ENDOCARDITA INFECIOAS

Definiie
Endocardita

infecioas = prezena i

dezvoltarea de microorganisme (bacterii, fungi, chlamidii, rickettsii) la nivelul endocardului. Endarterit infecioas Endocardit trombotic nebacterian

Definiie
Leziunea caracteristic: vegetaia (mas de dimensiuni variabile, format din trombocite, fibrin, microorganisme i celule inflamatorii)

Istoric
descrieri: secolele XVII XVIII evoluia tabloului clinic dezvoltarea antibioterapiei modificarea caracterelor pacienilor
primele

Clasificare
EI acut

Clasificarea tradiional: sptmni EI acut distrugeri valvulare + metastaze EI subacut infecioase - cauz : Clasificare dup natura aparatului valvular frecvent: Staphylococcus aureus EI pe valv nativ EI subacut - toxicitate EI pe protez valvular moderat - evoluie: EI precoce (primele sptmni 2 luni -postop.) luni rar EI tardiv Etiologie metastaze infecioase - cauza: Clasificarea actual Sediul anatomic al infeciei
staphylococci

- toxicitate - evoluie: zile -

viridans, enterococci Factori destreptococci risc patogenici

Etiopatogenie
Leziunile

preexistente ale endocardului

Agenii
Factori

infecioi

de risc: manevrele care permit intrarea agenilor infecioi

Etiopatogenie
Leziunile preexistente ale endocardului
Valvulopatii reumatismale Proteze valvulare, unturi sau conducte sistemico - pulmonare Cardiopatii congenitale (! DSA; defecte corectate) CMHO PVM (+ RM) EI n antecedente indivizii cu abuz de droguri iv.

Etiopatogenie
Agenii infecioi
Streptococi (viridans, enterococi, viridans) Stafilococi (aureus, epidermidis) Bacili gram negativi Fungi (candida, aspergilus)

Etiopatogenie
Factori de risc
manevrele care permit intrarea agenilor infecioi = poarta de intrare: manevre stomatologice amigdalectomia, adenoidectomia intervenii chirurgicale pe cile respiratorii (bronhoscopia) intervenii chirurgicale pe tractul digestiv chirurgia veziculei biliare intervenii chirurgicale pe tractul urinar incizie i drenaj la nivelul unui esut infectat natere normal complicat cu infecie, histerectomie transvaginal

Fiziopatologie

EBNT
2 mecanisme majore: - injuria endotelial - status de hipercoagulare

Fiziopatologie

fixarea i multiplicarea microorganismelor:

EI subacut colonizarea unor vegetaii EBNT Conversia NBTE EI EI acut

- infecie localizat sau traumatism microorganismele infecioase n circulaie - microorganismele - capabile s persiste i s se nmulesc la nivelul endoteliului - rezisten la mecanismele de aprare ale gazdei

Fiziopatologie

Evoluia leziunilor:
efecte distructive locale (intracardiace) embolizare de material infectat (infarcte, embolii septice) reacii autoimune tip III cicatrizri, deformri

Morfopatologie
Localizarea

vegetaiilor

frecvena - presiuni abuz de droguri iv. inima dreapt leziuni de jet faa atrial valve AV; faa ventricular valve sigmoide

Morfopatologie
Morfologia

vegetaiilor:

variat vegetaii fungice abcese

Morfopatologie

Morfopatologie

Morfopatologie

Bioprotez nlturat din poziie aortic n EI cu enterococ

Tablou clinic
Debut: EI subacut insidios EI acut brutal

Poarta de intrare ?

Tablou clinic
a. semne ale infeciei sistemice

b. semne date de modificri cardiovasculare c. semne ale reaciei imune a organismului la infecie.

Tablou clinic

Tablou clinic

Tablou clinic

Tablou clinic

Examene paraclinice
A.

Probe biologice
a. Teste de laborator nespecifice (anemie, leucocitoz, trombocitopenie, trombofilie, VSH, complexe imune circulante, FR, prot C) ; funcie renal, funcie hepatic, hematurie b. Hemocultura

Examene paraclinice
B. ECG

C. Examen radiologic D. Examen ecocardiografic

E. Cateterism cardiac i cineangiografie

F. Explorri izotopice

Examen ecocardiografic

Examen ecocardiografic

Diagnostic pozitiv
Orice valvular sau cardiac congenital care prezint febr de cauz necunoscut cu durat mai mare de 7 zile trebuie serios suspectat de EI.

Diagnostic pozitiv

Diagnostic pozitiv
I. Diagnostic pozitiv definitiv EI: 2 criterii majore, sau 1 criteriu major + 3 minore, sau 5 criterii minore

Diagnostic pozitiv
II. Diagnostic posibil EI

Diagnostic pozitiv
III. Excludere diagnostic EI

Diagnostic diferenial
Diagnosticul diferenial n EI acut stri septicemice fr afectare endocardic; pneumonie; meningit; abces cerebral; accident vascular cerebral malarie; pericardit acut; coagulare intravascular diseminat.

