INFECTIVE ENDOCARDITIS

Nurkhalis Muchlis, MD , FIHA

DEPARTMENT OF CARDIOLOGY & VASCULAR MEDICINE
FACULTY OF MEDICINE UNIVERSITY OF SYIAH KUALA
BANDA ACEH

INTRODUCTION

Mortality rate remain as high as 20% for both

native and prosthetic valve endocarditis.
Despite improvements in health technology,
incidence of IE has not changed much
Approximately 1.7-6.2 cases per 100,000
person-years
Risk factors : cardiac structural abnormalities,
immunosuppressed status, pacemaker-related
infections, prolonged surgery, reoperation,
catheter-related bacteremia and sternal wound
infection

DEFINITION
Infection on any structure within the heart including
normal endothelial surfaces (eg, myocardium and
valvular structures), prosthetic heart valves
(eg, mechanical, bioprosthetic, homografts, and
autografts),
and
implanted
devices
(eg,
pacemakers,
Implantable cardioverter defibrillators, and
ventricular assist devices)

Clinical Presentation
Signs

and Symptoms :
* The hallmarks of IE are fever and a new
mumur (more than 85 %).
* The patient often has nonspecific
symptoms of fatigue, weight loss, malaise,
chills, night sweats, and/or musculoskeletal
aches

CRITERIA THAT SHOULD RAISE

SUSPICION OF IE

High clinical suspicion (urgent indication for echocardiographic

screening and possibly hospital admission)

New valve lesion/(regurgitant) murmur

Embolic events of unknown origin (esp. cerebral and renal infarction)
Sepsis of unknown origin
Haematuria, glomerulonephritis, and suspected renal infarction
Fever plus

Prosthetic material inside the heart

Other high predispositions of IE
Newly developed ventricular arrhythmias or conduction disturbances
First manifestation of chronic heart failure
Positive blood cultures (if the organism identified is typical for NVE/PVE)
Cutaneous (Osler, janeway) or ophthalmic (roth) manifestations
Multifocal/rapid changing pulmonary infiltrations (right heart IE)
Peripheral abscesses (renal, spienic, spine) of unknown origin
Predisposition and recent diagnostic/therapeutic interventions known to
result in significant bacteraemia

Low Clinical Suspicion

Fever plus none of the above

Modified Duke Criteria for the

Diagnosis of IE
MAJOR CRITERIA
1. Positive blood culture for IE
Typical microorganism consistent with IE from 2 separate blood
cultures :

Streptococcus viridans, Streptococcus bovis, or HACEK group, or

Staphylococcus aureus or community-acquired enterococci, in the
of a primary focus
Microorganisms consistent with IE from persistently positive blood
cultures defined as :
at least 2 positive cultures of blood samples drawn >12 hours apart or
all of 3 or a majority of 4 separate cultures of blood (with first and
last sample drawn at least 1 hour apart
Single positive blood culture for Coxiella burnetti or anti-phase1 IgG
antibody titer > 1:800
HACEK: Haemophylus aphrophilus, Actinobacillus actinomycetemtemcomitens, Cardiobacterium hominis, Eikenella corrodens, Kingella
kingae

Circulation 1998;98;2936-2948
Circulation 2005;111;e394-e433
5

Modified Duke Criteria for the

Diagnosis of IE
MAJOR CRITERIA
2. Evidence of endocardial involvement
A. Positive echocardiogram for IE
TEE recommended for: patient with prosthetic valves; at least possible IE
by clinical criteria, or complicated IE; TTE as first test in other patients
defined as
(i) oscillating intracardiac mass on valve or supporting structures, in the
path of regurgitant jets, or on implanted material in the absence of an
alternative anatomic explanation, or
(ii) abscess, or
(iii) new partial dehiscence of prosthetic valve, or
B. New valvular regurgitation (worsening or changing of preexisting
murmur not sufficient)
Circulation 1998;98;2936-2948
Circulation 2005;111;e394-e433 7

Modified Duke Criteria for the

Diagnosis of IE
1.
2.
3.

4.
5.

6.

