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Infective endocarditis
Diagnosis & treatment ESC 2009 guidelines
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roadmap Definitions, general information Clinical symptoms Diagnosis
Duke criteria Blood cultures Echocardiography Treatment basics Complications Prophylaxis 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/ /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
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roadmap Definitions, general information Clinical symptoms Diagnosis
Duke criteria Blood cultures Echocardiography Treatment basics Complications Prophylaxis 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, vertebral column)
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roadmap Definitions Clinical symptoms Diagnosis Treatment basics
Duke criteria Blood cultures Echocardiography Treatment basics Complications Prophylaxis Summary
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Duke criteria Major criteria Minor criteria
Blood culture positive for typical IE-causing microorganism Evidence of endocardial involvement Predisposition – heart condition or i.v. drug abuse Fever – temp. >38 °C Vascular phenomena – arterial emboli etc. Immunologic phenomena – glomerulonephritis, Osler’s nodes, Roth’s spots Microbiological evidence – positive blood cultures but do not meet major criteria Diagnosis 2 major criteria 1 major and 3 minor 5 minor criteria
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roadmap Definitions Clinical symptoms Diagnosis Treatment basics
Duke criteria Blood cultures Echocardiography Treatment basics Complications Prophylaxis 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 Definitions Clinical symptoms Diagnosis Treatment basics
Duke criteria Blood cultures Echocardiography Treatment basics Complications Prophylaxis 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 % vs % ) 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 Definitions Clinical symptoms Diagnosis Treatment basics
Duke criteria Blood cultures Echocardiography Treatment basics Complications Prophylaxis 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 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
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roadmap Definitions Clinical symptoms Diagnosis Treatment basics
Duke criteria Blood cultures Echocardiography Treatment basics Complications Prophylaxis Summary
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Complications Congestive heart failure Uncontrolled infection
Most common complication Main indication to surgical treatment ~60% of IE patients Uncontrolled infection Persisting infection Perivalvular extension in infective endocarditis Systemic embolism Brain, spleen and lungs 30% of IE patients May be the first symptom
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Complications - continued
Neurologic events Acute renal failure Rheumatic problems Myocarditis
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roadmap Definitions Clinical symptoms Diagnosis Treatment basics
Duke criteria Blood cultures Echocardiography Treatment basics Complications Prophylaxis 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 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 min prior to intervention
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roadmap Definitions Clinical symptoms Diagnosis Treatment basics
Duke criteria Blood cultures Echocardiography Treatment basics Complications Prophylaxis Summary
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Summary IE is rare but serious disease, with high mortality rate
Every case of fever of unknown origin should be suspected for IE Blood cultures are essential for diagnosis TTE/TEE is the best method to monitor and follow-up of IE Antibiotics are main treatment CHF is the most common complication Pharmacological prophylaxis is reserved for a narrow group of high risk patients
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