Infective endocarditis

Diagnosis & treatment

Cholid Tri Tjahjono, dr. SpJP

roadmap

1.1. DefinitionsDefinitions, general information, 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 Infective endocarditis

inflammatory process on-going inside endocardium

due to infection after endothelium damage

most often involving aortic and mitral valves

Definitions, general information - continuedAcording to localisation 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

AAcording to the mode of acquisitioncording 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

2.2. Clinical symptomsClinical 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

1.1. Duke criteriaDuke criteria

2. Blood cultures

3. Echocardiography

4. Treatment basics

5. Complications

6. Prophylaxis

7. Summary

Duke criteria

Major criteria1. Blood culture positive for

typical IE-causing microorganism

2. Evidence of endocardial involvement

Minor criteria1. Predisposition – heart

condition or i.v. drug abuse

2. Fever – temp. >38 °C

3. Vascular phenomena – arterial emboli etc.

4. Immunologic phenomena – glomerulonephritis, Osler’s nodes, Roth’s 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

2.2. Blood culturesBlood 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

3.3. EchocardiographyEchocardiography

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 IEEchocardiographic 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

4.4. Treatment basicsTreatment 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 β-laktams with aminoglycosides

Most widely used drugs – amoxycylin, gentamycin

In case of β-laktams alergy - vancomycin

roadmap

1. Definitions

2. Clinical symptoms

3. Diagnosis

1. Duke criteria

2. Blood cultures

3. Echocardiography

4. Treatment basics

5.5. ComplicationsComplications

6. Prophylaxis

7. Summary

Complications

1.1. Congestive heart failureCongestive heart failure

• Most common complication

• Main indication to surgical treatment

• ~60% of IE patients

2.2. Uncontrolled infectionUncontrolled infection

• Persisting infection

• Perivalvular extension in infective endocarditis

3.3. Systemic embolismSystemic embolism

• Brain, spleen and lungs

• 30% of IE patients

• May be the first symptom

Complications - continued

5.5. Neurologic eventsNeurologic events

6.6. Acute renal failureAcute renal failure

7.7. Rheumatic problemsRheumatic problems

8.8. MyocarditisMyocarditis

roadmap

1. Definitions

2. Clinical symptoms

3. Diagnosis

1. Duke criteria

2. Blood cultures

3. Echocardiography

4. Treatment basics

5. Complications

6.6. ProphylaxisProphylaxis

7. Summary

Prophylaxis

First and most important – proper oral hygieneproper oral hygiene

Regular Regular dental reviewdental 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

7.7. SummarySummary

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