• endocarditis
  • infection of endocardial surface of heart
  • this includes valves, septal defects, and mural endocardium
• endarteritis
  • infection of arterial endothelium
  • includes infected aneurysms, AV fistulae
• suppurative thrombophlebitis
  • infection of vein
  • vein filled with pus and bacteria

• acute bacterial endocarditis
• subacute bacterial endocarditis
• endocarditis in IV drug abusers
• health care associated endocarditis
• prosthetic valve endocarditis
• fungal endocarditis
• culture negative endocarditis

• clincal presentation
  • more toxic/septic presentation
  • underlying valve frequently normal
  • rapid onset, fulminant course
  • extensive valve destruction
  • high mortality
• predominant causative agents
  • S. aureus
  • Enterococcus
• other potential causers
  • pneumococci
  • gonococci
  • Group A and B Strep

• course- slow, indolent
• presentation
  • underlyin valve usually normal
• predominant causative agents
  • alpha or gamma streptococci
• potential causer- coagulase negative staph cause native valve SBE

• develops after invasive diagnostic or therapeutic procedures done in hospital
• predominant causative agent- S aureus

• could be acute or subacute based on time of onset and bacteria involved
• causative agent- coagulase negative Staph

• there is prior antibiotic therapy OR
• organisms are fastidious or difficult to grow in culture

• lesions that develop on heart valves in the absence of infection, but usually in association with a debilitation disease

• median age- 50-60

• turbulent blood flow
  • high pressure flow to low pressure sink, explaining why most endocarditis occurs on the left side of the heart
  • effect secondary to structural abnormality
    • regurgitant stream
    • narrow orifice
  • damaged epithelium will release tissue thromboplastin leading to a deposition of fibrin and platelet mesh on valve surface
    • hypercoagulability also risk factor
• bacteremia
  • critical factor- ability of organism to adhere to fibrin-platelet complex forming a vegetation
  • in case of acute endocarditis, they adhere to valvular endothelium

• valvular heart disease
• malignancies
• CT disorders
• intracardiac catheters
• prolonged febrile illness
• persistent fetal circulation

• valves (aortic, mitral most common while tricupsid, pulmonic rare except with IV drug use)
  • rheumatic heart disease
  • bicuspid aortic valve
  • prosthetic heart valves
  • mitral valve prolapse
  • degenerative: calcific aortic stenosis, calcified mitral annulus
• ventricular septal defects (usually not atrial due to low pressure flow)

• procedures that cross mucus membranes that are colonized by streptococci and enterococci
  • dental procedures- extractions, teeth cleaning, brushing
  • GU procedures

• Viridans streptococci (MOST COMMON)
  • pt of oral flora
  • adherence promotied by high molecular weight dextrans, surface glycoproteins, lipoteichoic acid
  • S mutans, sanguis more commonly assoc. w/endocarditis
  • S anginosus more commonly associated with pyogenic abscesses
• Group D streptococci
  • enterococci- frequently related to GI, GU manipulation (could cause ABE) or elderly men
  • S bovis (connect with colonic lesion)
    • increase frequency of polyp or cancer
    • increase stool colonization in pateints with cancer

• S aureus (MOST COMMON of ALL ENDOCARDITIS)
  • frequent in IV drug users
  • increasingly methicillin resistance
• Pneumococci, Gonnococci, Group A streptococcus
• gram negative bacilli
  • usually cause PVE and has slime production
  • rare except in drug abusers

• slime production
• usually associated with PVE
  • usually at previously abnormal valve
• subacute presentation

S lugdunensis has high morbidity with CHF and emboli

What could cause culture negative results for endocarditis

• non infectious cause- Marantic, Libman-Sacks
• organisms that fail to grow
  • Coxiella burnetti
  • Chalmydia psittaci
  • fungi
• prior antibiotics

• frequently have right side valves affected (tricupsid more than mitral is effected)
• MRSA tends to be the main cause
  • occasional Pseudomonas, Serratia
• less hemodynamic compromise, so easier to treat

Hemophils

Actinobacillus

Cardiobacterium

Eikenella cordodens

Kingella kingae

• evasion of host response by being sequestered by the fibrin matrix from teh serum bactericidal Ab (PMN's)
• titers of bacteria reach 10¹⁰ to 10¹¹
  • reduced metabolic activity deep in vegetation
  • reduced susceptibility to cell wall antibiotics

• classic triad
  • fever- may be absent in elderly or with uremia)
  • anemia (may be absent in ABE)
  • heart murmor (changing heart murmor)

• systemic symptoms (esp. with SBE)
  • malaise
  • fatigue
  • anorexia
  • weight loss
• splenomegaly (in SBE)
• musculoskeletal symptoms
  • arthralgias
  • back pain
  • arthritis

• conjunctival petecchiae
• splinter hemorrhage
• Osler's nodes (loc- pads of fingers, toes)
• Janeway lesions (nontender erythematous macules on palms and soles)
• Roth's spots (retinal hemorrhages w or w/o pale centers)

• valve
  • SBE- damage
  • ABE- normal
• source
  • SBE- dental GI after invasive procedure
  • ABE- skin, IV routes
• organism causing most of time
  • SBE- group A streptococci
  • ABE- S aureus
• onset
  • SBE- insidious
  • ABE- abrupt
• course
  • SBE- weeks, months
  • ABE- days
• fever/toxicity
  • SBE- low grade
  • ABE- marked
• cardiac function
  • SBE- gradual decline in function
  • ABE- rapid decline in function
• mortality
  • AGE much higher than SBE

• clinical findings- persistant bacteremia
  • via blood cultures
• echocardiogram
  • transthoracic
  • transesophageal (MAJORITY)
• nonspecific lab abnormalities
  • elevated ESR
  • hematuria
  • elevated CRP
  • positive for rhematoid factor
  • anemia
• use Duke criteria

• valve destruction, perforation
• heart failure
• relapse
• myocardial or valve ring abscess
  • leads to conductio abnormalities
• suppurative pericarditis
• MI

• recurrent emboli
  • CNS, mycotic aneurysms
  • systemic
• metastatic abscess: brain, lung, spleen, kidney
• Ag-Ab complex disease
  • ex: glomerulonephritis
• bony lesions (osteomyelitis)

• high dose, IV antibiotics
  • bactericidal
  • consider bacterial sensitivies
  • synergy w/aminoglycosides necessary in some species (ex: enterococci, some strep, pseudomonas)
• prolonged therapy required
  • duration dep. on valve type and organism (longer for enterococci, S. aureus)
• early surgical intervention

• CHF
• recurrent systemic embolization
• persistant bacteremia
• valve ring abscess (conduction disturbance)
• fungal endocarditis
• large vegetations

• early PVE (less than 60 days after surgery)
  • S aureus
  • S epidermis
  • gram negative bacilli
• late PVE (more than 60 days after surgery)
  • Viridans streptococci
• treatment- valve replacement

• prosthetic valve
• prior endocarditis
• major CHF
• heart transplant with valve abnormalities

• MVP with murmur or thick leaflets
• Rheumatic heart disease
• SH/IHSS (septal hypertrophy, idiopathic hypertrophic subaortic stenosis)

• MVP with no murmur
• pacemaker
• CABG
• ASD
• other CHD

• antibiotics against oral streptococci
• a single dose is all that is needed