,
Staphilococic
etiology, (Stph.
aureus) with
Trivalvular
affectation,

Hemorrhages in splinter

Roth spots
Retinal
Hemorrhages Dried branches
Localized on the
retina
The patient C. 35 y,
IE streptococic etiology
Pyogenes St. , with
The afectation of VA,
Cusp prosthetic rupture,

Hipocratic fingers
Fingers of
specific form
of a chronic
process
(in IE
With trenant
evolution )
The patient D. 33 years
IE subacute,
Streptococal etiology
with
The afection VM i VT.
Diagnosed after
11 months after the
debut.

IE, echocardiographic changes

Vegetations
Valvular

Extravalvular
cordage
papilar muscules
Ascending aorta
DSV membrane
The ejection tract of
VD
Bifurcation trunk AP

IE, echocardiographical changes

The rift of cordages
The rift of valve
Films of valve
Cardiac Abcesses
Paraprotetic fistulas

IE, vegetation on AVo

Patient R., 67 years

IE nosocomial, after
surgery (pancreatic cancer )
Enterococcic etiology with the
Ejection of VA
Vegetation on VA of 11 mm

IE , izolated damage of
VTs

Patient Z., 23 Years

IE of right heart,
Staphylococci etiology
(Stph.aureus), UDIV
Vegetation24 mm on VT

IE , trivalvular damage
VS
VS
Ao
AS

VD

AD

VM
AS

Pacient O. 24 ani,
primary IE, staphylococci etiology
(Staphyloccocus aureus), trivalvular
afection .
Big vegetations on VA 7 mm,
On VM 18 mm and on VT 11 mm.
Anterior cordage rupture of the VM

IE, cusp rift VM

the Pacient C. 48 y
IE Secondary heart
RHEUMATISM,
unidentified etiology
With VM, cusp rift
anterior to the VM

Laboratory Investigations
Blood count : (anaemia, accelerated ESR,
leucocitoza neutrofilie monocitoz)
Urine count (sediment urinar pathologic
(microhematuria proteinuria cilindrurie)
general protein (dysproteinemia + hiper-globulinemia)
Urea, creatinina ( elevated in renal impairment)
Laboratory examinations are not suggestive only for
IE, but may be characteristic for other
Infectious pathology

Laboratory investigations

elevated rheumatoid factor

Increased C-reactive protein
Elevated circulating immune complexes
Polymerase chain reaction,
which demonstrate bacterial DNA is performed
in patients:

with negative blood cultures and

Binding on all patients undergoing cardiac surgery

Laboratory investigations

Serological tests for :

Rickettsiae (Coxiella burnetii)
Chlamidya (Chlamydia psittaci, Chlamydia

pneumoniae i Chlamydia trachomatis)

Brucella
Bartonella
Spirochete (Spirillum minus)
These serological tests is performed when is
maintaining a high level of clinical suspicion but
blood cultures over 7 days after the harvest are
negative

ECG

Changes caused by congenital clinic sugestiv,

depending on the length of the process, the level of
activity and the endocardium and myocardium injury
LV hypertrophy with systolic overload, RV
hypertrophy, atrial hypertrophy
atrial fibrillation, flutter, fluter block of ram left and/or
right to beam His rheumatic and congenital heart
disease .
atrioventricular block gr. II, gr. III (during the first 3
days after the prosthesis or anastomotic parainelar
abscess)
ECG in myocardial ischemia array of clinically
suggestive context, caused by embolisms coronary

Radiological examination
of the rib cage is informative in tracing :
Progress of the rheumatic heart patients with IE
Progress in IE law heart:
to heart UDIV :
Destructive multifocal pneumonia,
Lung abscesses
Radiological signs of pulmonary emboli

The patients with IE left heart,on the merits of

congenital heart disease with left-right cardiac
shunts-radiological signs of pulmonary emboli
In IE prosthesis valve, x-ray examination can be
determined by the valve prosthesis dysfunction

Further investigation in the case of

complications in IE
USG internal organs for the detection of spleen
and renal lymphocytes,
Doppler cerebral vessels, renal and lower limb
artery used for specifying the dynamic artery in
process
Dynamic Scintigraphy of the kidneys
CT cerebral internal organs in case of cerebral
embolisms, renal, mesenteric, spleen
MRI-splenic lymphocytes mycotic aneurysms,
intracerebral aneurysms, cerebral embolisms septic;
Holter monitoring ECG arrhythmias and
disturbances in conductibility

IE, complications

IE , neurological
complications

Embolic cerebral infarct

Transient ischemic attack

Meningitis
Intracranial Haemorrahage
mycotic aneurysms
Brain abscess
Others

IE,

diffuse Glomerulonephritis

Renal touch with triggering IR indicate

a prognosis reserved especially for the streptococci IE
,which in its evolution, it becomes more malignant than
the staphylococci one
Causes:
High share of IE of streptococci, which frequently
evaluates with the immunological complications
The late diagnosis when IE is already complicated with
immunological manifestations, GN being the most

The treatment of patients with IE

The treatments initiation as earlier (delay of 2 to 8

weeks increase mortality of 2 times )
Combined Antibioticoterapia (2 3 antibiotics)
in maximum doses

Administered intravenous

Antibiotics are administerred according to the

susceptibility to pathogens and CIM
Correction dose of antibiotics according to the
degree of kidney damage
In the event of inefficiency of the antibiotic
replacing it after 3-4 days

The treatment of patients with IE

Prolonged Treatment with average of

antibioticoterapa:
in IE of streptococci etiology 4 weeks
in

staphylococci IE and
in IE negative gram bacteria 6 8 weeks
Until the clinical effect.
Antibacterial therapeutic regimes in IE is given
according to National Clinical Protocol
Infectious Endocarditis in adults,
Updated in 2011 (www. ms.md)

IE, causes of deaths, n=78

Died 78 patients

Other Kidney
causes failure

7,7%

12,8%

Mortality - 19,1%
Tromboembolic
Syndrome

20,5%

Progressive
heart
Septic shock
failure

30,8%

with
poliorganica
sauce

33,3%
tirbul A., Grejdieru A, Mazur M.,.Infectious Endocarditis : clinic profile, prezentation and
evolution (effectuated on a lot of 408 patients by 16 years 1992-2007)
Bulletin of Academy of Sciences of Moldovei, 4 (18), Chiinu 2008.

Antibioticoprofilaxia

Peroral administration of Amoxicillin 2 - 3 gr

in allergy to penicilins:
Azithromycin 500 mg
Clarithromycin 500 mg

with 30min before the dental procedure

Dental hygiene has a major importance in the prevention of IE!

Periajul zilnic
Tratamentul dinilor cariai
imediat la
apariia semnelor suspecte

Adresarea

cleaning
The Caria teeth

Daily teeth
brushing

immediate
addressing to the
doctor,
In case of suspicious
signs

Famous people died of IE

Alexander
Alexander
Blok
Blok
1880-1921
1880-1921
Russian
Russian
poet
poet
Savely
Savely
Cramarov
Cramarov
1934-1995
1934-1995
Russian
Russian
actor
actor
Ottorino
Ottorino
Respighi
Respighi
1879-1936
1879-1936
Italian
Italian
composer

Roberts
Roberts
Burns
Burns
1759-1796
1759-1796
Scottish
Scottish
poet
poet
Alois
Alois
Alzheimer
Alzheimer
1864-1915
1864-1915
German
German
neurologist
neurologist
Gustav
Gustav
Mahler
Mahler
1860-1911
1860-1911
Austrian,
Austrian,
jewish
jewish

God bless you!