Predisposition,
predisposing
heart condition, or IDU
Minor
Duke
Criteria
Fever, temperature > 38o C
Vascular phenomena, major arterial emboli, septic
pulmonary infarcts, mycotic aneurysm, intracranial
hemorrhage, conjunctival hemorrhages and Janeways
lesions
Immunologic phenomena: glomerulonephritis, Oslers
node, Roths spot and rheumatoid factor
Microbiological evidence: positive blood culture but
does not meet a major criterion as noted above or
serological evidence of active internal infection with
organism consistent with IE
Non specific echocardiographic findings omitted

DIAGNOSIS IE
Endophtalmitis

Macula irregular erythematous tak nyeri, 1-4mm,

di thenar/ hypothenar
tangan/ kaki vasculitis

Retinal hemorrhages
with pale centers
Immune-mediated
vasculitis

Janeway lesion

Nodul kecil, lunak, merahungu, di terminal falangs

jari tangan/kaki, telapak
kaki, thenar/hypothenar
tangan Immunemediated vasculitis

Roths spot

Osler node

Diagnosis of IE According to Modified Duke Criteria

DEFINITE
Pathological criteria

Microorganisms: demonstrated by culture or histology in a vegetation,

or in an intracardiac abscess, or
Pathological lesions: vegetation or intracardiac abscess confirmed by
histology

Clinical criteria
2 major criteria, or
1 major + 3 minor criteria, or
5 minor criteria
POSSIBLE

Findings consistent with IE that fall short of Definite but not Rejected
1 major criterion + 1 minor criterion; or 3 minor criteria

REJECTED

Firm alternate diagnosis for IE, or

Resolution of manifestations of IE with antibiotic therapy for < 4 days, or
No pathological evidence of IE at surgery or autopsy, after antibiotic
therapy for < 4 days
Does not meet criteria for possible IE as above

11
Circulation 2005;111;e394-e433

Culture-negative endocarditis

Proportion of CNE: 1-55 %

Five main cause of CNE:

Fastidious growing bacteria; HACEK group, Coxiella

burnetti, Bartonella sp
Non bacterial organism; namely fungi
Antibiotic administration preceding culture
Right-sided endocarditis
Endocarditis in patient with permanent pacemaker

Further investigation in CNE: serological testing,

histological techniques, molecular techniques
(PCR)

COMPLICATION
Embolic Events :
Most common & predictor of death
Higher prevalence in cerebral than peripheral
Increased risk of emboli in:

Infection of staphylococci, enterococci, HACEK, fungi

Vegetation: 10 mm, mobile, low density, rapid
growth
IE in Mitral valve
Early course of IE

Embolic Signs

COMPLICATION
CARDIAC FAILURE
Acute

regurgitation, myocarditis
Has greatest impact in prognosis
Acute aortic regurgitation has worse clinical
tolerance than mitral & tricuspid
Should undergo surgery. Delay should be
discouraged.
Poor outcome for surgery, but better than
medical therapy alone

COMPLICATION
ACUTE RENAL FAILURE
Due

to

Immune complex glomerulonephritis

Hemodynamic instability
Renal infarct / emboli
Drug toxicity

Treatment

depends on clinical
Usually reversible

COMPLICATION
PERIANNULAR EXTENSION OF INFECTION
Predict

death, CHF and need of surgery

Can manifest as

Perivalvular abscess (usually in PVE)

Arrhytmia or conduction disturbance (aortic
NVE)
Fistula, pseudoaneurysm
Obstructive lesion

More

frequent in PVE and aortic NVE

COMPLICATION
MYCOTIC ANEURYSM
Uncommon
Result

from septic embolization of

vegetations to arterial vasa vasorum or
intraluminal space
Intracranial MA is more frequent than
extracranial MA (visceral and extremities)

ANTIMICROBIAL THERAPY

If initiation of antimicrobial therapy is urgent,

empiric antibiotic treatment can be started
thereafter (blood culture)
In all other cases it is recommended to postpone therapy until blood cultures become
positive.

Previous short term antibiotic discontinue for

at least 3 day before taking blood cultures.