Diagnosticul diferenial n EI subacut toi pacienii cu sindrom febril de origine necunoscut reumatismul articular acut; osteomielit; tuberculoz; meningit; infecii intraabdominale; salmoneloz; bruceloz; glomerulonefrit; infarct miocardic acut; accident vascular cerebral; mixom atrial; boli ale esutului conjunctiv; vasculite; insuficien cardiac; pericardit.

Forme clinice
1. 2. 3. 4.

5.
6. 7.

pacienii cu boli valvulare reumatismale populaia cu abuz de droguri intravenos pacienii cu proteze valvulare vrstnici (afectare degenerativ a valvelor cardiace) EI n obstetric i ginecologie EI nosocomial EI la copii

Evoluie. Complicaii. Prognostic.

EI netratat EI tratat corect EI recurent: - recdere - reinfecie

Evoluie. Complicaii. Prognostic.

Complicaii:
1. 2. 3.

4.

Insuficiena cardiac Embolia arterial Manifestri neurologice Anevrism micotic

Evoluie. Complicaii. Prognostic.

Factori de pronostic nefavorabil: - insuficiena cardiac, - insuficiena renal, - EI cu hemoculturi negative, - EI cu bacili gram-negativi, - EI fungic, - EI pe protez valvular, - dezvoltarea unui abces (miocardic, inel valvular).

Evoluie. Complicaii. Prognostic.

Factori de pronostic favorabil: - vrsta tnr, - diagnostic i tratament precoce, - EI cu streptococ sensibil la penicilin - EI cu stafilococ aureus, pe valv tricuspid, , la indivizi tineri cu abuz de droguri intravenos.

Tratament
Obiective:
1. Eradicarea infeciei microbiene 2. Tratamentul complicaiilor

Tratament
Mijloace:
I. Terapia antibiotic II. Tratamentul chirurgical III. Terapia anticoagulant IV. Tratamentul complicaiilor

Tratament
I. Terapia antibiotic
Pricipii: Ce antibiotic i n ce doz? Pe ce cale? Durat? Frecvena administrrii? Cnd se ncepe? Criterii pentru iniierea antibioterapiei. Strategie: - terapie empiric - terapie specific

Tratament
Terapia antibiotic empiric
EI pe valv nativ:
Vancomicin 15mg/kg iv. la 12 ore + Gentamicina. 1,5mg./kg: iv. la 8 ore

EI pe protez valvular:
Vancomicin + 15 mg iv. la 12 ore Rifampicin + 300-450 mg o la 8 ore Gentamicina 1,5mg./kg. iv. la 8 ore

Tratament
Terapia antibiotic specific

Tratament
II. Tratamentul chirurgical
Indicaii la pacienii cu valve native: insuficiena aortic sau mitral acut asociate cu insuficien cardiac; insuficiena aortic acut asociat cu tahicardie i nchidere prematur a valvei mitrale; endocardit fungic; existena dovezilor de abces aortic, anevrism fals sau adevrat de aort sau sinus aortic; dovezi de disfuncie valvular terapie i persistena infeciei dup 7-10 zile de tratament antibiotic corespunztor (persistena febrei, leucocitozei, bacteriemiei), fr alte cauze noncardiace pentru infecie; embolii recurente dup terapia antiinfecioas corespunztoare infecie cu bacterii gram negative sau cu rspuns slab la tratamentul antibiotic, la persoane cu disfuncie valvular; vegetaii mari, mobile, de peste 10 mm; febr i leucocitoz persitente, cu hemoculturi negative; infecie precoce a valvei mitrale, cu anse de corectare;

Tratament
II. Tratamentul chirurgical
Indicaii la pacienii protezai valvular: endocardit recent a valvei protezate (pn la 2 luni de la intervenie); insuficien cardiac i disfuncie a valvei protezate; endocardit fungic; EI cu stafilococ auriu, fr rspuns la tratamentul antibiotic; infecie cu bacterii gram negative sau cu rspuns slab la tratamentul antibiotic; persistena bacteriemiei dup 7-10 zile de tratament antibiotic, fr alte cauze noncardiace pentru infecie; embolii periferice recurente aprute n ciuda tratamentuli administrat; vegetaii pe/n apropierea protezei valvulare, indiferent de mrimea lor;

Tratament
III. Terapia anticoagulant

Tratament
IV. Tratamentul complicaiilor

Profilaxie
A.

Profilaxie primar Profilaxie secundar

B.

