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 Circulation 1998;98;2936-2948
5

HACEK: Haemophylus aphrophilus, Actinobacillus actinomycetemtemcomitens, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae Circulation 2005;111;e394-e433

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 Minor Duke Criteria

1. 2. 3.

4. 5.

6.

Predisposition, predisposing heart condition, or IDU 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

Endophtalmitis

Macula irregular erythematous tak nyeri, 1-4mm, di thenar/ hypothenar tangan/ kaki vasculitis

Janeway lesion

Retinal hemorrhages with pale centers Immune-mediated vasculitis

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 Findings consistent with IE that fall short of Definite but not Rejected 1 major criterion + 1 minor criterion; or 3 minor criteria 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
Circulation 2005;111;e394-e433

POSSIBLE

REJECTED

11

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 Streptococcus viridan Streptococcus bovis SUSCEPTIBLE / RESISTANT Penicillin susceptible Ceftriaxone Sodium* + Gentamicin Vancomycin HCl Streptococcus viridan Streptococcus bovis Relatively Penicillin Resistant Penicillin G Sodium Ceftriaxone Sodium + Gentamicin Vancomycin HCl Staphylococci Oxacillin-susceptible strains Nafcillin or oxacillin Optional addition of gentamicin For penicillin allergic Cefazolin Optional addition of gentamicin Oxacillin-resistant strains Vancomycin HCl REGIMEN Penicillin G Sodium DOSAGE & ROUTE 1218 million U/24 h IV either continuously or in 4 or 6 equally divided doses 2 g/24 h IV/IM in 1 dose + 3 mg/kg per 24 h IV/IM in 1 dose 30 mg/kg per 24 h IV in 2 equally divided dose 24 million U/24 h IV either continuously or in 46 equally divided doses 2 g/24 h IV/IM in 1 dose + 3 mg/kg per 24 h IV/IM in 1 dose 30 mg/kg per 24 h IV in 2 equally divided dose 12 g/24 h IV in 46 equally divided doses 3mg/kg/24h IV/IM in 2-3 equally divided doses 6 g/24 h IV in 3 equally divided doses 3 mg/kg/24 h IV/IM in 2-3 equally divide doses 30 mg/kg/ 24 h IV in 2 equally divided doses
14

Durati on 4 wk 4 wk 2 wk 4 wk 4 wk 2 wk 4 wk 6 wk 3-5 d 6 wk 3-5 d 6 wk

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

Circulation 2005;111;e394-e433

Antimicrobial Therapy for Prosthetic Valves

BAKTERIAL Streptococ viridan SUSCEPTIBLE / RESISTANT Penicillin susceptible REGIMEN Penicillin G Sodium DOSAGE & ROUTE 24 million U/24 h IV either continuously or in 4 or 6 equally divided doses Duration 6 wk

Streptococ bovis
Streptococ viridan Streptococ bovis Staphylococci Oxacillin-susceptible Relatively Penicillin Resistant

Ceftriaxone Sodium + Gentamicin

Vancomycin HCl Penicillin G Sodium Ceftriaxone Sodium + Gentamicin Vancomycin HCl Nafcillin or oxacillin + Rifampin Gentamicin Oxacillin-resistant strains Vancomycin + Rifampin

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

30 mg/kg.24 h IV in 2 equally divided dose 24 million U/24 h IV either continuously or in 46 equally divided doses 2 g/24 h IV/IM in 1 dose + 3 mg/kg per 24 h IV/IM in 1 dose 30 mg/kg/24 h IV in 2 equally divided dose 12 g/24 h IV in 6 equally divided doses + 900 mg/24 h IV/PO in 3 equally divided doses 3 mg/kg/24 h IV/IM in 2 or 3 equally divide dose 30 mg/kg/24 h IV in 2 equally divided doses + 900 mg/24 h IV/PO in 3 equally divided doses

6 wk + 2 wk
6 wk 6 wk 6 wk 6 wk > 6 wk 2 wk > 6 wk

Gentamicin

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

2 wk

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Circulation 2005;111;e394-e433

