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Infective

endocarditis
Diagnosis & treatment
Cholid Tri Tjahjono, dr. SpJP

roadmap
1.

Definitions, general information

2.

Clinical symptoms

3.

Diagnosis
1.

Duke criteria

2.

Blood cultures

3.

Echocardiography

4.

Treatment basics

5.

Complications

6.

Prophylaxis

7.

Summary

Definitions, general
information

Infective endocarditis

inflammatory process on-going inside endocardium

due to infection after endothelium damage

most often involving aortic and mitral valves

Definitions, general information


- continued
Acording to localisation

Left sided IE

Native valve IE (NVE)

Prosthetic valve IE(PVE)

Early < 1 year after surgery

Late >1 year after surgery

Right sided IE

Device- related IE (ICD)

Definitions, general information


- continued
Acording to the mode of acquisition

Health-care associated IE

Nosocomial

Non-nosocomial

Community acquired IE

Intravenous drug abuse-associated IE

Definitions, general information


- continued

Active IE

Recurrence

Relpse

Reinfection

Definitions, general information


- continued

3-10/100 000/year

Maximum at the age of 70-80

More common in women

Staphylococcus aureus is the most common pathogen

Streptococcal IE is still the most common


in developing countries

roadmap
1.

Definitions, general information

2.

Clinical symptoms

3.

Diagnosis
1.

Duke criteria

2.

Blood cultures

3.

Echocardiography

4.

Treatment basics

5.

Complications

6.

Prophylaxis

7.

Summary

Clinical symptoms

Fever over 90% of patients

New intra-cardiac murmur - about 85% of patients

Roth spots, petechiae, glomerulonephritis up to 30% of


patients

Clinical symptoms when to


suspect?

Sepsis of unknown origin

Fever coexsisting with:

Intracardiac implantable material


IE history

Congenital heart disease or valve disease

IE risk factors

Congestive heart failure symptoms

New heart block

Positive blood cultures

Focal neurological signs without known aetiology

Periferal abscesess (kidney, spleen, brain, vertebral column)

roadmap
1.

Definitions

2.

Clinical symptoms

3.

Diagnosis
1.

Duke criteria

2.

Blood cultures

3.

Echocardiography

4.

Treatment basics

5.

Complications

6.

Prophylaxis

7.

Summary

Duke criteria
1.

Blood culture positive for typical

2.

Evidence of endocardial
involvement

Major
criteria
IE-causing
microorganism

Diagnosis
2 major criteria
1 major and 3
minor
5 minor criteria

Minor criteria
1.

Predisposition heart
condition or i.v. drug abuse

2.

Fever temp. >38 C

3.

Vascular phenomena
arterial emboli etc.

4.

Immunologic phenomena
glomerulonephritis, Oslers
nodes, Roths spots

5.

Microbiological evidence
positive blood cultures but
do not meet major criteria

roadmap
1.

Definitions

2.

Clinical symptoms

3.

Diagnosis
1.

Duke criteria

2.

Blood cultures

3.

Echocardiography

4.

Treatment basics

5.

Complications

6.

Prophylaxis

7.

Summary

Blood cultures

Always before starting antibiotics

Always triple samples aerobe, anaerobe and mycotic , 10 ml each

Three sets of samples required

roadmap
1.

Definitions

2.

Clinical symptoms

3.

Diagnosis
1.

Duke criteria

2.

Blood cultures

3.

Echocardiography

4.

Treatment basics

5.

Complications

6.

Prophylaxis

7.

Summary

Echocardiography

Transthoracic (TTE) and transoesophageal (TEE)

fundamental importance in diagnosis, management,


and follow-up

Should be performed as soon as the IE is suspected

Sensitivity of TEE is bigger than TTE (vs 90-100% vs. 4063% )

TEE is first choice to find IE complications

Echocardiography
Echocardiographic findings in IE

Vegetation

Abscess

Pseudoaneurysm

Perforation

Fistula

Valve aneurysm

Dishence of prosthetic valve

roadmap
1.

Definitions

2.

Clinical symptoms

3.

Diagnosis
1.

Duke criteria

2.

Blood cultures

3.

Echocardiography

4.

Treatment basics

5.

Complications

6.

Prophylaxis

7.

Summary

Treatment basics

Sucess relies on eradication of pathogen

Bactericidal regiment should be used

Drug choice due to pathogen

Surgery is used mainly to cope with structural


complications

Treatment basics - continued

NVE standard therapy - it takes 2-6 weeks to eradicate


the pathogen

PVE longer regime is necessery over 6 weeks

In Streptococcal IE shorter, 2 week course, can be used


when combining -laktams with aminoglycosides

Most widely used drugs amoxycylin, gentamycin

In case of -laktams alergy - vancomycin

roadmap
1.

Definitions

2.

Clinical symptoms

3.

Diagnosis
1.

Duke criteria

2.

Blood cultures

3.

Echocardiography

4.

Treatment basics

5.

Complications

6.

Prophylaxis

7.

Summary

Complications
Congestive heart failure

1.

Most common complication

Main indication to surgical treatment

~60% of IE patients

Uncontrolled infection

2.

Persisting infection

Perivalvular extension in infective endocarditis

Systemic embolism

3.

Brain, spleen and lungs

30% of IE patients

May be the first symptom

Complications - continued

5.

Neurologic events

6.

Acute renal failure

7.

Rheumatic problems

8.

Myocarditis

roadmap
1.

Definitions

2.

Clinical symptoms

3.

Diagnosis
1.

Duke criteria

2.

Blood cultures

3.

Echocardiography

4.

Treatment basics

5.

Complications

6.

Prophylaxis

7.

Summary

Prophylaxis

First and most important proper oral hygiene

Regular dental review

Antibiotics only in high-risk group patients

Prosthetic valve or foreign material used for heart repair

History of IE

Congenital heart disease

Cyanotic without correction or with residual lickeage

CHD without lickeage but up to 6 months after surgery

Use amoxycilin or ampicylin 30-60 min prior to


intervention

roadmap
1.

Definitions

2.

Clinical symptoms

3.

Diagnosis
1.

Duke criteria

2.

Blood cultures

3.

Echocardiography

4.

Treatment basics

5.

Complications

6.

Prophylaxis

7.

Summary

Summary
1.

IE is rare but serious disease, with high mortality rate

2.

Every case of fever of unknown origin should be


suspected for IE

3.

Blood cultures are essential for diagnosis

4.

TTE/TEE is the best method to monitor and follow-up


of IE

5.

Antibiotics are main treatment

6.

CHF is the most common complication

7.

Pharmacological prophylaxis is reserved for a narrow


group of high risk patients