microorganisms related to cardiac infections ramlan sadeli
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MICROORGANISMS RELATED MICROORGANISMS RELATED TO CARDIAC INFECTIONSTO CARDIAC INFECTIONS
Ramlan SadeliRamlan Sadeli
CARDIAC INFECTIONS :CARDIAC INFECTIONS :
Infective endocarditisInfective endocarditis
Myocarditis Myocarditis
Pericarditis Pericarditis
INFECTIVE ENDOCARDITISINFECTIVE ENDOCARDITIS
The proliferation of microorganisms on The proliferation of microorganisms on to endothelium of the heart. The to endothelium of the heart. The prototypic lesion at the site of prototypic lesion at the site of infection : the vegetation; is a mass of infection : the vegetation; is a mass of platelets, fibrins, micro-colonies of platelets, fibrins, micro-colonies of microorganisms and scant microorganisms and scant inflammatory cells.inflammatory cells.
INFECTIVE ENDOCARDITIS :INFECTIVE ENDOCARDITIS :
Infection most commonly involves Infection most commonly involves heart valvesheart valves
May also occur on the ventricular May also occur on the ventricular septum (on the lower pressure site)septum (on the lower pressure site)
Or on the mitral endocardiumOr on the mitral endocardium
CLASSIFICATION BASE ON :CLASSIFICATION BASE ON :
Temporal evolution of diseaseTemporal evolution of disease
Site of infectionsSite of infections
The cause of infectionsThe cause of infections
Predisposing risk factor Predisposing risk factor
PORTAL OF ENTRY :PORTAL OF ENTRY :
Community-acquired native valve Community-acquired native valve
Endocarditis :Endocarditis :
Oral cavityOral cavity
Skin Skin
Upper respiratory tractUpper respiratory tract
Etiology :Etiology :- Viridans streptococciViridans streptococci- StaphylococciStaphylococci- HaemophilusHaemophilus- ActinobacillusActinobacillus- CardiobacteriumCardiobacterium- EikenellaEikenella- KingellaKingella
PORTAL OF ENTRY :PORTAL OF ENTRY :
Community-acquired :Community-acquired :
Gastrointestinal tractGastrointestinal tract
Genitourinary tractGenitourinary tract
Etiology :Etiology :
StreptococcusStreptococcus
EnterococciEnterococci
PORTAL OF ENTRY :PORTAL OF ENTRY :
Nosocomial infection :Nosocomial infection :
Intravascular catheterIntravascular catheter
Nosocomial woundNosocomial wound
Urinary tract infectionsUrinary tract infections
Etiology :Etiology :
Staphylococci (coagulase-negative)Staphylococci (coagulase-negative)
S. aureusS. aureus
Gram negative bacilliGram negative bacilli
DiphtheroidDiphtheroid
Fungi Fungi
Etiology of endocarditis among injection Etiology of endocarditis among injection
drug users :drug users :
S. aureusS. aureus
Pseudomonas aeruginosaPseudomonas aeruginosa
CandidaCandida
BacillusBacillus
LactobacillusLactobacillus
CorynebacteriumCorynebacterium
5-15% of patients with endocarditis have 5-15% of patients with endocarditis have negative blood culturenegative blood culture
1/3 – ½ of these cases, cultures negative 1/3 – ½ of these cases, cultures negative because of prior antibiotic exposurebecause of prior antibiotic exposure
The remainder of these patients are The remainder of these patients are infected by fastidious organismsinfected by fastidious organisms
Pathogenesis :Pathogenesis :
The normal endothelium is resistant to The normal endothelium is resistant to infectionsinfections
Direct infections by virulent organisms (S. Direct infections by virulent organisms (S. aureus can adhere directly to intact aureus can adhere directly to intact endothelium or exposed sub-endothelium endothelium or exposed sub-endothelium tissue)tissue)
Development of an uninfected platelet-fibrin Development of an uninfected platelet-fibrin thrombus thrombus serves as site of bacterial serves as site of bacterial attachmentattachment
Diagnosis :Diagnosis :
The diagnosis of infection endocarditis is The diagnosis of infection endocarditis is
Established with certainty only when :Established with certainty only when :
Vegetations obtained at cardiac Vegetations obtained at cardiac surgerysurgery
At autopsyAt autopsy
Or from an embolus are examined Or from an embolus are examined histologically and microbiologicallyhistologically and microbiologically
Tabel 1. The Duke Criteria for the Clinical Diagnosis of Infective Tabel 1. The Duke Criteria for the Clinical Diagnosis of Infective Endocarditis Endocarditis
Major criteriaMajor criteria
1. Positive blood culture :1. Positive blood culture :
- Typical microorganisms for infective endocarditis from two separate blood - Typical microorganisms for infective endocarditis from two separate blood
