1. Infective endocarditis
Infection of heart valves
~25% mortality

2. Classification
 Acute/short incubation- fulminant,
due to S.aureus, frequent metastatic infection
Chronic/long incubation- slow
progression, commonly due to S.viridans,
localized
 Culture positive- S.viridans, S.aureus, enterococci, S.bovis
Culture negative-
fastidious bacteria-HACEK or fungal
 Right-sided- affects TV, common in IVDU, due to S.aureus
Left-sided- more common due to
high-pressure flows
 Community acquired
Nosocomial- within 1 month of prior hospitalization, usually 2°
to central catheters
 Native valve- healthy or diseased
Prosthetic valve- early within 2
months due to intraop./postop. nosocomial seeding with
coagulase –ve staphylococci or late after 2

3. Predisposition
 Valve abnormality-
 RHD- regurgitant > stenotic
 CHD- high pressure jet- BiAV, MVP, VSD, TOF, CoA, PDA
 Procedures causing significant bacteremia-
 Dental procedures- with gingival manipulation or causing bleed
 Respiratory procedures involving mucosal incision
 Procedures on infected skin or muskuloskeletal tissue
 Central catheters-
 For IV access, monitoring, fluids/nutrition, pacemaker
 Intravenous drug use
 Cardiac surgery- specially valvular

4. Clinical presentation
 Fever
 New or changing murmur
 Vascular phenomena-
 Septic embolism- CVA, infarcts, abscess, gangrene
 Janeway lesion- painless erythematous lesions in palms & soles
 Conjunctival/subungual splinter hemorrhage
 Immunologic phenomena-
 Glomerulonephritis- hematuria & proteinuria
 Osler’s nodes- painful subcutaneous lesion of finger pulp
 Roth’s spot- exudative spots on retina
 +ve rheumatoid factor
 Other-
 Anemia, clubbing, splenomegaly

5. Diagnosis
 Modified Dukes’ criteria
 Definitive Dx-
 2 major criteria
 1 major + 3 minor criteria
 5 minor criteria
 Possible Dx-
 1 major + 1 minor criterion
 3 minor ctiteria

6. Modified Dukes’ criteria
 Major-
 2 positive blood cultures, for an
organism known to cause IE
or
persistent bacteremia- 2 +ve 12
hours apart or 3 of 4 +ve drawn
over 1 hour
 ECHO evidence-
oscillating mass on valve or
supporting structures
or abscess
or new valvular
regurgitation or partial
dehiscence of prosthetic valve
 Minor-
 Predisposing factor-
cardiac lesion, IVDU
 Fever >38 °C
 Vascular phenomenon
 Immunologic phenomenon
 +ve blood culture
 +ve ECHO

7. Treatment- antibiotics
 High-dose, IV, duration 2-6 weeks
 Empiric-
ceftriaxone, 2 gm OD + vancomycin, 1 gm BD
 Following blood culture report-
 Streptococci- penicillin G/ampicillin/ceftriaxone
+ gentamycin (shortens duration)
or vancomycin in penicillin allergic
 Staphylococci- oxacillin/cefazolin/vancomycin
 Prosthetic valve- coagulase –ve staphylococcus
vanco. + genta. + rifampicin

8. Surgery
 Acute heart failure,
unresponsive to medical Rx
 Infection unresponsive after 7-10 days of Abx
 Fungal & gram –ve endocarditis
 Infection involving sinus of Valsalva
 Recurrent septic emboli
 Septal abscess
 Large vegetation

9. Prophylaxis
 Indications- predisposing procedures for
significant bacteremia
 Cardiac conditions-
 Prosthetic valve
 Previous IE
 CHD- unrepaired cyanotic CHD,
repaired CHD with prosthetic material/device for 6
months
 Cardiac transplantation with valvulopathy
 Regimens- single dose before procedure
 Oral- 1 hour before- amoxy./clinda./cephalexin/azithro.
 IV- 30 mins. before- ampi./cefazolin/clinda.

10. Finally
Document sterilization
of blood culture