Infective endocarditis

Diagnosis & treatment ESC 2009 guidelines

roadmap
1. Definitions, general information 2. Clinical symptoms 3. Diagnosis
1. Duke criteria 2. Blood cultures 3. Echocardiography

4. 5. 6. 7.

Treatment basics Complications Prophylaxis 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. 5. 6. 7.

Treatment basics Complications Prophylaxis 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. 5. 6. 7.

Treatment basics Complications Prophylaxis Summary

Duke criteria
Major criteria 1. Blood culture positive for typical IE-causing microorganism 2. Evidence of endocardial involvement 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. 5. 6. 7.

Treatment basics Complications Prophylaxis 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. 5. 6. 7.

Treatment basics Complications Prophylaxis 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 90100% 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. 5. 6. 7.

Treatment basics Complications Prophylaxis 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. 5. 6. 7.

Treatment basics Complications Prophylaxis Summary

Complications
1. Congestive heart failure

Most common complication Main indication to surgical treatment ~60% of IE patients Persisting infection Perivalvular extension in infective endocarditis
Brain, spleen and lungs 30% of IE patients May be the first symptom

2. Uncontrolled infection 3. Systemic embolism

Complications - continued
5. 6. 7. 8. Neurologic events Acute renal failure Rheumatic problems Myocarditis

roadmap
1. Definitions 2. Clinical symptoms 3. Diagnosis
1. Duke criteria 2. Blood cultures 3. Echocardiography

4. 5. 6. 7.

Treatment basics Complications Prophylaxis 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. 5. 6. 7.

Treatment basics Complications Prophylaxis 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