Cardiovascular

infections
Shyam Kumar Mishra
Assistant Professor,
Department of Microbiology,
Institute of Medicine,
Tribhuvan University
Endocarditis
Bacterial
Staphylococcus aureus and other Staphylococcus species
Viridans streptococci (S. mitis, S. oralis, S. sanguis, S. mutans)
Streptococcus bovis
Streptococcus pneumoniae
Enterococcus spp. (E. faecalis, E. faecium)
HACEK bacteria (Haemophilus aphrophilus, Actinobacillus
actinomycetemcomitans, Cardiobacterium hominis, Eikenella
corrodens, Kingella kingae)
Salmonella spp.
Brucella spp.
Bartonella spp.
Coxiella burnettii

Fungal
Candida spp. (C. parapsilosis, C. albicans, C. tropicalis, and others)
Aspergillus spp.
Myocarditis
Bacterial Viruses
Corynebacterium Coxsackievirus groups A
diphtheriae and B
Clostridium perfringens Echoviruses
Borrelia burgdorferi Poliovirus
Neisseria meningitidis Adenoviruses
Staphylococcus aureus Arenaviruses
Salmonella spp.
Mycoplasma pneumoniae Fungi
Chlamydophila spp. Aspergillus spp.
Rickettsia rickettsii Candida spp.
Orientia tsutsugamushi
Parasites
Trichinella spiralis
Toxoplasma gondii
Pericarditis
Bacterial Viruses
Streptococcus pneumoniae Coxsackievirus groups A
and B
Staphylococcus aureus
Echoviruses
Neisseria spp. (primarily N.
Adenoviruses
meningitidis, N.
Mumps virus
gonorrhoeae)
M. tuberculosis Parasites
Toxoplasma gondii
Entamoeba histolytica
Fungi
Cryptococcus
Histoplasma capsulatum
neoformans
Coccidioides immitis

Blastomyces dermatitidisCandida spp.
Aspergillus spp.
BACTEREMIA/ SEPTICAEMIA
&
LABORATORY DIAGNOSIS

Shyam Kumar Mishra

5
 INTRODUCTIO
N
Microorganisms present in the circulating blood, whether
transiently or intermittently or continuously, are threat to
every organ in the body.

Invasion in bloodstream usually occurs by:

Drainage from primary focus of infection
Direct entry to blood vessels .

Bloodstream infection is basically unimicrobial, and only

sometimes it is polymicrobial (6-18%)4.

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Types of bloodstream infection
1. Intravascular originate within the cardiovascular system
infective endocarditis, mycotic aneurysm & suppurative
thrombophlebitis, catheter-associated bacteremia

2. Extravascular result from bacteria entering the blood circulation

through the lymphatic system from another site of infection
e.g., Genitourinary tract
Respiratory tract
Abscesses
Surgical wound infection
Biliary tract

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 Introduction
Terminologies
Bacteraemia
a phase in natural course of some infection as typhoid fever.
It also occur as spill over effect in serious infection when
patient is immunocompromised.1
Transient presence of bacteria in blood in absence of
symptoms the source of which may be existing focus of
infection, site of commensal flora, inoculation.2
Septicaemia -
An overwhelming invasion of the bloodstream from the focus
of infection.1
Presence of bacteria in blood with clinical signs & symptoms
of infection.2

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Signs and Symptoms of septicaemia

Fever or hypothermia
Chills
Hyperventilation and subsequent respiratory
alkalosis
Skin lesions
Change in mental status
Diarrhoea

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When sepsis results in a drop in blood
pressure (shock) and dysfunction of at
least one organ, it is considered to be
severe sepsis.

A final stage, when low blood pressure

can no longer be controlled by addition of
fluids, is septic shock.

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Severe sepsis - Redundant

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SEPSIS (3rd International Consensus
Definitions for Sepsis and Septic Shock 2016)
Sepsis represents the hosts systemic
inflammatory response to infection.
The inflammatory response in patients with
sepsis depends on the causative pathogen and
the host (genetic characteristics and coexisting
illnesses), with differential responses at local,
regional, and systemic levels.
If left untreated, it may lead to the functional
impairment of one or more vital organs or
systems.

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 Sepsis is defined as life-threatening organ dysfunction caused by a
dysregulated host response to infection. Organ dysfunction can be
represented by an increase in the Sequential [Sepsis-related]
Organ Failure Assessment (SOFA) score of 2 points or more which
is associated with an in-hospital mortality greater than 10%.

Septic shock should be defined as a subset of sepsis and should be

clinically identified by a vasopressor requirement to maintain a
mean arterial pressure of 65 mm Hg or greater and serum lactate
level greater than 2 mmol/L (>18 mg/dL) in the absence of
hypovolemia.

This combination is associated with hospital mortality rate greater

than 40%.

