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INTRODUCTION
DEFINITION
Infection on any structure within the heart including
normal endothelial surfaces (eg, myocardium and
valvular structures), prosthetic heart valves
(eg, mechanical, bioprosthetic, homografts, and
autografts),
and
implanted
devices
(eg,
pacemakers,
Implantable cardioverter defibrillators, and
ventricular assist devices)
Clinical Presentation
Signs
and Symptoms :
* The hallmarks of IE are fever and a new
mumur (more than 85 %).
* The patient often has nonspecific
symptoms of fatigue, weight loss, malaise,
chills, night sweats, and/or musculoskeletal
aches
Circulation 1998;98;2936-2948
Circulation 2005;111;e394-e433
5
4.
5.
6.
Predisposition,
predisposing
heart condition, or IDU
Minor
Duke
Criteria
Fever, temperature > 38o C
Vascular phenomena, major arterial emboli, septic
pulmonary infarcts, mycotic aneurysm, intracranial
hemorrhage, conjunctival hemorrhages and Janeways
lesions
Immunologic phenomena: glomerulonephritis, Oslers
node, Roths spot and rheumatoid factor
Microbiological evidence: positive blood culture but
does not meet a major criterion as noted above or
serological evidence of active internal infection with
organism consistent with IE
Non specific echocardiographic findings omitted
DIAGNOSIS IE
Endophtalmitis
Retinal hemorrhages
with pale centers
Immune-mediated
vasculitis
Janeway lesion
Roths spot
Osler node
Clinical criteria
2 major criteria, or
1 major + 3 minor criteria, or
5 minor criteria
POSSIBLE
Findings consistent with IE that fall short of Definite but not Rejected
1 major criterion + 1 minor criterion; or 3 minor criteria
REJECTED
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Circulation 2005;111;e394-e433
Culture-negative endocarditis
COMPLICATION
Embolic Events :
Most common & predictor of death
Higher prevalence in cerebral than peripheral
Increased risk of emboli in:
Embolic Signs
COMPLICATION
CARDIAC FAILURE
Acute
regurgitation, myocarditis
Has greatest impact in prognosis
Acute aortic regurgitation has worse clinical
tolerance than mitral & tricuspid
Should undergo surgery. Delay should be
discouraged.
Poor outcome for surgery, but better than
medical therapy alone
COMPLICATION
ACUTE RENAL FAILURE
Due
to
Treatment
depends on clinical
Usually reversible
COMPLICATION
PERIANNULAR EXTENSION OF INFECTION
Predict
More
COMPLICATION
MYCOTIC ANEURYSM
Uncommon
Result
ANTIMICROBIAL THERAPY
SUSCEPTIBLE /
RESISTANT
Durati
on
REGIMEN
Penicillin G Sodium
4 wk
Ceftriaxone Sodium*
+ Gentamicin
4 wk
2 wk
Vancomycin HCl
4 wk
Penicillin G Sodium
4 wk
Ceftriaxone Sodium
+ Gentamicin
2 wk
Vancomycin HCl
4 wk
Nafcillin or oxacillin
6 wk
Optional addition of
gentamicin
3-5 d
Cefazolin
6 wk
Optional addition of
gentamicin
3-5 d
Vancomycin HCl
6 wk
Streptococcus
viridan
Penicillin susceptible
Streptococcus
bovis
Streptococcus
viridan
Relatively Penicillin
Resistant
Streptococcus
bovis
Staphylococci
Oxacillin-susceptible
strains
Oxacillin-resistant strains
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Circulation 2005;111;e394-e433
SUSCEPTIBLE /
RESISTANT
Duration
Penicillin G Sodium
6 wk
Ceftriaxone Sodium +
Gentamicin
Vancomycin HCl
6 wk
Penicillin G Sodium
6 wk
Ceftriaxone Sodium +
Gentamicin
6 wk
Vancomycin HCl
6 wk
Nafcillin or oxacillin +
Rifampin
> 6 wk
Gentamicin
2 wk
Vancomycin +
Rifampin
> 6 wk
Gentamicin
REGIMEN
Streptococ
viridan
Penicillin susceptible
Streptococ
bovis
Streptococ
viridan
Relatively Penicillin
Resistant
Streptococ
bovis
Staphylococci
Oxacillin-susceptible
Oxacillin-resistant strains
15
6 wk +
2 wk
2 wk
Circulation 2005;111;e394-e433
Entero cocci
Susceptible/Resistant
Penicillin, Genytamycin,
Vancomycin Susceptible
Regimen
Duration
Ampicillin sodium
4-6 wk
Penicilin G
sodium+Gentamicin
4-6 wk
Vancomycin+Gentamicin
6 wk
Penicillin, Streptomycin,
Ampilin sodium
4-6 wk
Vancomycin Susceptible,
Penicillin G +Streptomycin
4-6 wk
Vancomicin+Streptomycin
6 wk
Vancomycin, aminoglycoside
Susceptible, Penicillin
Resistant
AmpicillinSulbactam+Gentamicin
6 wk
Vancomycin+Gentamicin