Previous long term antibiotic treatment

discontinue for 6 - 7 days.
ESC guideline; European Heart J 2004

Antimicrobial Therapy for Native Valves

BAKTERIAL

SUSCEPTIBLE /
RESISTANT

Durati
on

REGIMEN

DOSAGE & ROUTE

Penicillin G Sodium

1218 million U/24 h IV either continuously or

in 4 or 6 equally divided doses

4 wk

Ceftriaxone Sodium*
+ Gentamicin

2 g/24 h IV/IM in 1 dose

+ 3 mg/kg per 24 h IV/IM in 1 dose

4 wk
2 wk

Vancomycin HCl

30 mg/kg per 24 h IV in 2 equally divided dose

4 wk

Penicillin G Sodium

24 million U/24 h IV either continuously or in

46 equally divided doses

4 wk

Ceftriaxone Sodium
+ Gentamicin

2 g/24 h IV/IM in 1 dose +

3 mg/kg per 24 h IV/IM in 1 dose

2 wk

Vancomycin HCl

30 mg/kg per 24 h IV in 2 equally divided dose

4 wk

Nafcillin or oxacillin

12 g/24 h IV in 46 equally divided doses

6 wk

Optional addition of
gentamicin

3mg/kg/24h IV/IM in 2-3 equally divided doses

3-5 d

Cefazolin

6 g/24 h IV in 3 equally divided doses

6 wk

Optional addition of
gentamicin

3 mg/kg/24 h IV/IM in 2-3 equally divide doses

3-5 d

Vancomycin HCl

30 mg/kg/ 24 h IV in 2 equally divided doses

6 wk

Streptococcus
viridan

Penicillin susceptible

Streptococcus
bovis
Streptococcus
viridan

Relatively Penicillin
Resistant

Streptococcus
bovis

Staphylococci

Oxacillin-susceptible
strains

For penicillin allergic

Oxacillin-resistant strains

* Ceftriaxone alone could be administrated for 4 weeks instead of Penicillin G

14

Circulation 2005;111;e394-e433

Antimicrobial Therapy for Prosthetic Valves

BAKTERIAL

SUSCEPTIBLE /
RESISTANT

DOSAGE & ROUTE

Duration

Penicillin G Sodium

24 million U/24 h IV either continuously or in 4 or 6

equally divided doses

6 wk

Ceftriaxone Sodium +
Gentamicin

2 g/24 h IV/IM in 1 dose +

3 mg/kg per 24 h IV/IM in 1 dose

Vancomycin HCl

30 mg/kg.24 h IV in 2 equally divided dose

6 wk

Penicillin G Sodium

24 million U/24 h IV either continuously or in 46

equally divided doses

6 wk

Ceftriaxone Sodium +
Gentamicin

2 g/24 h IV/IM in 1 dose +

3 mg/kg per 24 h IV/IM in 1 dose

6 wk

Vancomycin HCl

30 mg/kg/24 h IV in 2 equally divided dose

6 wk

Nafcillin or oxacillin +
Rifampin

12 g/24 h IV in 6 equally divided doses +

900 mg/24 h IV/PO in 3 equally divided doses

> 6 wk

Gentamicin

3 mg/kg/24 h IV/IM in 2 or 3 equally divide dose

2 wk

Vancomycin +
Rifampin

30 mg/kg/24 h IV in 2 equally divided doses +

900 mg/24 h IV/PO in 3 equally divided doses

> 6 wk

Gentamicin

3 mg/kg per 24 h IV/IM in 2 or 3 equally divide

doses

REGIMEN

Streptococ
viridan

Penicillin susceptible

Streptococ
bovis
Streptococ
viridan

Relatively Penicillin
Resistant

Streptococ
bovis
Staphylococci

Oxacillin-susceptible

Oxacillin-resistant strains

15

6 wk +
2 wk

2 wk

Circulation 2005;111;e394-e433

Antimicrobial Therapy for Native or Prosthetic Valves

Bacterial

Entero cocci

Susceptible/Resistant
Penicillin, Genytamycin,
Vancomycin Susceptible

Regimen

Duration

Ampicillin sodium

12 g/24 h IV in 6 equally divided doses

4-6 wk

Penicilin G
sodium+Gentamicin

1830 million U/24 h IV either continuously or in 6 equally divided

doses+3 mg/kg per 24 h IV/IM in 3 equally divided doses

4-6 wk

Vancomycin+Gentamicin

30 mg/kg per 24 h IV in 2 equally divided doses+3 mg/kg per 24 h IV/IM in

3 equally divided doses

6 wk

Penicillin, Streptomycin,

Ampilin sodium

12 g/24 h IV in 6 equally divided doses

4-6 wk

Vancomycin Susceptible,