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 New definition of sepsis suggests that patients
with at least 2 of these 3 clinical variables:
Glasgow coma scale score of 13 or less,
systolic blood pressure of 100 mmHg or less, and
respiratory rate 22/min or greater

Glasgow coma scale considers following behaviors

Eye opening response (4-1)
Best verbal response (5-1)
Best motor response (6-1)

Total score
BEST RESPONSE 15
COMATOSE CLIENT 8 OR LESS
TOTALLY UNRESPONSIVE - 3

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Septic shock
Characterized by
Fever
Acute respiratory distress
Shock
Renal failure
Intravascular coagulation, DIC
Tissue destruction

Initiated by either exotoxin or endotoxin

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16
Infection Normal Environment
flora

Clinical
disease
range:
Source None

to
Bacteraemia
Septicaemia

Metastatic
infection

Intravascular Extravascular

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Endocarditis Abscess
 Introduction
Risk factors1
A. Conditions
Immune deficient status.
Extreme of age
Hematological & non hematological malignancies
Diabetes mellitus ,renal failure. hepatic cirrhosis
Burns
B. Therapeutic maneuvers
IV catheterization
Surgery of all types
Endoscopic procedures
C. Medications
Corticosteroids
Chemotherapies

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19
 INTRODUCTION
Bacteremia
Types of bacteremia
Transient incidental, minor events cause.
May lead to significant septicaemia3. lasts for minutes to
hours.4 E.g : chewing food,endoscopy,cytoscopy e.t.c

Intermittent occurs, clears & then reoccurs in same patient

due to same organism.E.g:undrained abscess4.

Continuous organisms released at fairly constant rate3.E.g:

bacterial endocarditis.

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Bacteria
Pathogen
Escherichia coli
Salmonella Typhi
Salmonella Paratyphi A
Staphylococcus aureus
Coagulase-negative staphylococci
Enterococcus spp.
Pseudomonas aeruginosa
Klebsiella pneumoniae
Viridans streptococci
Streptococcus pneumoniae
Enterobacter cloacae
Proteus spp.
Beta-hemolytic streptococci
Anaerobic bacteria Bacteroides and Clostridium spp.
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 Organisms responsible
HACEK bacteria3
Represents fastidious, gram negative bacilli including :
Haemophilus aphrophilus
Actinobacillus actinomycetemcomitans
Cardiobacterium hominis
Eikenella corrodens
Kingella kingae

Anaerobes as: Bacteroides, Clostridium

Microorganism that do not grow on artificial media including:
Coxiella burnetii, Rickettsia, Chlamydophila sp., Trophermyma
whippleii
Mycobacterium tuberculosis - 42% of HIV +ve cases have +ve
blood culture.4
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 Organisms responsible
Parasites 3
Parasitemia causing eukaryotes include :
1. Tachyzoites of Toxoplasma gondii,
2. Microfilariae during infection with Mansonella, Loa loa,
Wuchereria or Brugia
3. Plasmodium, Trypanosoma, & Babesia

Mature trophozoite
in RBC 23
 Organisms responsible
Fungi 3

Fungemia ; a serious condition ,occuring primarily in

immumocompromised patients. It is more prevalent
than anaerobic bacteremia4. includes:
1. Candida albicans
2. Malassezia furfur
3. Microconidia of Histoplasma capsulatum, Blastomyces
dermatitidis
4. Arthroconidia of Coccidioidis immitis

Histoplasma capsulatum yeasts in the 24

Candida albicans cytoplasm of two of three neutrophils

 Organisms responsible
Viruses 3

Viruses preferentially infecting blood cells include

Epstein Barr virus (lymphocyte)
Cytomegalovirus (monocytes, lymphocytes)
HIV (T-lymphocytes & macrophages)
Human retroviruses

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Infective Endocarditis

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 Laboratory diagnosis
Laboratory investigation of bloodstream
infection varies with the suspicion of
causative organisms.
Some methods are:

1. Blood smear examination

2.Blood culture
3. Serological investigations
4. Molecular techniques
5. Cell culture techniques
6. Electron microscopy
7. Endotoxin detection
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 Blood cultures are the current
gold standard of BSI diagnosis
and are based on the detection
of viable microorganisms present
in blood.

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 LABORATORY
DIAGNOSIS

Basic objective: Blood Culture

To recover small no. of bacteria from the
blood.
Regardless of systems used it essentially
comprises of :
1. Aseptic collection of blood
2. Culture of this in liquid medium
3. Detecting the presence of bacteria
4. Subculture in solid medium for identification
and sensitivity testing.

Strategy is dictated by clinical consideration and

urgency to start treatment. 29
Laboratory diagnosis

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31
 Laboratory
Blood culture systems diagnosis
Conventional and automated/semiautomated systems are
used according to availability.
Usually broth based systems in conjunction with lysis
centrifugation is recommended.

1. Automated/semiautomated systems- monitors the culture

for an early sign of bacterial growth such as by detecting
change in electrical impedence or release of radioactive
CO2 or non-radioactive gases.

