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MIOKARDITIS
Masrul Syafri
Bagian Kardiologi dan Kedokteran Vaskular
FKUA/ RS Dr M Jamil Padang
Infective Endocarditis
Definitions
Acquired
19% CHD
22%
IV drug users and nosocomial cases excluded.
Strom BL, Abrutyn E, Berlin JA, Kinman JL, Feldman RS, Stolley PD, et al.
Ann Intern Med. 1998;129:761-9.
Risk Factors for Infective Endocarditis
Immunologic origin?
Subungual (splinter) hemorrhage
Conjunctival hemorrhage
Retinal hemorrhage: Roth Spot
Clinical features
Strep. viridans
S. bovis
Lancefield group D
Gut flora: associated with GI pathology
S. pneumonia
1-3% of cases of IE with predilection for AV
Usually, in those with immune suppression
DM and Ethanolism
Group B Streptococci
Elderly with chronic disease
Normal inhabitant of GI tract.
Frequently encountered in UTIs.
Up to 40% of cases without identified
underlying predisposition to IE.
Difficult to treat due to drug resistance.
Coagulase Positive (Staph. aureus)
a major causative agent in all populations of IE
typically produces acute IE
fulminant, rapidly progressive with few immunologic
signs.
CNS complications in 30-50%
Coagulase Negative (Staph. epi, et al)
Major cause of PVE. 3-8% of NVE.
Hemophilus, Actinobacillus,
Cardiobacterium, Eikenella, Kingella
Gram negative inhabitants of the upper
airways.
Large vegetations, high likelihood of
embolization.
Slow growing: hold cultures for 3 weeks.
Traditionally sensitive to beta lactams,
now some produce beta lactamase.
Commonly encountered agents:
Candida, Torulopsis, Aspergillus
Predispositions
Prosthetic valves
IVDA
Immunosupression
Hyperalimentation
Prolonged abx treatment
Large vegetations and frequent embolic
events.
Pseudomonas
Brucella
Diphtheroids
Listeria
Bartonella
Coxsiella
Chlamydia
Accounts for 25% of
cases of IE in US. MV
5:1 male:female 24% AV
6%
Pre-existing
valvular diseases
uncommon.
TV
Variable 70%
microbiology.
Mortality<10%.
Affects 3% of prosthesis patients.
Highest risk in first 6 months post op.
Accounts for 10-20% of all IE cases.
Increased risk in
Males
Blacks
Prolonged pump time
Multiple valve replacement
Early (<12 months)-Staph epi
late (after 12 months)- mimics NVE
DIAGNOSIS
KRITERIA DUKE
A. Endokarditis infektif definitif :
1. Kriteria patologi
Mikroorganisme : dibuktikan dengan hasil biakan
atau histologi vegetasi atau pada vegetasi yang
mengalami emboli atau pada abses dalam jantung
atau
Lesi patologi : abses dalam jantung dan vegetasi
yang diperjelas oleh histologis yang
memperlihatkan
EI aktif
2. Kriteria klinik :
2 kriteria mayor atau
1 kriteria mayor dan 3 minor atau
5 kriteria minor
DIAGNOSIS
ESC guidelines
Blood cultures critical for specific diagnosis
3 sites 30-60 minutes apart
before starting antibiotics.
86 96% of 1st cultures positive
98 100% of 1st 2 cultures positive
ESC guidelines
DIAGNOSIS
Kriteria mayor
1. Biakan darah positif
a. Mikroorganisme tipikal untuk EI dari 2 biakan
darah terpisah :
- S. viridans, S. bovis, HACEK
- S. aureus atau enterokokus tanpa ditemukan
fokus primer
b. Biakan tetap positif, apabila
- > 2 sampel positif dengan jarak pengambilan
12 jam
atau
- Tiga sampel atau mayoritas dari 4 sampel
atau lebih hasil positif, dengan jarak waktu
pengambilan pertama dan terakhir paling sedikit
1 jam
DIAGNOSIS
2. Bukti keterlibatan endokardium
KECURIGAAN EI
SEGERA TTE
ESC guidelines
Principles of Therapy
EVALUASI :
- DEMAM MENETAP
ULANGAN BIAKAN DARAH (8 MGG
SETELAH DARAH I)
- BERHASIL : BIAKAN DARAH NEGATIF
SETELAH 7 HARI PENGOBATAN
- GAGAL : BIAKAN DARAH POSITIF
SETELAH 10 HARI PENGOBATAN
PENATALAKSANAAN
1. Medikamentosa
Terapi endokarditis oleh karena
streptokokus
Penisilin G : 12 20 juta IU/ 24 jam iv, dibagi dalam 4-6 dosis
Ceftriakson : 2 gr i.v dosis tunggal (infuse cepat). Bila
diberikan secara intramuskular, sebaiknya hanya 1 gram dalam
satu lokasi suntikan.