cultureculture
- Persistently positive blood culture- Persistently positive blood culture
- Single positive blood culture for Coxiella burnetii or phase I IgG antibody t iter- Single positive blood culture for Coxiella burnetii or phase I IgG antibody t iter
of 1 : 800of 1 : 800
Major CriteriaMajor Criteria
2. Evidence of endocardial involvement2. Evidence of endocardial involvement
- positive echocardiogram- positive echocardiogram
- new valvular regurgitation- new valvular regurgitation
Minor CriteriaMinor Criteria
1.1. PredispositionPredisposition
2.2. FeverFever
3.3. Vascular phenomenaVascular phenomena
4.4. Immunologic phenomenaImmunologic phenomena
5.5. Microbiologic evidenceMicrobiologic evidence
Bacteremic Pattern
Definite infective endocarditisDefinite infective endocarditis
Two mayor criteriaTwo mayor criteria
One mayor criterion and 3 minor One mayor criterion and 3 minor criteriacriteria
Five minor criteriaFive minor criteria
Possible infective endocarditisPossible infective endocarditis
One mayor and 1 minor criterionOne mayor and 1 minor criterion
Three minor criteriaThree minor criteria
Treatment :Treatment :
Since all bacteria in the vegetation Since all bacteria in the vegetation must be killed, therapy for endocarditis must be killed, therapy for endocarditis must be bactericidal and must be given must be bactericidal and must be given for prolonged periodfor prolonged period
Are given par-enterallyAre given par-enterally
Requires precise knowledge of the Requires precise knowledge of the susceptibility of the causative susceptibility of the causative microorganismsmicroorganisms
MyocarditisMyocarditis
Cardiac inflammation is most commonly Cardiac inflammation is most commonly the result of an infectious processthe result of an infectious process
Most commonly caused by viruses, Most commonly caused by viruses, especially coxsackie virus Bespecially coxsackie virus B
Clinical manifestations :Clinical manifestations :
AsymptomaticAsymptomatic
Fulminant condition, with arrhytmia, Fulminant condition, with arrhytmia, heart failure, and deathheart failure, and death
Most often self-limited and without Most often self-limited and without sequelaesequelae
Or progresses to a chronic form and to Or progresses to a chronic form and to dilated cardiomyopathydilated cardiomyopathy
Often a history of flu-like syndrome, Often a history of flu-like syndrome, viral nasopharyngitis or tonsillitisviral nasopharyngitis or tonsillitis
Bacterial myocarditis :Bacterial myocarditis :
Usually as a complication of Usually as a complication of endocarditisendocarditis
Patients with diphtheria may develop Patients with diphtheria may develop diphtheritic myocarditisdiphtheritic myocarditis
Diagnosis :Diagnosis :
The isolation of virus from the stool, The isolation of virus from the stool, pharyngeal washing or other body fluidpharyngeal washing or other body fluid
Changes in specific antibody titersChanges in specific antibody titers
Endomyocardial biopsyEndomyocardial biopsy
MyocarditisMyocarditis
Treatment :Treatment :
Beta interferonBeta interferon
Bed restBed rest
Drug for congestive heart failureDrug for congestive heart failure
arrythmiaarrythmia
anticoagulationanticoagulation
MyocarditisMyocarditis
Full recovery is usualFull recovery is usual
Fulminant cases require heart Fulminant cases require heart transplanttransplant
Acute pericarditis :Acute pericarditis :
The most common pathologic process The most common pathologic process involving pericardiuminvolving pericardium
May be classified both clinically and May be classified both clinically and etiologicallyetiologically
Clinical manifestations :Clinical manifestations :
Chest pain, pericardial friction rub, Chest pain, pericardial friction rub, electrocardiographic change, electrocardiographic change, pericardial effusion with cardiac pericardial effusion with cardiac tamponade and paradoxal pulsetamponade and paradoxal pulse
Pain is often absent in a slowly Pain is often absent in a slowly developing tuberculosis, post-developing tuberculosis, post-irradiation, neo-plastic, or uremic irradiation, neo-plastic, or uremic pericarditispericarditis
Etiology of infective pericarditis :Etiology of infective pericarditis :
- Viral :- Viral :
– Coxsackie virus A and BCoxsackie virus A and B
– EchovirusEchovirus
– MumpsMumps
– Adenovirus Adenovirus
– HepatitisHepatitis
– HIVHIV
- Pyogenic bacteria :Pyogenic bacteria :
– PneumococcusPneumococcus
– StreptococcusStreptococcus