Penicillin G +Streptomycin

24 million U/24 h IV continuously or in 6 equally in divided doses+15

mg/kg per 24 h IV/IM in 2 equally divided

4-6 wk

Vancomicin+Streptomycin

30 mg/kg per 24 h IV in 2 equally divided doses+15 mg/kg per 24 h IV/IM

in 2 equally divided doses

6 wk

Vancomycin, aminoglycoside
Susceptible, Penicillin
Resistant

AmpicillinSulbactam+Gentamicin

12 g/24 h IV in 4 equally divided doses+3 mg/kg per 24 h IV/IM in 3

equally divided doses

6 wk

Intrinsic Penicillin resistant

Vancomycin+Gentamicin

30 mg/kg per 24 h IV in 2 equally divided doses+3 mg/kg per 24 h IV/IM in

3 equally divided doses

6 wk

Penicillin,
Aminoglycoside,Vancomycin
Resistant E faecium

Linazolid

1200 mg/24 h IV/PO in 2 equally divided doses

> 8 wk

Quinupristin-dalfopristin

22.5 mg/kg per 24 h IV in 3 equally divided doses

> 8 wk

Imipenem/cilastatin+Ampicillin

2 g/24 h IV in 4 equally divided doses+12 g/24 h IV in 6 equally divided

doses

> 8 wk

Ceftriaxone Sodium +
Ampicillin

2 g/24 h IV/IM in 1 dose+12 g/24 h IV in 6 equally divided doses

8 wk

Gentamicin Resistant

Penicillin,
Aminoglycoside,Vancomycin
Resistant E faecalis

16

Dosage and route

Circulation 2005;111;e394-e433

Antimicrobial Therapy for Native or Prosthetic Valves

REGIMEN
HACEK

DOSAGE & ROUTE

DURATION

Ceftriaxone sodium

2 g/24 h IV/IM in 1 dose

4 wk

Ampicillin- sulbactam

12 g/24 h IV in 4 equally divided doses

4 wk

Ciprofloxacin

1000 mg/24 h PO or 800 mg/24 h IV in 2

4 wk

Anti Bacterial Therapy for Culture negative

BACTERIA

Culture
Negative

Culture
Negative

17

VALVES

Native Valve

Prosthetic
Valve

REGIMEN

DOSAGE & ROUTE

DURATION

Ampicillin-sulbactam +
Gentamicin

12 g/24 h IV in 4 equally divided doses+

3mg/kg/24 h IV/IM in 3 equally divided doses

4-6 wk

Vancomycin +
Gentamicin

30 mg/kg/24 h IV in 2 equally divided doses+

3 mg/kg/24 h IV/IM in 3 equally divided doses

plus ciprofloxasin

1000 mg/24 h PO or 800 mg/24 h IV in 2 equally

divided doses

Vancomycin +
Gentamicin

30 mg/kg/24 h IV in 2 equally divided doses+

3 mg/kg/24 h IV/IM in 3 equally divided doses

6 wk
2 wk

plus Cefepim +
Rifampin

6 g/24 h IV in 3 equally divided doses+900 mg/24

h PO/IV in 3 equally divided doses

6 wk

4-6 wk
4-6 wk

Circulation 2005;111;e394-e433

Cardiac condition in Which

Antimicrobial Prophylaxis is Indicated

High Risk

Prosthetic heart valves

Complex congenital cyanotic heart diseases
Previous infective endocarditis
Surgically constructed systemic or pulmonary
conduits

Moderate Risk

Acquired valvular heart disease

Mitral valve prolapse with valvular regurgitation or
severe valve thickening
Non-cyanotic congenital heart diseases (except for
secundum type Atrial Septal Defect) including
bicuspid aortic valves
Hypertrophic cardiomyopathy

Predisposing diagnostic and therapeutic

interventions

Procedure which may cause bacteraemia and for which

antimicrobial prophylaxis is recommended
Diagnostic and therapeutic interventions likely to produce
bacteraemia

Bronchoscopy (rigid instrument)

Cystoscopy during urinary tract infection
Biopsy of urinary tract/prostate
Dental procedures with the riak of gingival/mucosal trauma
Tonsillectomy and adenoidectomy
Oesophageal dilatation/ sclerotherapy
Instrumentation of obstructed biliary tracts
Transurethral resection of prostate
Urethral instrumentation/ dilation
Lithotripsy
Gynaecologic procedures in the presence of infection