Vankomisin : 30 mg/kg/hari iv dibagi dalam 2 dosis (lama
pemberian tidak kurang dari 45 menit).
Teicoplanin : 10 mg/kg i.v 2 kali sehari dalam 9 dosis pertama,
dilanjutkan dengan 10 mg/kg hari dosis tunggal.
Aminoglikosid : diberikan dalam 2 dosis perhari. Merupakan
terapi kombinasi dengan obat tersebut di atas, selama 2
minggu perawatan pertama.
PENATALAKSANAAN
2. Bedah
INDIKASI :
NVE : - gagal jantung
- demam menetap
- destruksi jaringan sekitar katup
- kuman penyebabnya adalah jamur, Brucella spp,
Coxiella spp
- emboli berulang
- destruksi katup
- komplikasi neurologi
PENATALAKSANAAN
NVE
PVE
Penisilin MIC < 8 mg/l dan Penisilin G 16-20 juta IU terbagi 4-6 dosis +
gentamisin MIC < 500 mg/l gentamisin 3 mg/ kg /24jam terbagi 2 dosis
selama 4 mgg
Alergi penisilin dan enterococal yang Vankomisin 30 mg/kg/24 jam iv dosis terbagi 2
suseptibel terhadap penisilin/ + gentamisin seperti di atas selama 6 mgg
Gentamisin
Usia < 65 th, Penisilin G 12-20 juta UI/24 jam iv terbagi 4-6 dosis selama
serum kreatinin normal 4 mgg + gentamisin3 mg/ kg 24jam (max 240mg/hr), terbagi
2-3 dosis selama 2 mgg
Kondisi sama dg di atas Penisilin G 12-20 juta UI/24 jam iv terbagi 4-6 dosis selama
tanpa komplikasi dan 2 atau 4 mgg dilanjutkan terapi ambulatoarsetelah 7 hari
respon terapi cepat perawatan di rumah sakit
Usia > 65 th dan atau Penisilin G sesuai fungsi ginjal selama 4 mgg atau
serum kratinin meningkat ceftriaxon 2 g/ 24 jam dosis tunggal selama 4 mgg
atau alergi penisilin
Alergi penisilin atau Vankomisin 30 mg/kg/24 jam iv dosis terbagi 2 selama 4 mgg
Sepalosprorin
Regimen B :suseptibiliti terhadap penisilin (MIC 0,1 mg/l-0,5 mg/l) atau PVE
Regimen B PVE
MSSA Oksasilin 8-12 gr/24 jam iv,terbagi 4 dosis + rifampicin
900 mg/24 jam iv terbagi 3 dosis, selama 6-8 minggu, +
gentamisin 3 mg/ kg /24jam (max 240mg/hr), terbagi 3
dosis selama 2 mgg opertama pengobatan
MRSA, CONS Vankomisin30 mg/kg/24 jam iv dosis terbagi 2 selama
6 minggu, + rifampisin 300 mg/ 24 jam iv terbagi 3
dosis, + gentamisin 3 mg/ kg /24jam ( maksimal 240
ESC guidelines
Dura
Bacterial Susceptible/Resistant Regimen Dosage and route tion
Viridan 1218 million U/24 h IV either continuously or in
Streptococci Penicillin susceptible Penicillin G Sodium 4 or 6 equally divided doses 4 wk
Streptococcus Ceftriaxone Sodium* + 2 g/24 h IV/IM in 1 dose + 3 mg/kg per 24 h
bovis Gentamicin IV/IM in 1 dose 2 wk
Vancomycin
hydrochloride 30 mg/kg per 24 h IV in 2 equally divided dose 4 wk
Viridan 24 million U/24 h IV either continuously or in 46
Streptococci Relatively Penicillin Resistant Penicillin G Sodium equally divided doses 4 wk
Streptococcus Ceftriaxone Sodium + 2 g/24 h IV/IM in 1 dose + 3 mg/kg per 24 h
bovis Gentamicin IV/IM in 1 dose 2 wk
Vancomycin
hydrochloride 30 mg/kg per 24 h IV in 2 equally divided dose 4 wk
* Ceftriaxone alone could be administrated for 4 weeks instead of Penicillin G Circulation 2005;111;e394-e433
Durati
Bacterial Susceptible/Resistant Regimen Dosage and route on
Viridan 24 million U/24 h IV either continuously or in 4