2. Conventional/traditional system-examining blood

cultures by subculturing after different periods of
incubation.

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 Laboratory diagnosis
Timing of collection

Before administration of antibiotics

Optimal time-1 hour before the temperature rises ,with
the next best time as the temperature starts to rise.
Not necessary to time the sampling to coincide with
rising spike of fever as used to be taught.
Periodicity of microorganisms in bloodstream must be
considered in establishing standards for the timing.
The overall volume of blood cultured is more critical
than timing.

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 Laboratory diagnosis
Preparation of skin and blood collection4
1. Selection of likely site i.e: anticubital vein, apply
tourniquet and palpate.
2. Release tourniquet .
3. Clean site with 70% alcohol
4. Then with iodine in a circular fashion outward
for a final diameter of 5-6 c.m,begining over the
point of anticipated veinpuncture.
5. 70% Alcohol
6. Allow it to dry; do not palpate.
7. Reapply tourniquet
8. Draw the blood.

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 Laboratory diagnosis
Collection of blood for culture
1. Use of 21 gauge needle with that holds 5-10 ml of
blood or more.
2. Use of vacutainer system.

Vacutainer system

Traditional system
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 Laboratory diagnosis
Volume of blood
There is direct relation between volume & yield.1,2,3,4.
The no. of microorganisms present in adult is
10CFU/ml. On the other hand it is 100-
1000CFU/ml for children.4

For adult 10-20 ml, and for infant 1-5 ml is

recommended.

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MacCartney bottle
 Laboratory diagnosis
Antibiotics removal
In case of antibiotic therapy, collection of sample
just before the next dose of antibiotic is more
reliable than to remove antibiotics.

Some examples of agents (incorporated with

media) removing antibiotics effect:
P-aminobenzoic acid- neutralize sulphonamide
drugs
Broad spectrum lactamase-neutralizes penicillin &
cepahalosporin

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 Laboratory diagnosis
Anticoagulants
Heparin, EDTA, citrate inhibit numerous
organism so they are not recommended.
Sodium polyanethol sulfonate (0.025-0.03%)
is recommended.
Advantage - acts as anticoagulant,
anticomplementary, antiphagocytic and
interferes activity of aminoglycosides.

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 Laboratory diagnosis
Dilution of sample.
It is basically blood: broth ratio. It is
recommended to maintain 1:5-1:10 to
reduce concentration of natural inhibitors.

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 Laboratory diagnosis
Conventional blood culture system
Detecting growth1
Generally detected after 6-8 hours. Blind
sub-cultures after first 6-12 hours of
incubation is performed in blood/chocolate
agar. Plate is then incubated at 5-10%
CO2 /48 hours

Culture negative reincubated for 5-7 days

if required.

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41
Fever of Unknown Origin
The first formal definition of FUO to gain broad
acceptance was proposed by Petersdorf and
Beeson:
fever higher than 38.3 C (101 F) on several occasions,
persisting without diagnosis for at least 3 weeks in spite
of at least 1 weeks investigation in hospital.

Cases of FUO are currently codified into four

distinct subclasses of the disorder: classic FUO,
nosocomial FUO, immune-deficient FUO, and HIV-
related FUO
Types of FUO
Classic FUO
>38.0 C, >3 wk, >2 visits or 3 d in hospital
Nosocomial FUO
>38.0 C, 3 d, not present or incubating on
admission
Immune-deficient FUO
>38.0 C, >3 d, negative cultures after 48 h
HIV-related FUO
38.0 C, >3 wk for outpatients, >3 d for inpatients,
HIV infection confirmed
Laboratory diagnosis of PUO

Tests should be first done for the more likely

infections and then, if these are negative,
test for the less likely should be done.

1. Attempt blood culture always. First specimen before

antibiotics.
2. Paired sera for serology.
3. Haematological investigations .
4. Thick & thin blood film
5. A tuberculin test

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PUO Tests in the first week
CBC, DC
ESR, CRP
Serum ferritin,
Urea, Creatinine
LFT
Blood sugar
Bone biochemistry
CPK
Malaria blood film (if travel history)
Urinalysis R/E, C/S
Stool C/S
Sputum Gram stain, AFB and C/S
Blood C/S * 3
Chest radiograph
USG- Abdomen
ECG
Further non-invasive investigations
PCR for different pathogens
Immunology
ANA, Anti dsDNA, ANCA,
C3 and C4 levels
Cryoglobulin
Mantoux test
Serological investigations
Viral- CMV, EBV, HIV, HAV, HBV, HCV, Parvovirus
Bacterial Chlamydia, Brucella, Mycoplasma, Treponema
pallidum, Leptospira, Yersinia, ASO titre
Fungi Cryptococcus, Histoplasma, Coccidioidis
Protozoa Toxoplasma, Leishmania, Amoebiasis, Schistosomiasis
Biopsy
Thank
Thank
you
you
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