Infective endocarditis Diagnosis & treatment ESC 2009 guidelines

roadmap

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

Definitions, general information

• 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 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

• • • Acording 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 information

2. Clinical symptoms

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

1. Duke criteria

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

Duke criteria

Major criteria

1. Blood culture positive for typical IE-causing microorganism 2. Evidence of endocardial involvement • • • Diagnosis 2 major criteria 1 major and 3 minor 5 minor criteria

Minor criteria

1. Predisposition – heart condition or i.v. drug abuse 2. Fever – temp. >38 °C 3. 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

roadmap

1. Definitions 2. Clinical symptoms 3. Diagnosis 1. Duke criteria

2. Blood cultures

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

Blood cultures

• • • Always before starting antibiotics Always triple samples – aerobe, anaerobe and mycotic , 10 ml each Three sets of samples required

roadmap

1. Definitions 2. Clinical symptoms 3. Diagnosis 1. Duke criteria 2. Blood cultures

3. Echocardiography

4. Treatment basics 5. Complications 6. Prophylaxis 7. 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 IE Vegetation Abscess Pseudoaneurysm Perforation Fistula Valve aneurysm Dishence of prosthetic valve

roadmap

1. Definitions 2. Clinical symptoms 3. Diagnosis 1. Duke criteria 2. Blood cultures 3. Echocardiography

4. Treatment basics

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

5. Complications

6. Prophylaxis 7. Summary

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

Complications - continued

5. Neurologic events 6. Acute renal failure 7. Rheumatic problems 8. Myocarditis

roadmap

1. Definitions 2. Clinical symptoms 3. Diagnosis 1. Duke criteria 2. Blood cultures 3. Echocardiography 4. Treatment basics 5. Complications

6. Prophylaxis

7. Summary

Prophylaxis

• • • First and most important –

Regular dental review proper oral hygiene

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

7. Summary

Summary

1. IE is rare but serious disease, with high mortality rate 2. Every case of fever of unknown origin should be suspected for IE 3. Blood cultures are essential for diagnosis 4. TTE/TEE is the best method to monitor and follow-up of IE 5. Antibiotics are main treatment 6. CHF is the most common complication 7. Pharmacological prophylaxis is reserved for a narrow group of high risk patients