Senhouse-Kirkes 1852

Osler-Jaccoud 1885 1923

1930 Thayer Gibson-
1945-1960 -
1961 - Star

EPIDEMIOLOGY
310 episodes/100 000 person-years

14.5 episodes/100 000 person-years (70 and 80 years).

IE, the male:female ratio is >2:1
An estimated 10,000 to 15,000 new cases of IE are diagnosed in the
United States each year
IE has increasingly become a disease of the elderly
More than one-half of all IE cases in the United States now occur in
patients over the age of 60
This trend is probably due to two factors
the decline in the incidence of rheumatic heart disease
the increasing proportion of elderly subjects in the general population

A changing epidemiology
Before : young adults with previously well-identified
(mostly rheumatic) valve disease
Now: IE is now affecting older patients who more
often develop IE
as the result of health care-associated procedures,
In patients with no previously known valve disease
or in patients with prosthetic valves.

RISK FACTORS
Injection drug use
Highest risk factor in patients < 40 years of age

Prosthetic heart valves

Prosthetic valve endocarditis comprises a small but important
segment of IE cases
More than 100,000 heart valves are implanted annually in the
United States
IE develops in 1 to 4 % of valve recipients during the 1st year
following valve replacement, and in approximately 1 % per
year thereafter

RISK FACTORS
Invasive procedure or a vascular device
Nosocomial endocarditis is usually a complication
of bacteremia induced by an
Structural heart disease
Approximately three-fourths of all patients with IE
have a preexisting structural cardiac abnormality
Congenital heart disease is present in 10-20% cases
The most common predisposing congenital heart lesions
are bicuspid aortic valves, coarctation of the aorta, and
tetralogy of Fallot etc.

RISK FACTORS

Degenerative valvular lesions

The risk of IE in patients with Mitral Valve

Prolapsus and associated regurgitation is estimated
to be 5 to 8 times higher than that in the normal
population
Aortic valve disease(stenosis or/and regurgitation) is
present in 12 to 30 percent of cases

Newer predisposing factors have emerged

Valve prostheses, degenerative valve sclerosis,
intravenous drug abuseassociated with increased
use of invasive procedures

RISK FACTORS
Recurrent endocarditis occurred in 4.5 percent of one
large cohort of non-addicts
Other studies have reported rates of IE recurrence ranging
from 2.5 to 9 percent

HIV infection
A number of cases of IE have been reported in patients with
HIV infection
It has been suggested that HIV infection is an independent
risk factor for IE in IV drug abusers

 A number of other, less common predisposing

factors for IE include

Pregnancy
AV fistulas used for hemodialysis
Central venous and pulmonary artery catheters
Peritoneovenous shunts for the control of ascites
Ventriculoatrial shunts for the management of
hydrocephalus

In addition, patients with ulcerative lesions of the

colon due to carcinoma or inflammatory bowel
disease have a poorly understood predilection to
develop endocarditis secondary to S.bovis



-
underlyng etracellular matrix proteins


( )
- -

:
( -)

(, )
( ,)

( ?)


:

(NBTE)
+ +
= >80%
Surface ligants
1.FimA protein that is a lipoprotein receptor antigen I (LraI) that
serves as a major adhesin to the fibrin platelet matrix of
NBTE
2.Staphylococcal adhesins microbial surface components recognizing
a)adhesive matrix molecules facilitate the attachment of staphylococci to human
extracellular matrix proteins and to medical devices and
b) bacterial extracellular structures contribute to the formation of biofilm
MSCRAMM (Microbial Surface Component reacting with
adhesive matrix molecules)

C.burnetii, Chlamydia spp., Legionella spp. , Bartonella spp.

 -
( )
( )
<10 100cfu/ml

Gram- Gram+

C5b-C9 GramHACEK group
Gram+ (Platelet Microbicidal Proteins)

( )



-
--

-
-

()


STREPTOCOCCUS 60-80%
Streptococcus Viridans 30-40%
E 5-18%
S. faecalis
S. faecium
15-25%
STAPHYLOCOCCUS 20-35%
coagulase (+) 10-27%
coagulase (-) 1-3%
Oral streptococci had fallen into second place to staphylococci as
the leading cause of IE

Mandel : Principles and Practice of Infectious diseases p753

-
Gram (-) 1,5-13%
2-4%
H.A.C.E.K

-- ()
Ridkettsiae-

5-24%
Mandel : Principles and Practice of Infectious diseases p753


-Strepto Viridans
- 15 % Strepto D
- 5%
(-) 8%
-Strepto D 22% (Enterocoques 8%)
-Strepto bovis ( Ca -)
-Staph
. --
Strepto D
Staph epidermidis


..- --
B .. Osler
--. - .

