Infective Endocarditis

INFECTIVE ENDOCARDITIS

Nurkhalis Muchlis, MD , FIHADEPARTMENT OF CARDIOLOGY & VASCULAR MEDICINE

FACULTY OF MEDICINE UNIVERSITY OF SYIAH KUALA BANDA ACEH

Mortality rate remain as high as 20% for both native and prosthetic valve endocarditis.

Despite improvements in health technology, incidence of IE has not changed much

Approximately 1.7-6.2 cases per 100,000 person-years

Risk factors : cardiac structural abnormalities, immunosuppressed status, pacemaker-related infections, prolonged surgery, reoperation, catheter-related bacteremia and sternal wound infection

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

High clinical suspicion (urgent indication for echocardiographic screening and possibly hospital admission)

New valve lesion/(regurgitant) murmur Embolic events of unknown origin (esp. cerebral and renal infarction) Sepsis of unknown origin Haematuria, glomerulonephritis, and suspected renal infarction “Fever “ plus

• Prosthetic material inside the heart • Other high predispositions of IE• Newly developed ventricular arrhythmias or conduction disturbances• First manifestation of chronic heart failure• Positive blood cultures (if the organism identified is typical for NVE/PVE)• Cutaneous (Osler, janeway) or ophthalmic (roth) manifestations• Multifocal/rapid changing pulmonary infiltrations (right heart IE)• Peripheral abscesses (renal, spienic, spine) of unknown origin• Predisposition and recent diagnostic/therapeutic interventions known to

result in significant bacteraemia

Low Clinical Suspicion Fever plus none of the above

CRITERIA THAT SHOULD RAISE SUSPICION OF IE

“Modified Duke Criteria” for the Diagnosis of IE

MAJOR CRITERIA1. Positive blood culture for IE Typical microorganism consistent with IE from 2 separate blood cultures :

Streptococcus viridans, Streptococcus bovis, or HACEK group, or Staphylococcus aureus or community-acquired enterococci, in the

of a primary focus Microorganisms consistent with IE from persistently positive blood cultures defined as :

• at least 2 positive cultures of blood samples drawn >12 hours apart or• all of 3 or a majority of ≥ 4 separate cultures of blood (with first and

last sample drawn at least 1 hour apart• Single positive blood culture for Coxiella burnetti or anti-phase1 IgG

antibody titer > 1:800Circulation 1998;98;2936-2948

Circulation 2005;111;e394-e433HACEK: Haemophylus aphrophilus, Actinobacillus actinomycetem- temcomitens, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae 5


MAJOR CRITERIA

2. Evidence of endocardial involvement

A. Positive echocardiogram for IE TEE recommended for: patient with prosthetic valves; at least “possible IE” by clinical criteria, or complicated IE; TTE as first test in other patients 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, or

B. New valvular regurgitation (worsening or changing of preexisting murmur not sufficient)

Circulation 1998;98;2936-2948

Circulation 2005;111;e394-e4337


Minor Duke Criteria

1. Predisposition, predisposing heart condition, or IDU2. Fever, temperature > 38o C3. Vascular phenomena, major arterial emboli, septic

pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages and Janeway’s lesions

4. Immunologic phenomena: glomerulonephritis, Osler’s node, Roth’s spot and rheumatoid factor

5. 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

6. Non specific echocardiographic findings omitted

Janeway lesion

Roth’s spot Osler node

Endophtalmitis

Macula irregular erythe-matous tak nyeri, 1-4mm, di thenar/ hypothenar tangan/ kaki vasculitis

Retinal hemorrhages with pale centersImmune-mediated vasculitis

Nodul kecil, lunak, merah-ungu, di terminal falangs jari tangan/kaki, telapak kaki, thenar/hypothenar tangan Immune-mediated vasculitis

3

DEFINITE Pathological criteria

– Microorganisms: demonstrated by culture or histology in a vegetation, or in an intracardiac abscess, or

– Pathological lesions: vegetation or intracardiac abscess confirmed by histology

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– Firm alternate diagnosis for IE, or– Resolution of manifestations of IE with antibiotic therapy for < 4 days, or– No pathological evidence of IE at surgery or autopsy, after antibiotic

therapy for < 4 days– Does not meet criteria for possible IE as above

Diagnosis of IE According to “Modified Duke Criteria”