Regimens for a Dental Procedure

Regimen:
Situation

Agent

Single Dose 30 to 60 minute

Before Procedure
Adults

Children

Amoxicillin

2g

50 mg/kg

Ampicillin or
Cefazolin or Ceftriaxone

2 g IM or IV
1 g IM or IV

50 mg/kg IM or IV
50 mg/kg IM or IV

Allergic to Penicillin
or Ampicillin oral

Cephalexin* or
Clindamycin or
Azithromycin or
Clarithromycin

2g
600 mg
500 mg

50 mg/kg
20 mg/kg
15 mg/kg

Allergic to Penicillin
or Ampicillin and
unable to take oral
medicine

Cefazolin or Ceftriaxone
or
Clindamycin

1 g IM or IV
600 mg IM or IV

50 mg/kg IM or IV
20 mg/kg IM or IV

Oral
Unable to take oral
medicine

IM - intramuscular; IV - intravenous. *Or other first- or second- generation oral cephalosporin in

equivalent adult or pediatric dosage. Cephalosporins should not be used in an individual with a
history of anaphylaxis, angioedema, or urticaria with penicillins or ampicillin.
19

Guidelines From the American Heart Association. Published online Apr 19, 2007

Conclusion

IE often presents in an occult fashion, and early

diagnosis depends on a high index of clinical suspicion,
especially in patient at high risk groups

Latest modification on the widely used Duke criteria

include: recognizing the role of serological testing to
diagnose IE and the exclusion of non-specific
echocardiographic findings as a minor criteria

Molecular techniques to diagnose IE have been

introduced (PCR) and are waiting further validation for its
routine use

THANK YOU

Optimal techniques for blood culture

Avoid contamination: - optimal antiseptic skin preparation
- fresh venepuncture, not through indwelling vascular
access
Optimal timing: - no evidence suggest that cultures should be taken coincident with
peak temperature, as the bacteremia is constant
- acute endocarditis: 2-3 cultures from separate venepunctures
within 5 min of each other, prior to antibiotics
- subacute endocarditis; several cultures obtained over several
hours
Incubation; - most clinically important pathogens from blood culture are
recovered by 5 days, including the fastidious organisms
- it is better to subculture the negative samples onto enriched solid
media rather than extend it for 2-3 weeks

DIAGNOSIS IE

Sometimes difficult ?
SULIT pada kondisi :
echocardiography normal atau meragukan
IE mengenai intracardiac devices
kultur darah negatif
Echo negatif
+ 15% of cases of IE vegetasi kecil/(-)
sulit mengidentifikasi vegetasi pd lesi berat (katup
prostetik, lesi degeneratif)
Kesalahan diagnosis IE pada keadaan:

Sulit membedakan vegetasi dg. trombi, prolaps cusp,

tumor,
myxoma, vegetasi non infectif (marantic endocarditis)
Habib G, Heart 2006;92:124130.

The Use of Echocardiography During Dx and Rx of IE

Early
Echo as soon as possible (<12h after initial evaluation)
TTE preferred; obtain TTE view of any abnormal findings
TTE if TEE is not immediately available
TTE may be sufficient in small children

Repeat
TEE after positive TTE as soon as possible in high risk patients
TEE 7-10 days after initial TEE if suspicion exist

Intraoperative
Identification of vegetations, mechanism of regurgitation,
abscesses, fistula, pseudoaneurysms; confirmation of successful
repair; assessment of residual valve dysfunction

Completion of therapy
Establish new baseline for valve function and morphology;
ventricular size and function
9

Circulation 2005;111;e394-e433

Blood Culture Sampling & Treatment

If initiation of antimicrobial therapy is urgent,

empiric antibiotic treatment can be started
thereafter (blood culture). In all other cases it is
recommended to post-pone therapy until blood
cultures become positive.

If the patients has been on short term antibiotic,

one should be wait, if possible, for at least 3 day.

Long term antibiotic treatment may not become

positive until treatment has been discontinued for
6 - 7 days.

Conflicting data: artery vs. venous; high fever vs.

constant bacteraemia.

5-15% of cases are culture negative endocarditis,

the most frequent cause is previous
antimicrobial
ESC guideline; European Heart J 2004;00, 1-37 6
treatment.