Streptococci Penicillin susceptible Penicillin G Sodium or 6 equally divided doses 6 wk
Streptococcus Ceftriaxone Sodium + 2 g/24 h IV/IM in 1 dose + 3 mg/kg per 24 h 6 wk +
bovis Gentamicin IV/IM in 1 dose 2 wk
Circulation 2005;111;e394-e433
Bacterial Susceptible/Resistant Regimen Dosage and route Duration
Penicillin, Genytamycin,
Enterococci Vancomycin Susceptible Ampicillin sodium 12 g/24 h IV in 6 equally divided doses 4-6 wk
Penicilin G 1830 million U/24 h IV either continuously or in 6 equally divided
sodium+Gentamicin doses+3 mg/kg per 24 h IV/IM in 3 equally divided doses 4-6 wk
30 mg/kg per 24 h IV in 2 equally divided doses+3 mg/kg per 24 h
Vancomycin+Gentamicin IV/IM in 3 equally divided doses 6 wk
Penicillin, Streptomycin,
Vancomycin Susceptible,
Gentamicin Resistant Ampilin sodium 12 g/24 h IV in 6 equally divided doses 4-6 wk
24 million U/24 h IV continuously or in 6 equally in divided
Penicillin G +Streptomycin doses+15 mg/kg per 24 h IV/IM in 2 equally divided 4-6 wk
30 mg/kg per 24 h IV in 2 equally divided doses+15 mg/kg per 24 h
Vancomicin+Streptomycin IV/IM in 2 equally divided doses 6 wk
Vancomycin, aminoglycoside Ampicillin- 12 g/24 h IV in 4 equally divided doses+3 mg/kg per 24 h IV/IM in
Susceptible, Penicillin Resistant Sulbactam+Gentamicin 3 equally divided doses 6 wk
30 mg/kg per 24 h IV in 2 equally divided doses+3 mg/kg per 24 h
Intrinsic Penicillin resistant Vancomycin+Gentamicin 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
Penicillin,
Aminoglycoside,Vancomycin Imipenem/cilastatin+Ampi 2 g/24 h IV in 4 equally divided doses+12 g/24 h IV in 6 equally
Resistant E faecalis cillin 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
Circulation 2005;111;e394-e433
Regimen Dosage and route Duration
Circulation 2005;111;e394-e433
Bacterial Valves Regimen Dose Duration
12 g/24 h IV in 4 equally divided
doses+3 mg/kg per 24 h IV/IM in
Culture Negative Native Valve Ampicillin-sulbactam+Gentamicin 3 equally divided doses 4-6 wk
30 mg/kg per 24 h IV in 2 equally
divided doses+3 mg/kg per 24 h
Vancomycin+Gentamicin IV/IM in 3 equally divided doses 4-6 wk
Circulation 2005;111;e394-e433
Anti Bacterial Therapy for Culture negative
200 mg/24 h IV or PO in 2
equally divided doses+3
mg/kg per 24 h IV/IM in 3
Documented Doxycycline+Gentamicin equally divided doses 6+2 wk
Circulation 2005;111;e394-e433
TIMING OF SURGERY
TIMING OF SURGERY
Prosthetic cardiac valves, including
bioprosthetic and homograft valves
Previous bacterial endocarditis
Complex cyanotic congenital heart
disease (eg, single ventricle states,
transposition of the great arteries,
tetralogy of Fallot)
Surgically constructed systemic
pulmonary shunts or conduits
Most other congenital cardiac
malformations (other than above and
below)
Acquired valvular dysfunction (eg,
rheumatic heart disease)
Hypertrophic cardiomyopathy
Mitral valve prolapse with valvular
regurgitation and/or thickened leaflets
Isolated secundum atrial septal defect
Surgical repair of atrial septal defect,