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Culture-negative endocarditis

Proportion of CNE: 1-55 % Five main cause of CNE:

Fastidious growing bacteria; HACEK group, Coxiella burnetti, Bartonella sp

Non bacterial organism; namely fungi Antibiotic administration preceding culture Right-sided endocarditis Endocarditis in patient with permanent pacemaker

Further investigation in CNE: serological testing, histological techniques, molecular techniques (PCR)

Embolic Events : Most common & predictor of death Higher prevalence in cerebral than peripheral Increased risk of emboli in:

Infection of staphylococci, enterococci, HACEK, fungi Vegetation: 10 mm, mobile, low density, rapid growth IE in Mitral valve Early course of IE

COMPLICATION

Embolic Signs

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

CARDIAC FAILURE

Due to Immune complex glomerulonephritis Hemodynamic instability Renal infarct / emboli Drug toxicity

Treatment depends on clinical Usually reversible

COMPLICATION

ACUTE RENAL FAILURE

Predict death, CHF and need of surgery Can manifest as

Perivalvular abscess (usually in PVE) Arrhytmia or conduction disturbance (aortic

NVE) Fistula, pseudoaneurysm Obstructive lesion

More frequent in PVE and aortic NVE

COMPLICATION

PERIANNULAR EXTENSION OF INFECTION

Uncommon Result from septic embolization of

vegetations to arterial vasa vasorum or intraluminal space

Intracranial MA is more frequent than extracranial MA (visceral and extremities)

COMPLICATION

MYCOTIC ANEURYSM

If initiation of antimicrobial therapy is urgent, empiric antibiotic treatment can be started thereafter (blood culture)

In all other cases it is recommended to post-pone therapy until blood cultures become positive.

Previous short term antibiotic discontinue for at least 3 day before taking blood cultures.

Previous long term antibiotic treatment discontinue for 6 - 7 days.

ESC guideline; European Heart J 2004

ANTIMICROBIAL THERAPY

Antimicrobial Therapy for Native Valves

Circulation 2005;111;e394-e433* Ceftriaxone alone could be administrated for 4 weeks instead of Penicillin G

BAKTERIALSUSCEPTIBLE /

RESISTANT REGIMEN DOSAGE & ROUTE Duration

Streptococcus viridan Penicillin susceptible

Penicillin G Sodium 12–18 million U/24 h IV either continuously or in 4 or 6 equally divided doses 4 wk

Streptococcus bovis

Ceftriaxone Sodium* + Gentamicin

2 g/24 h IV/IM in 1 dose + 3 mg/kg per 24 h IV/IM in 1 dose

4 wk 2 wk

Vancomycin HCl 30 mg/kg per 24 h IV in 2 equally divided dose 4 wk

Streptococcus viridan

Relatively Penicillin Resistant

Penicillin G Sodium 24 million U/24 h IV either continuously or in 4–6 equally divided doses 4 wk

Streptococcus bovis

Ceftriaxone Sodium + Gentamicin

2 g/24 h IV/IM in 1 dose + 3 mg/kg per 24 h IV/IM in 1 dose 2 wk

Vancomycin HCl 30 mg/kg per 24 h IV in 2 equally divided dose 4 wk

StaphylococciOxacillin-susceptible

strains Nafcillin or oxacillin 12 g/24 h IV in 4–6 equally divided doses 6 wk

Optional addition of

gentamicin 3mg/kg/24h IV/IM in 2-3 equally divided doses 3-5 d

For penicillin allergic Cefazolin 6 g/24 h IV in 3 equally divided doses 6 wk

Optional addition of

gentamicin 3 mg/kg/24 h IV/IM in 2-3 equally divide doses 3-5 d

Oxacillin-resistant strains Vancomycin HCl 30 mg/kg/ 24 h IV in 2 equally divided doses 6 wk14

BAKTERIAL SUSCEPTIBLE /RESISTANT REGIMEN DOSAGE & ROUTE Dura-

tion

Streptococ viridan Penicillin susceptible

Penicillin G Sodium 24 million U/24 h IV either continuously or in 4 or 6 equally divided doses

