infective endocarditis diagnosis & treatment esc 2009 guidelines

Infective endocarditis

Diagnosis & treatmentESC 2009 guidelines

roadmap

1.1. DefinitionsDefinitions, general information, general information2. Clinical symptoms3. Diagnosis

1. Duke criteria2. Blood cultures3. Echocardiography

4. Treatment basics5. Complications6. Prophylaxis7. Summary

Definitions, general information

• Infective endocarditis Infective endocarditis – inflammatory process on-going inside

endocardium – due to infection after endothelium damage– most often involving aortic and mitral valves

Definitions, general information - continued

Acording to localisation 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)

Definitions, general information - continued

AAcording to the mode of acquisitioncording to the mode of acquisition• Health-care associated IE– Nosocomial– Non-nosocomial

• Community acquired IE• Intravenous drug abuse-associated IE

Definitions, general information- continued

• Active IE• Recurrence– Relpse– Reinfection

Definitions, general information- continued

• 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

roadmap

1. Definitions, general information2.2. Clinical symptomsClinical symptoms3. Diagnosis

1. Duke criteria2. Blood cultures3. Echocardiography

4. Treatment basics5. Complications6. Prophylaxis7. Summary

Clinical symptoms

• Fever – over 90% of patients• New intra-cardiac murmur - about 85% of

patients• Roth spots, petechiae, glomerulonephritis –

up to 30% of patients

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, vertebral

column)

roadmap

1. Definitions2. Clinical symptoms3. Diagnosis

1.1. Duke criteriaDuke criteria2. Blood cultures3. Echocardiography

4. Treatment basics5. Complications6. Prophylaxis7. Summary

Duke criteria

Major criteria1. Blood culture positive for

typical IE-causing microorganism

2. Evidence of endocardial involvement

Minor criteria1. Predisposition – heart

condition or i.v. drug abuse2. Fever – temp. >38 °C3. Vascular phenomena –

arterial emboli etc.4. Immunologic phenomena –

glomerulonephritis, Osler’s nodes, Roth’s spots

5. Microbiological evidence – positive blood cultures but do not meet major criteria

Diagnosis• 2 major criteria• 1 major and 3 minor• 5 minor criteria

Diagnosis• 2 major criteria• 1 major and 3 minor• 5 minor criteria

roadmap

1. Definitions2. Clinical symptoms3. Diagnosis

1. Duke criteria2.2. Blood culturesBlood cultures3. Echocardiography

4. Treatment basics5. Complications6. Prophylaxis7. Summary

Blood cultures

• Always before starting antibiotics• Always triple samples – aerobe, anaerobe and

mycotic , 10 ml each• Three sets of samples required

roadmap

1. Definitions2. Clinical symptoms3. Diagnosis

1. Duke criteria2. Blood cultures3.3. EchocardiographyEchocardiography

4. Treatment basics5. Complications6. Prophylaxis7. Summary

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

Echocardiography

Echocardiographic findings in IEEchocardiographic findings in IE• Vegetation• Abscess• Pseudoaneurysm• Perforation• Fistula• Valve aneurysm• Dishence of prosthetic valve

roadmap

1. Definitions2. Clinical symptoms3. Diagnosis

1. Duke criteria2. Blood cultures3. Echocardiography

4.4. Treatment basicsTreatment basics5. Complications6. Prophylaxis7. Summary

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

Treatment basics - continued

• 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 β-laktams with aminoglycosides

• Most widely used drugs – amoxycylin, gentamycin

• In case of β-laktams alergy - vancomycin

roadmap

1. Definitions2. Clinical symptoms3. Diagnosis

1. Duke criteria2. Blood cultures3. Echocardiography

4. Treatment basics5.5. ComplicationsComplications6. Prophylaxis7. Summary

Complications

1.1. Congestive heart failureCongestive heart failure• Most common complication• Main indication to surgical treatment• ~60% of IE patients

2.2. Uncontrolled infectionUncontrolled infection• Persisting infection • Perivalvular extension in infective endocarditis

3.3. Systemic embolismSystemic embolism• Brain, spleen and lungs• 30% of IE patients• May be the first symptom

Complications - continued

5.5. Neurologic eventsNeurologic events6.6. Acute renal failureAcute renal failure7.7. Rheumatic problemsRheumatic problems8.8. MyocarditisMyocarditis

roadmap

1. Definitions2. Clinical symptoms3. Diagnosis

1. Duke criteria2. Blood cultures3. Echocardiography

4. Treatment basics5. Complications6.6. ProphylaxisProphylaxis7. Summary

Prophylaxis • First and most important – proper oral hygieneproper oral hygiene• Regular Regular dental reviewdental 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

– Use amoxycilin or ampicylin 30-60 min prior to intervention

roadmap

1. Definitions2. Clinical symptoms3. Diagnosis

1. Duke criteria2. Blood cultures3. Echocardiography

4. Treatment basics5. Complications6. Prophylaxis7.7. SummarySummary

Summary

1. IE is rare but serious disease, with high mortality rate2. Every case of fever of unknown origin should be

suspected for IE3. Blood cultures are essential for diagnosis4. TTE/TEE is the best method to monitor and follow-up

of IE5. Antibiotics are main treatment6. CHF is the most common complication7. Pharmacological prophylaxis is reserved for a narrow

group of high risk patients