1. …………Myocarditis and pericarditis
Infective Endocarditis…..
…………Myocarditis and pericarditis
Dr.P.K.Rajesh.M.B.B.S:M.D

2. Learning outcomes
At the end of this activity, the student should be able to
discuss the risk factors for developing infective endocarditis (IE).
list the organisms that cause IE.(tricky)
discuss the lab diagnosis of IE.(include updates)
categorize pericarditis according to the type of effusion (serous, fibrinous, hemorrhagic, casseous).
Dr.P.K.Rajesh.M.B.B.S:M.D

3. Introduction
Infective endocarditis is an infection of the endocardium.
The high risk group
Rheumatic Heart Disease-already diseased valve
Congenital Heart Disease - PDA, VSD
Mitral valve prolapse-MVD or AVD
Prosthetic valves
Chronic indwelling catheters
Intravenous drug abusers
Dr.P.K.Rajesh.M.B.B.S:M.D

4. Critical thinking
Dr.P.K.Rajesh.M.B.B.S:M.D

5. Aetiopathology
Dr.P.K.Rajesh.M.B.B.S:M.D

6. Procedural risk Dental procedures (Streptococcus viridans) ENT surgery
What if Streptococcus bovis is isolated?
Sorry!
If I were you…I would check whether he has colon CA
Strep bovis in blood culture is a microbiological marker for colon CA
Dental procedures (Streptococcus viridans)
ENT surgery
Genitourinary (Enterococcal)
Obstetric and gynecological (On prosthetic valve)
Dr.P.K.Rajesh.M.B.B.S:M.D

7. Causative agents-until recent
Streptococcus spp % of which
S.viridans,α hemolytic 35%
S.bovis %
Others <5%
Staphylococcus spp % of which
Staph. aureus %
CONS %
Enterococcus sp %
HACEK* <5%
Coliforms,anearobic <5%
Fungi (Candida) <5%
Dr.P.K.Rajesh.M.B.B.S:M.D

8. Better clinical microbiologists
Increase in Staphylococcus isolation due to-increased IV drug users, increase in IV medication/nutrition dependant patients,
Better clinical microbiologists
Rajesh
Dr.P.K.Rajesh.M.B.B.S:M.D

9. NOW WHAT IF I GET THIS STUPID MCQ?
The most common causative organism of IE is
Staphylococcus aureus
Staphylococcus epidermidis
Streptococcus viridans
Streptococcus bovis
Depends on cause/valve/time
i.e source/native or prosthetic/early or late
Dr.P.K.Rajesh.M.B.B.S:M.D

10. HACEK GROUP Haemophilus aprophilus(paraprophilus) (H)
Actinobacillus actinomycetemcomitans (A)
Cardiobacterium hominis (C)
Eikenella corrodens (E)
Kingella kingae (K)
FASTIDUOUS-WON’T GROW WITH ROUTINE CULTURE METHODS
Dr.P.K.Rajesh.M.B.B.S:M.D

11. Dr.P.K.Rajesh.M.B.B.S:M.D

12. Lab diagnosis Routine Blood culture 3 samples from….3 sites…..
before antibiotics
Cultured on enrichment media
Sub-Culture on enriched Agar
Antibiotic sensitivity
Caution-Culture Negative
Endocarditis
Dr.P.K.Rajesh.M.B.B.S:M.D

13. Dr.P.K.Rajesh.M.B.B.S:M.D

14. Sub-culture & Sensitivity testing

15. Antibiogram

17. Update-keep it simple

18. Bactec Bacteria auto detect-(importance of liquid media)
Caution-machines are as good/bad as US.

19. Dr.P.K.Rajesh.M.B.B.S:M.D

20. Dr.P.K.Rajesh.M.B.B.S:M.D

21. Bactec’s been around for 20 years
Dr.P.K.Rajesh.M.B.B.S:M.D

22. Hic! hot and wet!
A 46-year-old homeless male with a history of excessive alcohol consumption presented to the emergency department with a two-week history of fever and night sweats.
Dr.P.K.Rajesh.M.B.B.S:M.D

23. The works….yawn!!!
The diagnosis of infective endocarditis was considered when he was found to have a systolic ejection murmur in the aortic area as well as an early diastolic murmur along the left sternal border.
A transthoracic echocardiogram revealed an aortic valve vegetation with moderate aortic regurgitation
Dr.P.K.Rajesh.M.B.B.S:M.D

24. Now what?
Two sets of blood cultures drawn prior to initiation of intravenous ceftriaxone and vancomycin yielded no growth after extended incubation in the microbiology laboratory.
Valve tissue obtained at the time of aortic valve replacement was sterile despite five days of culture.
Dr.P.K.Rajesh.M.B.B.S:M.D

25. REMEMBER PKR
Polymerase chain reaction (PCR) of the 16S–23S rDNA intergenic spacer region with sequencing of the PCR product confirmed the causative agent to be Bartonella quintana.
Dr.P.K.Rajesh.M.B.B.S:M.D

26. Email rajesh.perumbilavil@gmail.com
2 examples from the other methods of determining antibiotic resistance/sensitivity
for details
Phage assay
Plasmid profiling

27. Molecular methods can determine if the strains are the same/different in recurrent IE apart from drug resistance

28. Dr.P.K.Rajesh.M.B.B.S:M.D

29. Duke’s criteria for diagnosis of IE (Rajesh’s made easy version )
Modified Duke’s includes molecular evidence
Major criteria-
I. Positive blood culture for IE
(Isolation of typical microorganism from 2 separate cultures)
II. Evidence of endocardial involvement
(Positive ECHO for IE )
Minor criteria-
Clinical evidence
Microbiological and Radiological evidence
Modified Duke’s includes molecular evidence
Dr.P.K.Rajesh.M.B.B.S:M.D

30. Clinical features are seldom due to microorganisms-they are due to immunity!
RAJESH
Dr.P.K.Rajesh.M.B.B.S:M.D

31. Dr.P.K.Rajesh.M.B.B.S:M.D

32. Pericarditis Inflammation of Pericardium
Serous,Fibrinous,Purulent,Caseous,Haemorrhagic
(Pericardial effusion/Empyema)
Can follow-Lobar pneumonia/parotitis
Can spread by Haematogenous/Lymphatic
Direct-cardiotomy? (stab) can introduce organisms
Dr.P.K.Rajesh.M.B.B.S:M.D

33. Pericarditis-summary
Serous-viral
Fibrinous-viral
Purulent-bacterial
Caseous-Mycobaterium
Hgic-Mycobaterium
Dr.P.K.Rajesh.M.B.B.S:M.D

34. Rheumatic pancarditis
Group-A-β hemolytic Streptococci
Cross immune hypothesis
Duckett Jones Criteria
PANCARDITIS-aschoff body
Penicillin prophylaxis
Dr.P.K.Rajesh.M.B.B.S:M.D

35. Dr.P.K.Rajesh.M.B.B.S:M.D

36. Self study/references
This a PPP-do not consider this as NOTES per se
Infective endocarditis
Rheumatic Heart disease
Lab diagnosis of Gram positive cocci
Blood cultures and BACTEC.
Duke’s criteria (Original, Modified, PKR versions)
Study material suggested
Churchill’s pocketbook of Clinical Microbiology-TJJ.Inglis
Elsevier’s Medical Microbiology, Mims et al,3rd Ed
Dr.P.K.Rajesh.M.B.B.S:M.D