Antimicrobial Therapy for Native or Prosthetic Valves

Bacterial Susceptible/Resistant
Penicillin, Genytamycin, Vancomycin Susceptible

Regimen
Ampicillin sodium Penicilin G sodium+Gentamicin Vancomycin+Gentamicin

Dosage and route

12 g/24 h IV in 6 equally divided doses 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 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 12 g/24 h IV in 6 equally divided doses 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 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 12 g/24 h IV in 4 equally divided doses+3 mg/kg per 24 h IV/IM in 3 equally divided doses 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

Duration
4-6 wk 4-6 wk 6 wk 4-6 wk 4-6 wk

Entero cocci

Penicillin, Streptomycin, Vancomycin Susceptible, Gentamicin Resistant

Ampilin sodium Penicillin G +Streptomycin

Vancomicin+Streptomycin

6 wk

Vancomycin, aminoglycoside Susceptible, Penicillin Resistant Intrinsic Penicillin resistant Penicillin, Aminoglycoside,Vancomycin Resistant E faecium

AmpicillinSulbactam+Gentamicin Vancomycin+Gentamicin

6 wk 6 wk

Linazolid Quinupristin-dalfopristin

1200 mg/24 h IV/PO in 2 equally divided doses 22.5 mg/kg per 24 h IV in 3 equally divided doses 2 g/24 h IV in 4 equally divided doses+12 g/24 h IV in 6 equally divided doses

> 8 wk > 8 wk

Penicillin, Aminoglycoside,Vancomycin Resistant E faecalis

Imipenem/cilastatin+Ampicillin Ceftriaxone Sodium + Ampicillin

> 8 wk

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

8 wk

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Circulation 2005;111;e394-e433

Antimicrobial Therapy for Native or Prosthetic Valves

REGIMEN HACEK DOSAGE & ROUTE DURATION

Ceftriaxone sodium Ampicillin- sulbactam Ciprofloxacin

2 g/24 h IV/IM in 1 dose 12 g/24 h IV in 4 equally divided doses 1000 mg/24 h PO or 800 mg/24 h IV in 2

4 wk 4 wk 4 wk

Anti Bacterial Therapy for Culture negative

BACTERIA VALVES REGIMEN DOSAGE & ROUTE DURATION

Culture Negative

Native Valve

Ampicillin-sulbactam + Gentamicin Vancomycin + Gentamicin plus ciprofloxasin

12 g/24 h IV in 4 equally divided doses+ 3mg/kg/24 h IV/IM in 3 equally divided doses 30 mg/kg/24 h IV in 2 equally divided doses+ 3 mg/kg/24 h IV/IM in 3 equally divided doses 1000 mg/24 h PO or 800 mg/24 h IV in 2 equally divided doses 30 mg/kg/24 h IV in 2 equally divided doses+ 3 mg/kg/24 h IV/IM in 3 equally divided doses 6 g/24 h IV in 3 equally divided doses+900 mg/24 h PO/IV in 3 equally divided doses

4-6 wk

4-6 wk 4-6 wk 6 wk 2 wk 6 wk

Culture Negative

Prosthetic Valve

Vancomycin + Gentamicin plus Cefepim + Rifampin

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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
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

Moderate Risk

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

Oral

Amoxicillin

2g

50 mg/kg

Unable to take oral medicine

Allergic to Penicillin or Ampicillin oral

Ampicillin or Cefazolin or Ceftriaxone

Cephalexin* or Clindamycin or Azithromycin or Clarithromycin Cefazolin or Ceftriaxone or Clindamycin

2 g IM or IV 1 g IM or IV
2g 600 mg 500 mg 1 g IM or IV 600 mg IM or IV

50 mg/kg IM or IV 50 mg/kg IM or IV
50 mg/kg 20 mg/kg 15 mg/kg 50 mg/kg IM or IV 20 mg/kg IM or IV

Allergic to Penicillin or Ampicillin and 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

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.
4

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 postpone 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 treatment.
ESC guideline; European Heart J 2004;00, 1-37 6

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 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

Maintenance

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)
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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)

Early PVE (<1 year since surgery) Late PVE (>1 year since surgery)

IE

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 antiphase 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
2

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, 6th ed

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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