MIGUEL URINA-TRIANA MD, MSc, FACCDIRECTOR FUNDACION BIOS

NEJM VOL 345 # 18, NOV 1-2001PAG.1318

DEFINICION� LA ENDOCARDITIS INFECCIOSA (EI) ES LA

INFECCION MICROBIANA DE LA SUPERFICIE ENDOTELIAL DEL CORAZÒN

� LA VEGETACIÒN ES LA LESIÓN CARACTERÍSTICA(FIBRINA,PLAQUETAS, MICROORGANISMOS Y CEL. INFLAMATORIAS)

VEGETACIÓN VÁLVULA AÓRTICA

DEFINICION

LAS VÁLVULAS CARDÍACAS SON LAS MÀSFRECUENTES COMPROMETIDAS, SIN EMBARGO,LA INFECCIÒN PUEDE OCURRIR SOBRE ELENDOCARDIO MURAL

Trombo mural en hombre de 65 años

CLASIFICACIONAGUDA

TOXICIDAD SISTÉMICAPROGRESIÓN DE DIAS A SEMANAS HACIA

LA DESTRUCCIÓN VALVULAR E INFECCIÓN EN MÚLTIPLES SITIOS

TIPICA STAPHYLOCOCCUS.AUREUS

SUBAGUDA

MODESTA TOXICIDAD DE SEMANAS A MESES Y OCASIONALMENTE INFECCIÓN MÚLTIPLE

� STREPTOCOCCUS VIRIDANS� ENTEROCOCO� STAPHYLOCOCUS COAGULASA NEGATIVO� COCOBACILOS GRAM (-) DE CRECIMIENTO LENTO

FISIOPATOLOGIAENDOCARDITIS TROMBÓTICA NO BACTERIANA (ETNB) PRODUCTO DE LAHEMOSTASIS CON LA FORMACIÓN DE COMPLEJOS DE FIBRINA Y PLAQUETAS

Fibrina y plaquetas

(NEJM 1997;337:770-777)

ACTIVACIÓN PLAQUETARIA

BASALESACTIVADAS

AKKERMAN ET AL. HEMOSTASIS 1985:39

Bacterias en el endocardio por E. de whipple

NEJM 2000;342:620-625

INMUNOFLUORESCENCIA EN EL MISMO PACIENTE

NEJM 2000;342:620-625

FISIOPATOLOGIA

�“JET “ ENDOTELIAL CÁMARA DE ALTA A BAJA PRESIÓN O FLUJO DE ALTA VELOCIDAD POR ORIFICIO ESTRECHO

FISIOPATOLOGIA� EPISODIOS DE BACTEREMIA� LA ETNB ES VISTA EN CANCER, CID,

UREMIA,QUEMADURAS, LES,VALVULOPATÍAS Y CATÉTERES INTRACARDÍACOS

� DE LA ETNB A EI, SE PRODUCE LA ENTRADA DE MICROORGANISMOS A LA CIRCULACIÓN COMO RESULTADO DE INFECCIÓN LOCALIZADA O DE TRAUMA EN UNA SUPERFICIE DEL ORGANISMO

EMBOLISMO SEPTICO (ASPERGILLUS FUMIGATUS)NEJM 2000;342:1015HOMBRE,61A

CON VALVULAPROTESICAISQUEMIA PIEIZQUIERDO,EMBOLECTO

MIA DE PEDISDORSALIS YTIBIAL.CULTIVO POSITIVOTEE VEG.AORTICAS

SITUACIONESCLINICAS� ENDOCARDITIS DE VALVULAS NATIVAS

(LESIONES VALVULARES ADQUIRIDAS O CONGENITAS) ALGUNOS PATOGENOS (S.AUREUS O STREPTOCOCO PNEUMONIE) PUEDEN CAUSARLAS SOBRE VALVULAS NORMALES (ADICTOS)

SITUACIONESCLINICAS� ENDOCARDITIS INFECCIOSA EN NIÑOS � VALVULA TRICUSPIDE (CATETERES) ALTA

MORTALIDAD S.AUREUS,S.COAGULASA NEGATIVO,STREPTOCOCO GRUPO B, BACILOS GRAM -, CANDIDA

� ENF. CONGENITAS(AORTICA, FALLOT,CIV)

SITUACIONESCLINICASEI EN LOS ADULTOS� PROLAPSO V.MITRAL E INSUFICIENCIA(RIESGO

RELATIVO DE 3.4 A 8.2)� VALVULOPATÍA REUMÁTICA (VM,VA)

� CARDIOPATIAS CONGENITAS (PCA,CIV Y AORTA BICUSPIDE)

SITUACIONESCLINICAS� EI EN ADICTOS ADROGAS IV� 2-5 %/ANUAL HOMBRE 5.4:MUJER 1� VALVULAS DERECHAS� 50 % S. AUREUS,P.AUREUGINOSA� DOLOR TORACICO PLEURITICO, TOS Y

HEMOPTISIS, SOPLO DE I.TRICUSPIDEA

SITUACIONESCLINICAS� EI VALVULAS PROTESICAS� PRIMEROS 6 MESES >RIESGO (6SEMANAS)

