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.
5.
6.
7.
Treatment basics
Complications
Prophylaxis
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
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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.
5.
6.
7.
Treatment basics
Complications
Prophylaxis
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:
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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.
5.
6.
7.
Treatment basics
Complications
Prophylaxis
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.
5.
6.
7.
Treatment basics
Complications
Prophylaxis
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.
5.
6.
7.
Treatment basics
Complications
Prophylaxis
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 90100% 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.
5.
6.
7.
Treatment basics
Complications
Prophylaxis
Summary
Treatment basics
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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.
5.
6.
7.
Treatment basics
Complications
Prophylaxis
Summary
Complications
1. Congestive heart failure
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Most common complication
Main indication to surgical treatment
~60% of IE patients
2. Uncontrolled infection
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Persisting infection
Perivalvular extension in infective endocarditis
3. Systemic embolism
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Brain, spleen and lungs
30% of IE patients
May be the first symptom
Complications - continued
5.
6.
7.
8.
Neurologic events
Acute renal failure
Rheumatic problems
Myocarditis
roadmap
1. Definitions
2. Clinical symptoms
3. Diagnosis
1. Duke criteria
2. Blood cultures
3. Echocardiography
4.
5.
6.
7.
Treatment basics
Complications
Prophylaxis
Summary
Prophylaxis
• First and most important – proper oral hygiene
• Regular dental 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. Definitions
2. Clinical symptoms
3. Diagnosis
1. Duke criteria
2. Blood cultures
3. Echocardiography
4.
5.
6.
7.
Treatment basics
Complications
Prophylaxis
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