Profilaxie

Indicaii (pacieni cu risc crescut)

Manevre cu risc crescut

PROCEDURES FOR WHICH PROPHYLAXIS AGAINST ENDOCARDITIS ISCONSIDERED

PROPHYLAXIS RECOMMENDED Dental procedures known to induce gingival or mucosal bleeding, including professional cleaning and scaling Tonsillectomy or adenoidectomy Surgery involving gastrointestinal or upper respiratory mucosa Bronchoscopy with rigid bronchoscope Sclerotherapy for esophageal varices Esophageal dilation Gallbladder surgery Cytoscopy, urethral dilation Uretheral catheterization if urinary infection is present Urinary tract surgery, including prostate surgery Incision and drainage of infected tissue Vaginal hysterectomy Vaginal delivery complicated by infection PROPHYLAXIS NOT RECOMMENDED Dental procedures not likely to cause bleeding, such as adjustment of orthodontic appliances and simple fillings above the gum line Intraoral injection or local anesthetic Shedding of primary teeth Tympanostomy tube insertion Endotracheal tube insertion Bronchoscopy with flexible bronchoscope, with or without biopsy Cardiac catherization Gastrointestinal endoscopy, with or without biopsy Cesarean section In the absence of infection: Urethral catheterization, dilation and curettage, uncomplicated vaginal delivery, therapeutic abortion, insertion or removal of intrauterine device, sterilization procedures, laparoscopy

REGIMENS FOR PROPHYLAXIS AGAINST ENDOCARDITIS FOR USE WITH DENTAL, ORAL, AND UPPER RESPIRATORY TRACT PROCEDURES (1998)
SETTING Standard regimen REGIMEN Amoxicillin, 3.0 gm orally 1 hour before procedure; then 1.5 gm 6 hours after initial dose Erythromycinethylsuccinate, 800 mg, or erythromycin stearate, 1.0 gm, orally 2 hours before procedure then half the dose 6 hours after initial dose OR Clindamycin, 300 mg orally 1 hour before procedure and 150 mg 6 hours after initial dose Ampicillin, 2.0 gm IM or IV 30 minutes before procedure; then either ampicillin, 1.0 g IM or IV, or amoxicillin, 1.5 gm orally, 6 hours after initial dose Clindamycin, 300 mg IV 30 minutes before procedure then 150 mg 6 hours after initial dose

Regimen for amoxicillin/ penicillin- allergic patients

Regimen for patients unable to take oral medications Regimens for ampicillin/ amoxicillin/penicillin-allergic patients unable to take oral medications Regimen for patients considered at highest risk and not candidates for standard regimen Regimen for ampicillin/ amoxicillin/penicillin-allergic patients considered at highest risk

Use standard regimen for genitourinary and gastrointestinal procedures Use regimen for allergic patients undergoing genitourinary and gastrointestinal procedures

REGIMENS FOR PROPHYLAXIS AGAINST ENDOCARDITIS FOR USE WITH DENTAL, ORAL, AND UPPER RESPIRATORY TRACT PROCEDURES (2004)
SETTING Standard regimen Regimen for amoxicillin/ penicillin- allergic patients Regimen for patients unable to take oral medications REGIMEN Amoxicillin, 2.0 gm orally 1 hour before procedure; (children50mg/kg) Clindamycin 600 mg (children 20 mg/kg) or Azithromycin or Claritromycin 500 mg (children 15 mg/k) 1 hour before procedure Amoxicillin or Ampicillin, 2.0 gm IV 30 minutes befor procedure; children 50mg/kg

PROPHYLAXIS AGAINST ENDOCARDITIS: REGIMENS FOR USE WITH GENITOURINARY/GASTROINTESTINAL PROCEDURES (1998)

SETTING Standard regimen

REGIMEN Ampicillin, 2.0 gm IV plus gentamicin, 1.5 mg/kg (not to exceed 80 mg) IV or IM 30 minutes before procedure; followed by amoxicillin, 1.5 gm orally 6 hours after initial dose Alternatively, the parenteral regimen may be repeated once 8 hours after initial dose

Regimen for ampicillin/ amoxicillin/ penicillin-allergic patients

Vancomycin, 1.0 gm IV infused over 1 hour plus gentamincin, 1.5 mg/kg (not to exceed 80mg) IV or IM 1 hour before procedure; May be repeated once 8 hours after initial dose Amoxicillin, 3.0 gm orally 1 hour before procedure; then 1.5 gm 6 hours after initial dose

Alternative regimen for low-risk patient/low-risk procedure

PROPHYLAXIS AGAINST ENDOCARDITIS: REGIMENS FOR USE WITH GENITOURINARY/GASTROINTESTINAL PROCEDURES (2004)
SETTING Standard regim high risk group REGIMEN Amoxicillin or Ampicillin, 2.0 gm IV plus gentamicin, 1.5 mg/kg (not to exceed 80 mg) IV or IM with 30 minutes 1 hour before procedure; followed by amoxicillin or ampicillin, 1 gm orally 6 hours after initial dose Amoxicillin or Ampicillin, 2.0 gm IV with 30 minutes 1 hour before procedure or Amoxicillin 2g p. o. 1 hour before procedure (children 50 mg/kg); Vancomycin, 1.0 gm IV infused over 1-2 hour plus gentamincin, 1.5 mg/kg (not to exceed 80mg) IV or IM 1 hour before procedure;

Standard regim Moderate risk group

Regimen for ampicillin/ amoxicillin/ penicillin-allergic patients/ high risk group

Regimen for ampicillin/ amoxicillin/ penicillin-allergic patient/ low-risk group

Vancomycin, 1.0 gm IV infused over 1-2 hour (children 20mg/kg)

V MULUMESC