6 wk
Penicillin,
Aminoglycoside,Vancomycin
Resistant E faecium
Linazolid
> 8 wk
Quinupristin-dalfopristin
> 8 wk
Imipenem/cilastatin+Ampicillin
> 8 wk
Ceftriaxone Sodium +
Ampicillin
8 wk
Gentamicin Resistant
Penicillin,
Aminoglycoside,Vancomycin
Resistant E faecalis
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Circulation 2005;111;e394-e433
DURATION
Ceftriaxone sodium
4 wk
Ampicillin- sulbactam
4 wk
Ciprofloxacin
4 wk
Culture
Negative
Culture
Negative
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VALVES
Native Valve
Prosthetic
Valve
REGIMEN
DURATION
Ampicillin-sulbactam +
Gentamicin
4-6 wk
Vancomycin +
Gentamicin
plus ciprofloxasin
Vancomycin +
Gentamicin
6 wk
2 wk
plus Cefepim +
Rifampin
6 wk
4-6 wk
4-6 wk
Circulation 2005;111;e394-e433
High Risk
Moderate Risk
Agent
Children
Amoxicillin
2g
50 mg/kg
Ampicillin or
Cefazolin or Ceftriaxone
2 g IM or IV
1 g IM or IV
50 mg/kg IM or IV
50 mg/kg IM or IV
Allergic to Penicillin
or Ampicillin oral
Cephalexin* or
Clindamycin or
Azithromycin or
Clarithromycin
2g
600 mg
500 mg
50 mg/kg
20 mg/kg
15 mg/kg
Allergic to Penicillin
or Ampicillin and
unable to take oral
medicine
Cefazolin or Ceftriaxone
or
Clindamycin
1 g IM or IV
600 mg IM or IV
50 mg/kg IM or IV
20 mg/kg IM or IV
Oral
Unable to take oral
medicine
Guidelines From the American Heart Association. Published online Apr 19, 2007
Conclusion
THANK YOU
DIAGNOSIS IE
Sometimes difficult ?
SULIT pada kondisi :
echocardiography normal atau meragukan
IE mengenai intracardiac devices
kultur darah negatif
Echo negatif
+ 15% of cases of IE vegetasi kecil/(-)
sulit mengidentifikasi vegetasi pd lesi berat (katup
prostetik, lesi degeneratif)
Kesalahan diagnosis IE pada keadaan:
Repeat
TEE after positive TTE as soon as possible in high risk patients
TEE 7-10 days after initial TEE if suspicion exist
Intraoperative
Identification of vegetations, mechanism of regurgitation,
abscesses, fistula, pseudoaneurysms; confirmation of successful
repair; assessment of residual valve dysfunction
Completion of therapy
Establish new baseline for valve function and morphology;
ventricular size and function
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Circulation 2005;111;e394-e433
ECHOCARDIOGRAPHY
Three
Limit
Maintenance
CLASSIFICATION
Old
clasiffication: acute/subacute/chronic
Present classification, based on:
related to surgery
Active IE : if diagnosis of IE 2 months
before surgery
Recurrent IE: IE develops after had been
eradicated
Persistent IE: IE has never been
eradicated
ESC Guidelines of IE. EHJ 2004; 25: 267 276
Classification based on
PATHOGENESIS
Native
IE
side IE
Left side IE
Specific anatomical site (mitral, aortic,
mural, etc)
Classification based on
MICROBIOLOGY
Culture,
Surgery In PVE
Early
ECHOCARDIOGRAPHY
2.
MANAGEMENT OF COMPLICATIONS
common: S aureus *, **
MRSA had been emerging (60-70% in
Europe)**
Other organisms: P aeruginosa, Candida,
enterococci, streptococci *, **
Polymicrobial infection 5-10% **
IE PREVENTION
American Heart Association Guidelines (2007)
1) IE prophylaxis in dental procedures for patients with underlying
cardiac conditions associated with the highest risk of adverse
outcome from IE
2) IE prophylaxis is for all dental procedures (manipulation of gingival
tissue or the periapical region of teeth) or perforation of the oral
mucosa, and for procedures on respiratory tract or infected skin,
skin structures, or musculoskeletal tissue.
3) Prophylaxis is not recommended based solely on an increased
lifetime risk of acquisition of IE
4) Antibiotics solely to prevent IE is not recommended for patients
who undergo a genitourinary or gastrointestinal tract procedure.
The writing group reaffirms the procedures noted in the 1997
prophylaxis guidelines for which endocarditis prophylaxis is not
recommended and extends this to other common procedures,
including ear and body piercing, tattooing, and vaginal delivery and
hysterectomy.
Guidelines From the American Heart Association. Published online Apr 19, 2007
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