:--
-

15-20%

10-25%

20-25%
(. -) 9-30%
5-35%
(-)

-

Case Definition
Duke criteria
In 1994 investigators from Duke University modified
the previous criteria to include the role of
echocardiography in diagnosis
They also expanded the category of predisposing heart
conditions to include intravenous drug use

1 62%
2 94%

6
-
-


- ()

- ( Roth)
- -C.I.C.
- C
- C
-
- .
- Waaler Rose (+)
-

, , ( )


- +
*/ (-)
*In vitro tests

> 4-10 MIC
-
* C.I.C.
* ..
*...

-
* (+ Doppler)

 .-
: 30-40%
:
:- -
-
- ()
-
-
- ()
:-
-
-
-...
:


(20% ..)
-1 1963

- 1975 75% ( )
45% ( )
- 10
:
: .. .
:
1 -- 80%
2 . (Streptococcus spp)


: + 2 +
1 2 :

.

:
-Strepto
:. , .

2.
3.Staph 80% Strepto 15%
4. Gram (-)
5..
6..

-
.
..
.
1.
2.
3.
4.
5.10 M.I.C.
6. (PBS)
-
- 40
4 (Strepto)
6

37
Taylor J. Eur Heart J. 2009

 oral streptococci
D streptococci
>30% : S. mitis and S. oralis
> 99% streptococci D: penicillin
Moet et al. Diagn Microbiol Infect Dis. 2007

(MIC >4 mg/L)

vancomycin + 6
Taylor J. Eur Heart J. 2009

38

Streptococcus pneumoniae

> 30%
(MIC <0.1 mg/L)

(MIC >1 mg/L)

oral streptococci 4

ceftriaxone or cefotaxime
vancomycin.

39

- A, B, C, G S.
milleri (S. constellatus, S. anginosus, S. intermedius)
A -

oral 4 (
- 2 )
PVE B


40

Nutritionally variant streptococci (Abiotrophia defectiva,

Granulicatella adiacens)
> 40%


penicillin G, ceftriaxone or vancomycin: 6
: 2

Lin CH et al. Am J Med Sci. 2007;334:235 41

42

o
1. MRSA: -
1. vancomycin

2. vancomycin

Heteroresistant (MIC<2 mg/L)

Vancomycin-intermediate S. aureus (VISA) (MIC 416 mg/L)
Highly vancomycin resistant (VRSA MIC >16 mg/L)
Daptomycin: S. aureus bacteraemia and right-sided IE (Fowler et al, NEJM 2006)
Daptomycin might also be considered in left sided IE (Levine et al. Am J Med 2007)

Newer b-lactams (Guingard et al. Curr Opin Pharmacol 2005)

Quinupristindalfopristin with or without b-lactams (Vouilamoz et al AAC 2000)
b-lactams plus oxazolidinones (Jacqueline et al. AAC 2005;49:45-51)
b-lactams plus vancomycin (Perichon et al. AAC 2006;50:3622)
43

44


(E. Faecalis- E. Faecium)
MIC >500 mg/L : aminoglycoside.
Streptomycin .
E. faecalis : ampicillin ceftriaxone (Gavalda et al. Ann Intern Med. 2007;146:574) or
b-lactams vancomycin (Taylor J. Eur Heart J. 2009;30:2185-6).

E. faecium : b-Lactam vancomycin

quinupristindalfopristin, linezolid, daptomycin, and

tigecycline.

45

Gram HACEK
5-10%

HACEK -.
ceftriaxone
3

ceftriaxone 2 g/day 4 .

46

 Gram
2-3% . - 60-80%
, ,

> 6
-

cotrimoxazole.

47

Morpeth S et al. Ann Intern Med. 2007 18;147:829

Taylor J. Eur Heart J. 2009;30:2185-6

48


PVE, , .
Candida Aspergillus spp.
>50%
.
amphotericin B azoles, echinocandins.
.

49

50
Taylor J. Eur Heart J. 2009;30:2185-6.

51

1. (U/S--/)

2. ( -
- ) 1)
,
, .

3.
(+ .+ )
4.
5.

 ..
1. . .
2. , , , ,

3.
4.
5. 2/3
- Strepto
-
- >8 .
6.

Indications and timing of surgery in left-sided

native valve infective endocarditis

54

55

56

.
.

( viridans strep)

( , )

.
57

K ?

Tooth extraction 10-100%

Periodontal surgery 36-88%
Teeth cleaning 40%
Tooth brushing, flossing 20-68%
Using wooden toothpicks 20-40%
Chewing food 7-51%
Lockhart PB et al. Circulation
2008;117:3118

58

 ,

.
(shunts conduits).

<6

.
>6 , .

Taylor J. Eur Heart J. 2009;30:2185-6.

59

 ,

, .
.

.
(shunts
conduits).
<6 .
> 6 , .

60
Wilson et al. Circulationaha. 2007

.. ,

61
Taylor J. Eur Heart J. 2009;30:2185-6.

:


( BAL )
.

62
Wilson et al. Circulationaha. 2007

63
Wilson et al. Circulation. 2007



.

4-6
.

. 50%

64

-. -