infective endocarditis esc 09
TRANSCRIPT
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Infective endocarditis
Diagnosis & treatment
ESC 2009 guidelines
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roadmap
1. Definitions, general information
2. Clinical symptoms
3. Diagnosis
1. Duke criteria2. Blood cultures
3. Echocardiography
4. Treatment basics
5. Complications6. Prophylaxis
7. Summary
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Definitions, general information
Infective endocarditis
inflammatory process on-going inside endocardium
due to infection after endothelium damage
most often involving aortic and mitral valves
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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)
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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
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Definitions, general information
- continued
Active IE
Recurrence Relpse
Reinfection
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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
StreptococcalIE is still the most commonin developing countries
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roadmap
1. Definitions, general information
2. Clinical symptoms
3. Diagnosis
1. Duke criteria2. Blood cultures
3. Echocardiography
4. Treatment basics
5. Complications6. Prophylaxis
7. Summary
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Clinical symptoms
Fever over 90% of patients
New intra-cardiac murmur - about 85% of
patients
Roth spots, petechiae, glomerulonephritis
up to 30% of patients
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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, vertebralcolumn)
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roadmap
1. Definitions
2. Clinical symptoms
3. Diagnosis
1. Duke criteria2. Blood cultures
3. Echocardiography
4. Treatment basics
5. Complications6. Prophylaxis
7. Summary
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Duke criteria
Major criteria
1. Blood culture positive for
typical IE-causing
microorganism2. Evidence of endocardial
involvement
Minor criteria
1. Predisposition heartcondition or i.v. drug abuse
2. Fever temp. >38 C
3. Vascular phenomenaarterial emboli etc.
4. Immunologic phenomena glomerulonephritis, Oslersnodes, Roths spots
5. Microbiological evidencepositive blood cultures but donot meet major criteria
Diagnosis 2 major criteria
1 major and 3 minor
5 minor criteria
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roadmap
1. Definitions
2. Clinical symptoms
3. Diagnosis
1. Duke criteria2. Blood cultures
3. Echocardiography
4. Treatment basics
5. Complications6. Prophylaxis
7. Summary
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Blood cultures
Always before starting antibiotics
Always triple samples aerobe, anaerobe and
mycotic , 10 ml each
Three sets of samples required
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roadmap
1. Definitions
2. Clinical symptoms
3. Diagnosis
1. Duke criteria2. Blood cultures
3. Echocardiography
4. Treatment basics
5. Complications6. Prophylaxis
7. Summary
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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
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Echocardiography
Echocardiographic findings in IE
Vegetation
Abscess
Pseudoaneurysm
Perforation
Fistula
Valve aneurysm
Dishence of prosthetic valve
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roadmap
1. Definitions
2. Clinical symptoms
3. Diagnosis
1. Duke criteria2. Blood cultures
3. Echocardiography
4. Treatment basics
5. Complications6. Prophylaxis
7. Summary
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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
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Treatment basics - continued
NVE standard therapy - it takes 2-6 weeks toeradicate the pathogen
PVE longer regime is necessery over 6 weeks
In Streptococcal IE shorter, 2 week course, canbe used when combining -laktams withaminoglycosides
Most widely used drugs amoxycylin,gentamycin
In case of-laktams alergy - vancomycin
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roadmap
1. Definitions
2. Clinical symptoms
3. Diagnosis
1. Duke criteria2. Blood cultures
3. Echocardiography
4. Treatment basics
5. Complications6. Prophylaxis
7. Summary
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Complications
1. Congestive heart failure Most common complication
Main indication to surgical treatment
~60% of IE patients
2. Uncontrolled infection Persisting infection
Perivalvular extension in infective endocarditis
3. Systemic embolism
Brain, spleen and lungs 30% of IE patients
May be the first symptom
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Complications - continued
5. Neurologic events
6. Acute renal failure7. Rheumatic problems
8. Myocarditis
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roadmap
1. Definitions
2. Clinical symptoms
3. Diagnosis
1. Duke criteria2. Blood cultures
3. Echocardiography
4. Treatment basics
5. Complications6. Prophylaxis
7. Summary
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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 heartrepair
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 tointervention
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roadmap
1. Definitions
2. Clinical symptoms
3. Diagnosis
1. Duke criteria2. Blood cultures
3. Echocardiography
4. Treatment basics
5. Complications6. Prophylaxis
7. Summary
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Summary
1. IE is rare but serious disease, with high mortality rate
2. Every case of fever of unknown origin should besuspected for IE
3. Blood cultures are essential for diagnosis4. TTE/TEE is the best method to monitor and follow-upof IE
5. Antibiotics are main treatment
6. CHF is the most common complication7. Pharmacological prophylaxis is reserved for a narrow
group of high risk patients