ENDOCARDITIS The Etiology and the Laboratory Studies

1. ENDOCARDITISThe Etiology and the Laboratory Studies Reşat Özaras, MD, Professor, Infectious Diseases Dept.

2. Definition • Endocarditis: it is an inflammation of the inner layer of the heart, the endocardium.

3. Clinical Features • Whom to consider IE • Injection drug users • Prostethic heart valve • Prior IE • Bacteremia • Hemodialysis • HIV infection

4. Clinical Features • Wide spectrum of signs&symptoms • Fatigue • Anorexia • Weight loss • Prolonged fever • Dizziness • Dyspnea • …..

5. PE • Murmur • Splenomegaly • Findings of complications (emboli etc..)

6. IE: Clinical Classification Acute IE Main etiology: S. aureus Mortality (untreated) : < 2 months, 100% Subacute—chronic IE Main etiology: Viridans streptococci Mortality (untreated) : < 1 year, 100%

7. Classification According to the Valve • Native Valve Endocarditis • Prosthetic Valve Endocarditis

8. Clinical criteria Using specific definitions : • 2 major criteria OR • 1 major and 3 minor criteria OR • 5 minor criteria • Possible IE • 1 major criterion and 1 minor criterion OR 3 minor criteria

9. Major Diagnostic Criteria • Positive blood culture for typical infective endocarditis • Echocardiography findings • with oscillating intracardiac mass • abscess

14. Search Google for echo videos! • http://www.echojournal.org/video/379/Aortic-valve-vegetation-1-of-2

15. Minor Diagnostic Criteria  • Predisposing heart condition or intravenous drug use      • Temp > 38.0° C • Vascular phenomena: arterial emboli, pulmonary infarcts, mycotic aneurysms, intracranial bleed, conjunctival hemorrhages, Janeway lesions      • Immunologic phenomena: glomerulonephritis, Osler nodes, Roth spots, rheumatoid factor      • Microbiological evidence: positive blood culture but does not meet a major criterion    • Echocardiographic findings: consistent with endocarditis but do not meet a major criterion

16. Clinical criteria Using specific definitions : • 2 major criteria OR • 1 major and 3 minor criteria OR • 5 minor criteria • Possible IE • 1 major criterion and 1 minor criterion OR 3 minor criteria

17. IE: Etiology NV PV 1-Streptococci: ~%50 ~40% 2-S. aureus: 3-Enterococci: 4-Coagulase-neg Staph: ~%5 ~70% 5-Gram-Neg Bacilli: 6-Fungus (Candida): 7-Diphteroids: 8-Polymicrobial: 9-Culture-neg./HACEK:

18. Our cases with IE 1-Viridans streptococci (8) (40%) 2-S. aureus (MSSA) (4) (20%) 3-Enterococci (2) (10%) 4-MSSE (1) (5%) 5-Anaerobs (1) 6-S. typhi (1) 7-Brucella (1) 8-Culture-negative (2)

19. IE: Streptococci Viridans streptococci (-hemolytic) (the most frequent ones) 1-S. sanguis 2-S. mutans 3-S. mitis S. bovis (non-hemolytic)

20. Staphylococci S. aureus S. epidermidis

21. DiagnosticsClinical Samples Blood Serum (for serology) Embolus, abscess, or removed infected valve (for microbiological and histolgical studies)

22. IE: S. aureus Fever+S.aureus: consider IE (echo.) Fever+S.aureus in injectiondruguser: considerrightside (tricuspid) IE (echo.)

23. Culture-negative IE Failuretoyieldanym.o. withautomatedbloodculturesystemswithin 7 days ~5% Use of antibiotics CoxiellaburnetiiandBartonella

24. IE: Serology 1-Brucella 2-Coxiella burnetii 3-Bartonella

25. Treatment • Antibiotics • Surgery may be needed

26. IE: Mortality is ~30 Major systemic emboli Heart Failure Septic shock

27. Complications • Cardiac • Septic • Embolic • Neurologic • Musculoskeletal • Renal • Associated with medical treatment

28. Complications • Embolic (eg, cerebral infarct) • Local spread of infection (eg, heart valve destruction) • Metastatic infection (eg, vertebral osteomyelitis) • Immune-mediated damage (eg, glomerulonephritis