Infective

Endocarditis
DIAGNOSIS & TREATMENT
ESC 2009 GUIDELINES
Bambang Widyantoro
2 Desember 2014

roadmap

1.

Definitions, general information, pathophysiology

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

Pathogenesis

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

Relapse

Reinfection

Definitions, general information

- continued
3-10/100

000/year

Maximum
More

at the age of 70-80

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
Major criteria

Minor criteria

1.

Blood culture positive for typical

IE-causing microorganism

1.

Predisposition heart
condition or i.v. drug abuse

2.

Evidence of endocardial
involvement

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

Diagnosis
2 major criteria
1 major and 3 minor
5 minor 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. 40-63% )

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