0,2-0.35/AÑO.� ESTREPTOCOCOS,S.AUREUS,

ENTEROCOCO,COCO BACILOS DEL GRUPO HACEK :HAEMOPHILUS,ACTINOBACILLUS ACTINOMYCETEMCOMITANS,CARDIOBACTERIUM HOMINIS, EIKENELLAY KINGELLA

SITUACIONESCLINICAS� EI NOSOCOMIAL

� POR CATETERES IV, INTRUMENTACIÓN DEL TRACTO URINARIO O GASTROINTESTINAL, PROCEDIMIENTOS QUIRURGICOS

SITUACIONESCLINICAS� EI CON CULTIVOS NEGATIVOS� 5 % � EN NUESTRO MEDIO >50 % SON NEGATIVOS POR

TTO PREVIO� LAS TECNICAS NO SON LAS MEJORES

MANIFESTACIONES� EFECTOS LOCALES

DESTRUCTIVOS� EMBOLIZACION DE

FRAGMENTOS

� SIEMBRA HEMATOGENA

� RESPUESTA INMUNOLOGICA MEDIADA POR CITOQUINAS Y ACS (depositos de complejos inmunes)

LESIONES PIEL Y UÑAS EN ENDOCARDITIS

HEMORRAGIATIPICA SUBUNGUEALY PETEQUIAS EN LAPIEL DEL ABDOMENEN ENDOCARDITISPOR STAFILOCOCO

HALLAZGOSALEXAMENFISICOYSINTOMAS

MANCHAS DE ROTHARTRALGIAS, MIALGIAS. ARTRITIS, DOLOR LUMBAR, EMBOLISMOS SITEMICOS NODULOS DE OSLER

LESIONES DE JANEWAYPETEQUIAS CONJUNTIVA

RMI MULTIPLES EMBOLOS

NEJM 1997;337:770-777

EXAMEN� ABCESO ESPLENICO-ESPLENOMEGALIA� SINTOMAS NEUROLOGICOS� ANEURISMAS MICOTICOS (INTRACRANEAL O

EXTRACRANEAL)

ANEURISMA MICOTICO ANTES CMI

CLINICA� ICC� EXTENSIÓN PERIANULAR� INSUFICIENCIA RENAL

DIAGNOSTICO� PARACLINICOS� HEMOCULTIVOS� ECOCARDIOGRAFIA� OTROS LABORATORIOS

ECO TTE Y ESPECIMEN POSTQUIRURGICO

ECOCARDIOGRAMA TRANSESOFAGICO

ECOCARDIOGRAMA TRANSTORACICO

Ecocardiografía TT vs TEE

Table 1. Criteria for Clinical Diagnosis of Infective Endocarditis

High probability

Persistently positive blood cultures1 plus one of the following: New regurgitant murmur2,Predisposing heart disease3 and vascular phenomena4 or

Negative or intermittently positive blood cultures5 plus all of the following: Fever6,New regurgitant murmur,Vascular phenomena

Criterios de probabilidad

Medium probability

Persistently positive blood culture plus one of the following: Predisposing heart disease,Vascular phenomena orNegative or intermittently positive blood cultures plus all of the following: Fever,Predisposing heart disease,Vascular phenomena orViridans group streptococcus only: at least two positive blood cultures without an extracardiac source and feverLow probability

None of the above classifications applicableorAlternative diagnosis generally apparent but

endocarditis not excluded

1 At least two blood cultures obtained with two of two positive, three of three positive, or at least 70% of cultures positive if four or more cultures obtained. 2 Not previously noted during current hospitalization, past hospitalizations, or past outpatient clinic visits. 3 Definite valvular or congenital heart disease or a cardiac prosthesis (excluding permanent pacemakers). 4 Petechiae, splinter hemorrhages, conjunctival hemorrhages, Roth's spots, Osler's nodes, Janeway lesions, aseptic meningitis, glomerulonephritis, and pulmonary, central nervous system, coronary, or peripheral emboli. 5 Any rate of blood culture positivity that does not meet the definition above of persistently positive. 6 Fever >38.0°C.

Reprinted from Durack et al,5 American Journal of MedicineDefinite IEPathological criteriaMicroorganisms: demonstrated by culture or histology in a vegetation, in a vegetation that has embolized, or in an intracardiac abscess, or Pathological lesions: vegetation or intracardiac abscess present, confirmed by histology showing active endocarditisClinical criteria, using specific definitions listed in Table 2,2 major criteria, or 1 major and 3 minor criteria, or 5 minor criteria Possible IEFindings consistent with IE that fall short of "Definite" but not "Rejected" Rejected Firm alternate diagnosis for manifestations of endocarditis, or Resolution of manifestations of endocarditis with antibiotic therapy for 4 days, or No pathological evidence of IE at surgery or autopsy, after antibiotic therapy for 4 days

