Cardiovascular Infections

Dr. Lakmini Yapa

Senior Registrar (Medical Microbiology)

3/27/2013

Y3S2 Infection 2

Infections of CVS

Infective Endocarditis
Infective endocarditis (IE) is defined as an infection of the endocardial surface of the heart, which may include one or more heart valves, the mural endocardium, or a septal defect.

Types of IE
Native Valve IE Prosthetic Valve IE Intravenous drug abuse (IVDA) IE

Nosocomial IE
Pace maker

Native valve endocarditis (NVE)

Rheumatic valvular disease (?% in SL. 20% industrialized countries where RF is now uncommon) Congenital heart disease (15% of NVE) - PDA; VSD; Fallot tetralogy; any native or surgical highflow lesion. Mitral valve prolapse with an associated murmur (20% of NVE) Degenerative heart disease - Including calcific aortic stenosis due to a bicuspid valve, (50% of IE in elderly)

Causative agents of NVE

1. Streptococci 60-80 %
Viridans streptococci 30-40 Enterococci 5-18 Other streptococci 15-25 ( NVS, strept. bovis, Group A,C,G,B)

2. Staphylococci 20-35%
Coagulase-positive 10-27 Coagulase-negative 1-3

3. Gram-negative aerobic bacilli 1.5-13%

HACEK group

4. Fungi 2-4 5. Mixed infections 1-2 6. Culture-negative <5-24

Acute / Sub acute Valves involved - MV 30 - 45 % - AV 5 - 35 % - Tricuspid 0 - 6% - Pulmonary 1%

Prosthetic valve
20% of IE 5% of prosthesis become infected Early onset 1 yr after surgery
CoNS S. aureus including MRSA

Late onset Viridans streptococcus

IVDA
In 75% no underlying valve abnormality 50% involve tricuspid valve S aureus - commonest aetiological agent Present with recurrent IE May involve multiple valves

Nosocomial
Right sided endocarditis associated with long lines

Associated with a previously damaged valve left sided

Most often, S aureus

Pacemaker endocarditis
infections of implantable pacemakers & cardioverter-defibrillators. Usually, infected within a few months of implantation
CoNS 42%

S.aureus 29%

Clinical Features
Fever - > 80% Anorexia, weight loss Embolic phenomena Immunologic - glomerulonephritis, Osler nodes, Roth spots. Vascular - septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, Janeway lesions

Osler nodes Janeway leisons

Splinter haemorrages

Roths spots

Infective Endocarditis
Modified Dukes criteria 1. Pathologic criteria
Microorganisms: shown by culture or histology in a vegetation histology showing active endocarditis

2. Clinical criteria

2 Major criteira OR 1 major criterian + 2 minor criteria OR 5 minor criteria

Major criteria

1. Blood culture - 2 positive blood cultures with compatible organism 2. ECHO cardiography oscillating mass, abscess, dehiscence of prosthetic valve
Minor criteria

1. 2. 3. 4. 5.

predisposing heart disease fever > 38C vascular phenomena immunologic phenomena blood culture / ECHO not meeting above criteria

Microbiological diagnosis
Blood culture
Pre- antibiotic at least 2 sets (aerobic + anaerobic) - anaerobic not done in Sri Lanka at present Proper preparation of skin prior to taking blood adequate volume

Problems
Contamination Negative blood cultures

Serology - for rare causes of IE - eg: brucella, Coxiella burnetii PCR not done routinely

Blood culture technique

Clean the venepuncture site with 70% alcohol and allow to dry . Wipe concentrically starting from center with 7.5% povidone iodine. Allow to dry for 2 min. Wash hands with soap and water and wear sterile gloves. Draw blood using disposable sterile needle and syringe. Thoroughly mix bottles to avoid clotting.

Blood volume manufactures instructions

Adults 6 -10 ml / bottle Children 3 5 ml Neonates 1 ml

Treatment
Needs to be bactericidal Needs to be prolonged Antibiotic choice dependent on likely causative organisms Use guidelines for antibiotic choice / dose / duration Treatment of complications

Prophylaxis
Principle of prophylaxis 2 risk factors - bacteraemia / cardiac antibiotic indicated if both present Practice of prophylaxis AHA 2007 IE is much more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteremia caused by a dental, GI tract, or GU tract procedure. dental procedures is reasonable only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis. Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure Important preventive measures Routine dental care in all those with cardiac risk

Cardiac conditions for which prophylaxis is reasonable

Prosthetic cardiac valve or prosthetic material used for cardiac valve repair Previous IE Congenital heart disease (CHD)* Cardiac transplantation recipients who develop cardiac valvulopathy

Myocarditis
Definition - inflammation of the cardiac muscle Clinical presentation often asymptomatic acute / chronic Aetiology
Infective Viruses enteroviruses Bacterial C diphtheriae (toxin) Parasitic chagas disease Inflammatory Many autoimmune diseases Drugs Cytotoxic drugs allergic reactions

Myocarditis
Diagnosis
often asymptomatic acute cardiac symptoms - cardiac enzymes cardiac failure Evidence of cardiac malfunction

Evidence of myonecrosis

Management
Mainly symptomatic

- ECG

Evidence of aetiology
- very difficult - endomyocardial biopsy - post-mortem

Pericariditis
Evidence of pericarditis
Pericardial pain Pericardial rub ECG Acute pericarditis - isolated entity or as the result of a systemic disease. Incidence of pericarditis postmortem studies 1% - 6 % ante mortem diagnosis only 0.1% of hospitalized patients and 5% of patients with chest pain but no myocardial infarction. The possible sequelae of pericarditis include cardiac tamponade, recurrent pericarditis, and pericardial constriction.

N Engl J Med 2004; 351:21952202November 18, 2004

Infection Blood vessels

Cannula site infections Endothelial infections
measles, dengue Rickettsia

Immune vasculitis
HIV Hepatitis B

Atherosclerosis
Chlamydia pneumoniae
Chlamydiae pneumoniae