– StaphylococcusStaphylococcus
– NeisseriaNeisseria
– LegionellaLegionella
- M. tuberculosisM. tuberculosis
- Fungal :Fungal :
– CandidaCandida
– HistoplasmaHistoplasma
– BlastomycesBlastomyces
– CoccidioidesCoccidioides
- Other infections :Other infections :
– SyphiliticSyphilitic
– ProtozoalProtozoal
– ParasiticParasitic
PericarditisPericarditis
Diagnosis :Diagnosis :
Echocardiography should be performed immediatelyEchocardiography should be performed immediately
- allows assesment of pericardial thickness, pericrdial- allows assesment of pericardial thickness, pericrdial
fluid and tamponadefluid and tamponade
- can be used to guide emergency pericariocentesis- can be used to guide emergency pericariocentesis
electrocardiogram shows diffuse ST and T changes,electrocardiogram shows diffuse ST and T changes,
depressed PR interval, decreased QRS voltagedepressed PR interval, decreased QRS voltage
Laboratory diagnosis :Laboratory diagnosis :
Pericardiocenthesis :Pericardiocenthesis :
Pericardial effusion nearly always has Pericardial effusion nearly always has the physical characteristics of an the physical characteristics of an exudateexudate
Bloody fluid is commonly due to Bloody fluid is commonly due to tuberculosistuberculosis
Or post-cardiac injury, post myocardial Or post-cardiac injury, post myocardial infarctions, and neoplasm, and effusion infarctions, and neoplasm, and effusion of rheumatic feverof rheumatic fever
Microscopic examination :Microscopic examination :
Gram-stain smear of the centrifuged Gram-stain smear of the centrifuged sediment of clear or slightly cloudy fluid sediment of clear or slightly cloudy fluid should be examinedshould be examined
Purulent material should be smeared Purulent material should be smeared directlydirectly
CultureCulture
Culture perform onto a variety of Culture perform onto a variety of specialized agar media for identification, specialized agar media for identification, base on microscopic examinationbase on microscopic examination
PericarditisPericarditis
Pericardial biopsy improves the diagnostic yieldPericardial biopsy improves the diagnostic yield
Viral or idiopathic pericarditis is self-limitingViral or idiopathic pericarditis is self-limiting
Purulent pericarditis requires emergency surgical Purulent pericarditis requires emergency surgical drainage and systemic antibioticdrainage and systemic antibiotic
Mortality is 30 %Mortality is 30 %
PericarditisPericarditis
Tuberculous pericarditis is treated with :Tuberculous pericarditis is treated with :
- a four-drug antituberculous regimen- a four-drug antituberculous regimen
= prednison to prevent constriction= prednison to prevent constriction
- calcific form requires pericardiectomy- calcific form requires pericardiectomy
Post streptococcal infection :Post streptococcal infection :
Following an acute Group A Following an acute Group A streptococcal infections (e.g. sore streptococcal infections (e.g. sore throat), there is a latent period of 1 – 4 throat), there is a latent period of 1 – 4 weeks after which rheumatic fever weeks after which rheumatic fever nephritis occasionally developsnephritis occasionally develops
Rheumatic fever :Rheumatic fever :
The most serious sequelae of The most serious sequelae of hemolytic streptococcal infectionshemolytic streptococcal infections
It results in damage to heart muscle It results in damage to heart muscle and valvesand valves
Antibodies of cell membrane antigen of Antibodies of cell membrane antigen of staphylococci cross react with the staphylococci cross react with the human tissue antigenhuman tissue antigen
The carditis characteristically leads to The carditis characteristically leads to thickened and deformed valvethickened and deformed valve
And to perivascular granulomas in the And to perivascular granulomas in the myocardium (Aschoff bodies) that are myocardium (Aschoff bodies) that are finally replace by scar tissuefinally replace by scar tissue
Rheumatic fever has marked tendency Rheumatic fever has marked tendency to be reactivated by recurrent to be reactivated by recurrent streptococcal infectionsstreptococcal infections
The first attack of rheumatic fever The first attack of rheumatic fever usually produce only slight cardiac usually produce only slight cardiac damagedamage
It is therefore important to protect such It is therefore important to protect such patient from recurrent beta-haemolytic patient from recurrent beta-haemolytic Group A streptococcal infectionsGroup A streptococcal infections