Table 1. Duke Clinical Criteria for Diagnosis of IE

Table 2. Definitions of Terms Used in the Duke Criteria for the Diagnosis of IE

Major criteria1. Positive blood culture for IEA. Typical microorganism consistent with IE from 2 separate blood cultures as noted below:(i) viridans streptococci,1 Streptococcus bovis, or HACEK group, or

(ii) community-acquired Staphylococcus aureus or enterococci, in the absence of a primary focus, orB. Microorganisms consistent with IE from persistently positive blood cultures defined as(i) 2 positive cultures of blood samples drawn >12 hours apart or(ii) all of 3 or a majority of 4 separate cultures of blood (with first and last sample drawn 1 hour apart)

CRITERIOS DE DUKE

2. Evidence of endocardial involvementA. Positive echocardiogram for IE defined as(i) oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomic explanation, or(ii) abscess, or(iii) new partial dehiscence of prosthetic valve, orB. New valvular regurgitation (worsening or changing of preexisting murmur not sufficient)not cause endocarditis

Minor criteria1. Predisposition: predisposing heart condition or intravenous drug use2. Fever: temperature 38.0°C3. Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions

CRITERIOS DE DUKE

4. Immunologic phenomena: glomerulonephritis, Osler's nodes, Roth spots, and rheumatoid factor5. Microbiological evidence: positive blood culture but does not meet a major criterion as noted above2 or serological evidence of active infection with organism consistent with IE6. Echocardiographic findings: consistent with IE but do not meet a major criterion as noted aboveReprinted from Durack et al,5 American Journal of Medicine, with permission from Excerpta Medica Inc. 1 Includes nutritionally variant strains (Abiotrophia species). 2 Excludes single positive cultures for coagulase-negative staphylococci and organisms that do

CRITERIOS DE DUKE

Table 4. Clinical Situations Constituting High Risk for Complications for IE •Prosthetic cardiac valves•Left-sided IE•S aureus IE•Fungal IE•Previous IE•Prolonged clinical symptoms (3 months)•Cyanotic congenital heart disease•Patients with systemic to pulmonary shunts•Poor clinical response to antimicrobial therapy

•Valvular dysfunction•Acute aortic or mitral insufficiency with signs of ventricular failure3

•Heart failure unresponsive to medical therapy3

•Valve perforation or rupture3

•Perivalvular extension•Valvular dehiscence, rupture, or fistula3

•New heart block3

•Large abscess, or extension of abscess despite appropriate antimicrobial therapy3

1 See text for more complete discussion of indications for surgery based on vegetation characterizations. 2 Surgery may be required because of risk of embolization. 3 Surgery may be required because of heart failure or failure of medical therapy.

TRATAMIENTO� ERRADICACION DEL MICROORGANISMO� ANTIBIOTICOS� ANTIMICOTICOS� POR PERIODOS LARGOS� TRATAMIENTO QUIRURGICOS

•Table 5. Echocardiographic Features Suggesting Potential Need for Surgical Intervention1

•Vegetation•Persistent vegetation after systemic embolization:•Anterior mitral leaflet vegetation, particularly with size >10 mm2 One or more embolic events during first 2 weeks of antimicrobial therapy2

•Two or more embolic events during or after antimicrobial therapy2

•Increase in vegetation size after 4 weeks of antimicrobial therapy2 3

PRONOSTICO� 16-27 % MORTALIDAD, SOBREVIDA DE EI

VALVULAS NATIVAS 80% A 10 AÑOSFACTORES DE MAL PRONOSTICO:>65AÑOSENF. SUBYACENTESE.VÁLVULA AÓRTICAICCCOMPROMISO DEL SNCCOMPLICACIONES INTRACARDIACASINFECC. POR S.AUREUS,S.NO VIRIDANS GRUPO B,C Y GC.BURNETTI,P.AERUGINOSA,ENTEROBACTERIACEAE,HONG

OS Y ENTEROCOCOS

PREVENCION� EVALUAR EL RIESGO Y PROFILAXIS AHA� PROC.DENTALES CON HEMORRAGIA� AMIGDALECTOMÍA O DENOIDECTOMÍA� CIRUGÍA DEL TRACTO SUPERIOR RESPIRATORIO� BRONCOSCOPIA CON BRONCO RIGIDO� ESCLEROTERAPIA,CIRUGÍA TRACTO URINARIO (PROSTATA)� DILATACION DE ESOFAGO, SONDA VESICAL EN IU� COLECISTECTOMIA, CISTOSCOPIA� HISTERECTOMÍA VAGINAL� PARTO VAGINAL COMPLICADO POR INFECCIÓN� INCISION Y DRENAJE DE TEJIDO INFECTADO

PROFILAXISPROCEDIMIENTOS DENTALES Y TR� AMOXICILINA 3.GR VO 1 HORA PRE Y LUEGO 1.5 6

HORAS DESPUES DE LA 1A DOSIS� ERITROMICINA,CLINDAMICINA,AMPICILINA

PROCEDIMIENTOS URINARIOS Y GASTROINSTESTINALES

� AMPICILINA, GENTAMICINA, VANCOMICINA, AMOXICILINA