6 wk

Streptococ bovis



6 wk + 2 wk

Vancomycin HCl 30 mg/kg.24 h IV in 2 equally divided dose 6 wk

Streptococ viridan

Relatively Penicillin Resistant

Penicillin G Sodium 24 million U/24 h IV either continuously or in 4–6 equally divided doses

6 wk

Streptococ bovis



6 wk

Vancomycin HCl 30 mg/kg/24 h IV in 2 equally divided dose 6 wk

Staphylo- cocci

Oxacillin-susceptible Nafcillin or oxacillin + Rifampin

12 g/24 h IV in 6 equally divided doses +900 mg/24 h IV/PO in 3 equally divided doses

> 6 wk

Gentamicin 3 mg/kg/24 h IV/IM in 2 or 3 equally divide dose 2 wk

Oxacillin-resistant strainsVancomycin + Rifampin

30 mg/kg/24 h IV in 2 equally divided doses + 900 mg/24 h IV/PO in 3 equally divided doses > 6 wk

Gentamicin 3 mg/kg per 24 h IV/IM in 2 or 3 equally divide doses

2 wk

Antimicrobial Therapy for Prosthetic Valves


Antimicrobial Therapy for Native or Prosthetic Valves


Bacterial Susceptible/Resistant Regimen Dosage and route Duration

Entero -cocci

Penicillin, Genytamycin, Vancomycin Susceptible Ampicillin sodium 12 g/24 h IV in 6 equally divided doses 4-6 wk

Penicilin G sodium+Gentamicin

18–30 million U/24 h IV either continuously or in 6 equally divided doses+3 mg/kg per 24 h IV/IM in 3 equally divided doses 4-6 wk

Vancomycin+Gentamicin30 mg/kg per 24 h IV in 2 equally divided doses+3 mg/kg per 24 h IV/IM in 3 equally divided doses 6 wk

Penicillin, Streptomycin, Ampilin sodium 12 g/24 h IV in 6 equally divided doses 4-6 wk

Vancomycin Susceptible, Penicillin G +Streptomycin24 million U/24 h IV continuously or in 6 equally in divided doses+15 mg/kg per 24 h IV/IM in 2 equally divided 4-6 wk

Gentamicin Resistant Vancomicin+Streptomycin

30 mg/kg per 24 h IV in 2 equally divided doses+15 mg/kg per 24 h IV/IM in 2 equally divided doses 6 wk

Vancomycin, aminoglycoside Susceptible, Penicillin Resistant

Ampicillin-Sulbactam+Gentamicin

12 g/24 h IV in 4 equally divided doses+3 mg/kg per 24 h IV/IM in 3 equally divided doses 6 wk

Intrinsic Penicillin resistant Vancomycin+Gentamicin30 mg/kg per 24 h IV in 2 equally divided doses+3 mg/kg per 24 h IV/IM in 3 equally divided doses 6 wk

Penicillin, Aminoglycoside,Vancomycin Resistant E faecium Linazolid 1200 mg/24 h IV/PO in 2 equally divided doses > 8 wk

Quinupristin-dalfopristin 22.5 mg/kg per 24 h IV in 3 equally divided doses > 8 wk

Penicillin, Aminoglycoside,Vancomycin Resistant E faecalis Imipenem/cilastatin+Ampicillin

2 g/24 h IV in 4 equally divided doses+12 g/24 h IV in 6 equally divided doses > 8 wk

Ceftriaxone Sodium + Ampicillin 2 g/24 h IV/IM in 1 dose+12 g/24 h IV in 6 equally divided doses 8 wk


REGIMEN DOSAGE & ROUTE DURATION

HACEK Ceftriaxone sodium 2 g/24 h IV/IM in 1 dose 4 wk

Ampicillin- sulbactam 12 g/24 h IV in 4 equally divided doses 4 wk

Ciprofloxacin 1000 mg/24 h PO or 800 mg/24 h IV in 2 4 wk

Antimicrobial Therapy for Native or Prosthetic Valves


Anti Bacterial Therapy for Culture negative

BACTERIA VALVES REGIMEN DOSAGE & ROUTE DURATION

Culture Negative

Native Valve Ampicillin-sulbactam +Gentamicin

12 g/24 h IV in 4 equally divided doses+3mg/kg/24 h IV/IM in 3 equally divided doses

