AHA Guidelines for the diagnosis, antimicrobial therapy,and management of complications of infective Endocarditis 2005 AHA Guidelines for

the prevention of infective endocarditis 2007 ESC 2009 guidelines Ahmad Yasa

1. 2. 3.

4.

5.
6. 7.

Definitions, general information Clinical symptoms Diagnosis 1. Duke criteria 2. Blood cultures 3. Echocardiography Treatment basics Complications Prophylaxis Summary

Infective endocarditis inflammatory process on-going inside endocardium due to infection after endothelium damage most often involving aortic and mitral valves

ESC 2009

 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

1. Definitions, general information

2.Clinical symptoms
3. Diagnosis 1. Duke criteria 2. Blood cultures 3. Echocardiography 4. Treatment basics 5. Complications 6. Prophylaxis 7. Summary

 over 90% of patients New intra-cardiac murmur - about 85% of patients Roth spots, petechiae, glomerulonephritis up to 30% of patients
Fever

ESC 2009

 Linear

reddish-brown lesions found under the nail bed

 painful,

reddish, on the palms or soles

 painless,

circular or oval, red macules, on the palms and soles that do not blanch with pressure

1. Definitions, general information 2. Clinical symptoms 3. Diagnosis

1.Duke criteria
2. Blood cultures 3. Echocardiography 4. Treatment basics 5. Complications 6. Prophylaxis 7. Summary

1. Definitions, general information 2. Clinical symptoms 3. Diagnosis 1. Duke criteria

2.Blood cultures
3. Echocardiography 4. Treatment basics 5. Complications 6. Prophylaxis 7. Summary

ESC 2009

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

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

AHA 2005

ESC 2009

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AHA 2005

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AHA

1. 2. 3.

Definitions Clinical symptoms Diagnosis

1. 2. 3.

Duke criteria Blood cultures Echocardiography

4. Treatment
5.
6. 7.

basics

Complications Prophylaxis Summary

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

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

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AHA2005

AHA 2005

AHA 2005

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AHA 2005

AHA 2005

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AHA 2005

AHA 2005

AHA 2005

AHA 2005

AHA 2005

ESC 2009

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ESC 2009

AHA 2005

AHA 2005

1. 2. 3.

Definitions Clinical symptoms Diagnosis

1. 2. 3.

Duke criteria Blood cultures Echocardiography

4. 5.

6.
7.

Treatment basics Complications Prophylaxis Summary

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

5. 6. 7. 8.

Neurologic events Acute renal failure Rheumatic problems Myocarditis

1. 2. 3.

Definitions Clinical symptoms Diagnosis

1. 2. 3.

Duke criteria Blood cultures Echocardiography

4. 5.

6.
7.

Treatment basics Complications Prophylaxis Summary

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

ESC 2009

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AHA 2007

An antibiotic for prophylaxis should be administered in a single dose before the procedure. not administered before the procedure, the dosage may be administered up to 2 hours after the procedure The presence of fever or other manifestations of systemic infection should alert the provider to the possibility of IE. So, it is important to obtain blood cultures and other relevant tests before administration of antibiotics intended to prevent IE. Failure to do so may result in delay in diagnosis or treatment of a concomitant case of IE.

ESC 2009

AHA 2007

variety of respiratory tract procedures reportedly cause transient bacteremia however, no published data demonstrate a link between these procedures and IE. Antibiotic prophylaxis with a regimen listed in Table 5 is reasonable (Class IIa, LOE C) for patients with the conditions listed in Table 3

 Recomended

: incision or biopsy of the respiratory mucosa, such as tonsillectomy and adenoidectomy, and invasive respiratory tract procedure , such as drainage of an abscess or empyema not recommend antibiotic prophylaxis for bronchoscopy contain an agent active against viridans group streptococci

 Enterococci

are part of the normal flora of the GI tract. These microorganisms may cause infection . Enterococci may cause urinary tract infections, particularly in older males with prostatic hypertrophy and obstructive uropathy or prostatitis

 Prophylactic

antibiotics is not recommended for patients who undergo GU or GI tract procedures, including diagnosticesophagogastroduodenoscopy or colonoscopy (Class III, LOE B) The possible association between GI or GU tract procedures and IE has not been studied as extensively as the possible association with dental procedures

 Patient

who have an GI or GU tract infection or for those who receive antibiotic therapy to prevent wound infection or sepsis associated with a GI or GU tract procedure, it may be reasonable that the antibiotic regimen include an agent active against enterococci, such as penicillin, ampicillin, piperacillin, or vancomycin (Class IIb, LOE B); however, no published studies demonstrate that such therapy would prevent enterococcal IE.

 For

patients scheduled for an elective cystoscopy or other urinary tract manipulation who have an enterococcal urinary tract infection or colonization, antibiotic therapy to eradicate enterococci from the urine before the procedure may be reasonable (Class IIb, LOE B). If the urinary tract procedure is not elective, it may be reasonable that the empiric or specific antimicrobial regimen administered to the patient contain an agent active against enterococci (Class IIb, LOE B)

 only

staphylococci and -hemolytic streptococci are likely to cause IE reasonable that the therapeutic regimen administered for treatment of the infection contain an agent active against staphylococci and -hemolytic streptococci, such as an antistaphylococcal penicillin or a cephalosporin (Table 5 for dosage; Class IIb, LOE C)

1. 2. 3.

Definitions Clinical symptoms Diagnosis

1. 2. 3.

Duke criteria Blood cultures Echocardiography

4. 5.

6.
7.

Treatment basics Complications Prophylaxis Summary

1. 2. 3. 4. 5. 6. 7.

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

TERIMA KASIH