Infective endocarditis

1. Infective endocarditis Diagnosis & treatment ESC 2009 guidelines

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

3. Definitions, general information • Infective endocarditis • inflammatory process on-going inside endocardium • due to infection after endothelium damage • most often involving aortic and mitral valves

4. 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)

5. 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

6. Definitions, general information-continued • Active IE • Recurrence • Relpse • Reinfection

7. 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

8. roadmap • Definitions, general information • Clinical symptoms • Diagnosis • Duke criteria • Blood cultures • Echocardiography • Treatment basics • Complications • Prophylaxis • Summary

9. Clinical symptoms • Fever – over 90% of patients • New intra-cardiac murmur - about 85% of patients • Roth spots, petechiae, glomerulonephritis – up to 30% of patients

10. 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 • Periferalabscesess (kidney, spleen, brain, vertebral column)

11. roadmap • Definitions • Clinicalsymptoms • Diagnosis • Duke criteria • Bloodcultures • Echocardiography • Treatmentbasics • Complications • Prophylaxis • Summary

12. Duke criteria Major criteria Minor criteria Predisposition – heartconditionori.v. drugabuse Fever – temp. >38 °C Vascular phenomena – arterial emboli etc. Immunologicphenomena – glomerulonephritis, Osler’snodes, Roth’sspots Microbiologicalevidence – positivebloodcultures but do not meet major criteria • Blood culture positive for typical IE-causing microorganism • Evidence of endocardial involvement • Diagnosis • 2 major criteria • 1 major and 3 minor • 5 minor criteria

13. roadmap • Definitions • Clinicalsymptoms • Diagnosis • Duke criteria • Bloodcultures • Echocardiography • Treatmentbasics • Complications • Prophylaxis • Summary

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

15. roadmap • Definitions • Clinicalsymptoms • Diagnosis • Duke criteria • Bloodcultures • Echocardiography • Treatmentbasics • Complications • Prophylaxis • Summary

16. 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

17. Echocardiography Echocardiographicfindingsin IE • Vegetation • Abscess • Pseudoaneurysm • Perforation • Fistula • Valveaneurysm • Dishence of prostheticvalve

18. roadmap • Definitions • Clinicalsymptoms • Diagnosis • Duke criteria • Bloodcultures • Echocardiography • Treatmentbasics • Complications • Prophylaxis • Summary

19. 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

20. Treatment basics - continued • NVE standard therapy - ittakes 2-6 weeks to eradicatethepathogen • PVE – longerregimeisnecessery – over 6 weeks • In Streptococcal IE shorter, 2 weekcourse, can be usedwhencombiningβ-laktamswithaminoglycosides • Most widelyuseddrugs – amoxycylin, gentamycin • In case of β-laktamsalergy - vancomycin

21. roadmap • Definitions • Clinicalsymptoms • Diagnosis • Duke criteria • Bloodcultures • Echocardiography • Treatmentbasics • Complications • Prophylaxis • Summary

22. Complications • Congestive heart failure • Most common complication • Main indication to surgical treatment • ~60% of IE patients • Uncontrolled infection • Persisting infection • Perivalvular extension in infective endocarditis • Systemic embolism • Brain, spleen and lungs • 30% of IE patients • May be the first symptom

23. Complications - continued • Neurologicevents • Acuterenalfailure • Rheumaticproblems • Myocarditis

24. roadmap • Definitions • Clinicalsymptoms • Diagnosis • Duke criteria • Bloodcultures • Echocardiography • Treatmentbasics • Complications • Prophylaxis • Summary

25. Prophylaxis • First and most important – proper oral hygiene • Regular dentalreview • 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 • Useamoxycilinor ampicylin 30-60 min prior to intervention

26. roadmap • Definitions • Clinicalsymptoms • Diagnosis • Duke criteria • Bloodcultures • Echocardiography • Treatmentbasics • Complications • Prophylaxis • Summary

27. Summary • IE israre but seriousdisease, with high mortalityrate • Everycase of fever of unknownoriginshould be suspected for IE • Bloodculturesareessential for diagnosis • TTE/TEE isthebestmethod to monitor and follow-up of IE • Antibioticsaremaintreatment • CHF isthe most commoncomplication • Pharmacologicalprophylaxisisreserved for a narrow group of high riskpatients