ECHOCARDIOGRAPHY

Any patient suspected of having Native Valve Endocarditis (NVE) by

clinical criteria should be screened by Transthoracic
Echocardiography (TTE).

When images are of good quality and prove to be negative and

there is only a low clinical suspicion of IE, endocarditis is unlikely
and other diagnosis are to be considered.

If suspicion of IE is high, TransEsophageal Echocardiography (TEE)

should be performed in all TTE-negative cases, in suspected
Prosthetic Valve Endocarditis (PVE), and if TTE is positive but
complications are suspected or likely and before cardiac
surgery during active IE.

If TEE remains negative and there is still suspicion, it should be

repeated within one week. A repeatedly negative study should
virtually exclude the diagnosis.

 Three

echocardiographic findings are

considered to be major critetria in the
diagnosis of IE:

A mobile, echodense mass attached to the

valvular or the mural endocardium or to
implanted prosthetic material
Demonstration of abscesses or fistulas
A new dehiscence of a valve prosthesis,
especially when occurring late after
implantation

New from AHA for IE prophylaxis

Bacteremia from daily activities (chewing food,

tooth brushing and flossing, use of wooden
toothpicks, use of water irrigation devices) is
much more likely to cause IE than a dental
procedure

Extremely small number of IE might be

prevented by antibiotic prophylaxis, even if
prophylaxis is 100% effective

AHA guideline: Prevention of Infective Endocarditis. Circulation 2007;115

 Limit

prophylaxis only to conditions with

high adverse outcome from endocarditis

Maintenance

of optimal oral health and

hygiene may reduce the incidence of
bacteremia from daily activities and is
more important than prophylactic
antibiotics
AHA guideline: Prevention of Infective Endocarditis. Circulation 2007;115

Masalah yang dihadapi setelah diagnosis:

1) Dx IE sulit kerusakan katup progresif & irreparable
2) IE sering mengakibatkan kematian di RS (1625%),
kejadian emboli (1049%) komplikasi & sequelae
3) strategi terapi perlu ditetapkan, mungkin individual
4) beberapa pasien mungkin disertai komplikasi spesifik
manajemen spesifik
5) Operasi diperlukan pada + 50% kasus.
Kalau pasien stabil operasi ditunda sampai terapi
antibotik selesai untuk mencegah prosthetic valve
endocarditis yang terjadi dini
12

OPERASI SEGERA BILA :

Hemodinamik memburuk akibat kerusakan katup

Demam menetap meski telah mendapat antibiotik
Terbentuk abses/fistula ok invasi infeksi perivalvar
Organisme penyebab resisten (aggressive
staphylococcal strains, Coxiella burnetti, Brucella
species, fungi)
Prosthetic valve endocarditis (t.u. segera postop)
Vegetations besar yg berpotensi terjadi emboli
( > 10 mm atau melekat pada katup mitral)
13

An approach to diagnosis of IE with echocardiography

AHA Scientific Statement, 2005

CLASSIFICATION
Old

clasiffication: acute/subacute/chronic
Present classification, based on:

Activity and recurrence

Diagnostic status
Pathogenesis
Anatomical site
Microbiology

ESC Guidelines of IE. EHJ 2004; 25: 267 276

Classification based on ACTIVITY

and RECURRENCE
Activity

related to surgery
Active IE : if diagnosis of IE 2 months
before surgery
Recurrent IE: IE develops after had been
eradicated
Persistent IE: IE has never been
eradicated
ESC Guidelines of IE. EHJ 2004; 25: 267 276

Classification Based on DIAGNOSIS

Established

IE: clinically and involvement of

endocardium is established
Suspected IE: clinical strongly suspected,
but no evidence of endocardium
involvement
Possible IE: potential differential diagnosis

ESC Guidelines of IE. EHJ 2004; 25: 267 276

Classification based on
PATHOGENESIS
Native

valve endocarditis (NVE)

Prosthetic valve endocarditis (PVE)

IE

Early PVE (<1 year since surgery)

Late PVE (>1 year since surgery)

in iv drug abuse (IE in IVDA)

ESC Guidelines of IE. EHJ 2004; 25: 267 276

Classification bassed on ANATOMIC

LOCATION
Right

side IE
Left side IE
Specific anatomical site (mitral, aortic,
mural, etc)

