Cardiovascular Infections

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Cardiovascular Cardiovascular Infections Infections Dr. Lakmini Yapa Senior Registrar (Medical Microbiology) 06/10/22 Y3S2 Infection 2

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Cardiovascular Infections

Transcript of Cardiovascular Infections

Page 1: Cardiovascular Infections

Cardiovascular InfectionsCardiovascular Infections

Dr. Lakmini YapaSenior Registrar (Medical Microbiology)

04/11/23 Y3S2 Infection 2

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Infections of CVS

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

septal defect.septal defect.

Infective Endocarditis

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Types of IE

• Native Valve IE

• Prosthetic Valve IE

• Intravenous drug abuse (IVDA) IE

• Nosocomial IE

• Pace maker

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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 high-flow 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)

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Causative agents of NVE

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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

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IVDA

• In 75% no underlying valve abnormality

• 50% involve tricuspid valve• S aureus - commonest aetiological

agent• Present with recurrent IE• May involve multiple valves

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Nosocomial

• Right sided endocarditis associated with ‘long’ lines

• Associated with a previously damaged valve – left sided

• Most often, S aureus

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Pacemaker endocarditis

• infections of implantable pacemakers & cardioverter-defibrillators. Usually, infected within a few months of implantation

CoNS 42%

S.aureus 29%

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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

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Janeway leisons

Osler nodes

Splinter haemorrages

Roths spots

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Infective Endocarditis

Modified Duke’s criteria1. Pathologic criteria Microorganisms: shown by culture or histology in a

vegetation histology showing active endocarditis

2. Clinical criteria 2 Major criteiraOR

1 major criterian + 2 minor criteria

OR5 minor criteria

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Major criteria1. Blood culture - 2 positive blood cultures with

compatible organism2. ECHO cardiography – oscillating mass,

abscess, dehiscence of prosthetic valve

Minor criteria

1. predisposing heart disease2. fever > 38°C3. vascular phenomena4. immunologic phenomena5. blood culture / ECHO not meeting above

criteria

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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

• Serology - for rare causes of IE - eg: brucella, Coxiella burnetii

• PCR – not done routinely

ProblemsContamination

Negative blood cultures

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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.

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Blood volume – manufactures instructions

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

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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

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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

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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

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Myocarditis• Definition - inflammation of the cardiac muscle• Clinical presentation – often asymptomatic

– acute / chronic• Aetiology

Infective Viruses – enterovirusesBacterial – C diphtheriae (toxin)Parasitic – chagas disease

Inflammatory Many autoimmune diseasesDrugs Cytotoxic drugs

‘allergic’ reactions

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Myocarditis• Diagnosis

– often asymptomatic– acute cardiac symptoms – cardiac failure

• Management – Mainly symptomatic

Evidence of myonecrosis

- cardiac enzymes

Evidence of cardiac malfunction

- ECG

Evidence of aetiology

- very difficult - endomyocardial biopsy - post-mortem

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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.

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N Engl J Med 2004; 351:2195-2202November 18, 2004

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Infection – Blood vessels• Cannula site infections• Endothelial infections

measles, dengueRickettsia

• Immune vasculitisHIV Hepatitis B

• Atherosclerosis Chlamydia pneumoniae Chlamydiae pneumoniae