ventricular septal defect, or patent
ductus arteriosus
(without residua beyond 6 mo)
Previous coronary artery bypass graft
surgery
Mitral valve prolapse without valvular
regurgitation *
Physiologic, functional, or innocent heart
murmurs
Previous Kawasaki disease without
valvular dysfunction
Previous rheumatic fever without valvular
dysfunction
Cardiac pacemakers (intravascular and
epicardial) and implanted defibrillators
Respiratory Tract
ET intubation
Flexible bronchoscopy
PE tubes
GI Tract
TEE
EGD
GU Tract
Vaginal hysterectomy
Vaginal delivery
C - section
In uninfected tissue:
D and C/Ab
Urethral cath
Sterilization
IUDs
Circumcision
Prophylaxis Recommended
Dental procedures - extractions, cleaning with
bleeding, periodontal procedures
Respiratory tract - tonsillectomy, rigid
bronchoscopy
Gastrointestinal - schlerotherapy, biliary tract
surgery
Genitourinary - C-section, cystoscopy, prostate
surgery
JAMA 277:1794, 1997
Dental, Oral, Oesophageal procedure
Allergic Penicillin
Emboli
Komplikasi paru
Gagal jantung
Miokarditis,
Acute Renal Failure
Gangguan konduksi
Congestive Heart Failure:
Circulation 2005;111;e394-e433
Risk of Embolization:
Periannularextension of Infection
Splenic Abscess
Mycotic Aneurysms
Circulation 2005;111;e394-e433
Myocarditis
Uncommon
(1% at autopsy)
(but 5% of patients in influenza,
polio, Coxsackie virus epidemics)
Manifestations
90% recovery,
10% chronic dilated cardiomyopathy,
death rare (in adults)
Staphylococcus aureus
(abscesses, part of disseminated infection)
Diphtheria (exotoxin)
Fungal Myocarditis
1. Candida
- in immunocompromised patients
- causes abscesses or granulomas
- part of disseminated infection
2. Aspergillus
- ditto
Protozoal Myocarditis
1. Toxoplasmosis
primarily in immunocompromised patients,
with foci of necrosis, chronic inflammation,
intra-myocyte cysts (containing bradyzoites)
and free tachyzoites
2. Trypanosomiasis
Chagas disease, in Latin America (esp. Brazil)
Definition of Infective Endocarditis
DUKES
CRITERIA
PENCEGAHAN
Profilaksis
terhadap kuman enterokokus,
streptokokus bovis dan
enterobacteriaceae
PENDAHULUAN
Oslers Gulstonian
EPIDEMIOLOGI
Patologi NVE
- Kardiak
- Non kardiak
Endokarditis sisi kanan
Endokarditis sisi kiri
Patologi PVE
PATOGENESIS
IVDA ?
KLASIFIKASI DAN TERMINOLOGI
ESC guidelines
KLASIFIKASI DAN TERMINOLOGI
Terminologi Endokarditis Infektif
aktifiti rekurens Terminologi
patologi anatomi mikrobiologi
diagnosis
aktif
sembuh
a bila kolom rekurens, terminologi diagnosis, dan atau patologi tanpa teks, menunjukkan episode pertama
(bukan relaps atau rekurens), definite IE (bukan suspected atau possible) dan keterlibatan katup asli
(native valve)
b intravenous drug abuse
ESC guidelines
PENATALAKSANAAN
Streptococcus spp. 34
Enterococcus spp. 6
Staphylococcus aureus 40
Coagulase-negative staphylococci 5
Gram negative bacilli 6
Fungi 2
Misc. / Polymicrobial 3
Culture negative 4
+ / - perforation of valve
+ / - adjacent abscess
+ / - fibrotic scarring
+ / - calcification
Microscopic Pathology