ESC Guidelines of IE. EHJ 2004; 25: 267 276

Classification based on
MICROBIOLOGY
Culture,

serological test, histological

and/or molecular biology (PCR)
Culture negative, serological
negative, histological negative, and/or
PCR negative
If all negative microbiologically
negative
ESC Guidelines of IE. EHJ 2004; 25: 267 276

Surgery In PVE
Early

PVE ( less than 12 months after

surgery)
Late PVE with complication, particularly if
staphylococci are the infecting organism
Postoperative antibiotic treatment
Full course of antimicrobial treatment should be
completed regardless duration treatment prior
to surgery

ECHOCARDIOGRAPHY

Major Duke Criteria

1.
-

Blood culture positive for IE

Typical microorganism consistent with IE from 2
separate blood cultures: viridans streptococci,
Streptococcus bovis, HACEK group, Staphylococcus
aureus or community acquired enterococci in the absence
of a primary focus; or
Microorganism consistent with IE from persistently
positive blood cultures defined as follows; At least 2
positive cultures of blood samples drawn > 12 hours
apart; or all of 3 or a majority of > 4 separate cultures of
blood (with first and last sample drawn at least 1 h apart)
Single positive blood culture for Coxiella burnetti or
anti-phase 1 IgG ntibody titer > 1:800

2.

Evidence of endocardial involvement

Echocardiogram positive for IE, defined as follows:
- oscillating intracardiac mass on valve or supporting
structures, in the path of regurgitant jets, or on implanted
material in the absence of an alternative anatomic
explanation
- or abcess
- or new partial dehiscence of prosthetic valve
- or new valvular regurgitation

MANAGEMENT OF COMPLICATIONS

Rapid and effective antimicrobial treatment may help

to prevent embolism.
If the patients is on longterm oral anticoagulation,
coumarin therapy should be discontinued and replaced
by heparin immediately after the diagnosis of IE has
been established
After an embolic complication, the risk for recurrent
episodes is high. After manifestation of a cerebral
embolism, cardiac surgery to prevent a recurrent
episode is not contraindicated if performed early (best
within 72 hours) and cerebral haemorrhage has been
excluded by cranial computed tomography immediately
before the operation.
If surgery is not performed early it is advisable to be
postponed for 3-4 weeks

Infective Endocarditis (IE)

a rising problem
Insidens IE terus meningkat
di AS terdapat + 20.000 kasus baru pertahun
Berisiko tinggi terjadi morbiditas & mortalitas

(gagal jantung & emboli)

Terus berkembang dalam hal:
risiko tinggi, prosedur diagnostik,
jenis mikro-organisme penyebab dan terapi
Diperlukan :
DIAGNOSIS CEPAT & TEPAT, TERAPI EFEEKTIF,
PENGENALAN KOMPLIKASI SEGERA
Circulation 1998;98;2936-2948, Circulation 2005;111;e394-e433

IE IN INTRAVENOUS DRUG USER

(IVDU)
Most

common: S aureus *, **
MRSA had been emerging (60-70% in
Europe)**
Other organisms: P aeruginosa, Candida,
enterococci, streptococci *, **
Polymicrobial infection 5-10% **

* AHA guidelines IE. Circulation 2005;111;e394-e433

** ESC guidelines Infective Endocarditis 2004

Proposed scheme for the pathogenesis of infective

endocarditis

Mandell, Bennett, & Dolin:

Principles and Practice of Infectious Diseases, 6t

IE PREVENTION
American Heart Association Guidelines (2007)
1) IE prophylaxis in dental procedures for patients with underlying
cardiac conditions associated with the highest risk of adverse
outcome from IE
2) IE prophylaxis is for all dental procedures (manipulation of gingival
tissue or the periapical region of teeth) or perforation of the oral
mucosa, and for procedures on respiratory tract or infected skin,
skin structures, or musculoskeletal tissue.
3) Prophylaxis is not recommended based solely on an increased
lifetime risk of acquisition of IE
4) Antibiotics solely to prevent IE is not recommended for patients
who undergo a genitourinary or gastrointestinal tract procedure.
The writing group reaffirms the procedures noted in the 1997
prophylaxis guidelines for which endocarditis prophylaxis is not
recommended and extends this to other common procedures,
including ear and body piercing, tattooing, and vaginal delivery and
hysterectomy.
Guidelines From the American Heart Association. Published online Apr 19, 2007

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