Infective Endocarditis ESC 09

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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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- 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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- 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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- continued

Active IE

Recurrence Relpse

Reinfection


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- 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


3. Diagnosis


3. Echocardiography

4. Treatment basics


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


3. Diagnosis


3. Echocardiography

4. Treatment basics


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


3. Diagnosis


3. Echocardiography

4. Treatment basics


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


3. Diagnosis


3. Echocardiography

4. Treatment basics


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


3. Diagnosis


3. Echocardiography

4. Treatment basics


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


3. Diagnosis


3. Echocardiography

4. Treatment basics


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


3. Diagnosis


3. Echocardiography

4. Treatment basics


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


3. Diagnosis


3. Echocardiography

4. Treatment basics


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

Infective Endocarditis ESC 09

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