4-6 wk

Vancomycin +Gentamicin

30 mg/kg/24 h IV in 2 equally divided doses+3 mg/kg/24 h IV/IM in 3 equally divided doses 4-6 wk

plus ciprofloxasin 1000 mg/24 h PO or 800 mg/24 h IV in 2 equally

divided doses4-6 wk

Culture Negative

ProstheticValve

Vancomycin +Gentamicin

30 mg/kg/24 h IV in 2 equally divided doses+3 mg/kg/24 h IV/IM in 3 equally divided doses

6 wk2 wk

plus Cefepim +Rifampin

6 g/24 h IV in 3 equally divided doses+900 mg/24 h PO/IV in 3 equally divided doses

6 wk

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High Risk Prosthetic heart valves Complex congenital cyanotic heart diseases Previous infective endocarditis Surgically constructed systemic or pulmonary

conduits Moderate Risk

Acquired valvular heart disease Mitral valve prolapse with valvular regurgitation or

severe valve thickening Non-cyanotic congenital heart diseases (except for

secundum type Atrial Septal Defect) including bicuspid aortic valves

Hypertrophic cardiomyopathy

Cardiac condition in Which Antimicrobial Prophylaxis is Indicated

Procedure which may cause bacteraemia and for which antimicrobial prophylaxis is recommended

Diagnostic and therapeutic interventions likely to produce bacteraemia

Bronchoscopy (rigid instrument) Cystoscopy during urinary tract infection Biopsy of urinary tract/prostate Dental procedures with the riak of gingival/mucosal trauma Tonsillectomy and adenoidectomy Oesophageal dilatation/ sclerotherapy Instrumentation of obstructed biliary tracts Transurethral resection of prostate Urethral instrumentation/ dilation Lithotripsy Gynaecologic procedures in the presence of infection

Predisposing diagnostic and therapeutic interventions

Situation AgentRegimen:

Single Dose 30 to 60 minute Before Procedure

Adults Children

Oral Amoxicillin 2 g 50 mg/kg

Unable to take oral medicine

Ampicillin orCefazolin or Ceftriaxone

2 g IM or IV1 g IM or IV

50 mg/kg IM or IV50 mg/kg IM or IV

Allergic to Penicillin or Ampicillin oral

Cephalexin*† or Clindamycin or Azithromycin or Clarithromycin

2 g600 mg500 mg

50 mg/kg20 mg/kg15 mg/kg

Allergic to Penicillin or Ampicillin and unable to take oral medicine

Cefazolin or Ceftriaxone†or

Clindamycin

1 g IM or IV600 mg IM or IV

50 mg/kg IM or IV20 mg/kg IM or IV

IM - intramuscular; IV - intravenous. *Or other first- or second- generation oral cephalosporin in equivalent adult or pediatric dosage. †Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with penicillins or ampicillin.

Regimens for a Dental Procedure

Guidelines From the American Heart Association. Published online Apr 19, 2007 19

IE often presents in an occult fashion, and early diagnosis depends on a high index of clinical suspicion, especially in patient at high risk groups

Latest modification on the widely used Duke criteria include: recognizing the role of serological testing to diagnose IE and the exclusion of non-specific echocardiographic findings as a minor criteria

Molecular techniques to diagnose IE have been introduced (PCR) and are waiting further validation for its routine use

Conclusion

THANK YOU

Optimal techniques for blood culture

Avoid contamination: - optimal antiseptic skin preparation - fresh venepuncture, not through indwelling vascular access

Optimal timing: - no evidence suggest that cultures should be taken coincident with peak temperature, as the bacteremia is constant - acute endocarditis: 2-3 cultures from separate venepunctures within 5 min of each other, prior to antibiotics - subacute endocarditis; several cultures obtained over several hours

Incubation; - most clinically important pathogens from blood culture are recovered by 5 days, including the fastidious organisms - it is better to subculture the negative samples onto enriched solid media rather than extend it for 2-3 weeks

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: Sulit membedakan vegetasi dg. trombi, prolaps cusp, tumor, myxoma, vegetasi non infectif (marantic endocarditis)

Sometimes difficult ?

Habib G, Heart 2006;92:124–130. 4

The Use of Echocardiography During Dx and Rx of IE

Early Echo as soon as possible (<12h after initial evaluation) TTE preferred; obtain TTE view of any abnormal findings TTE if TEE is not immediately available TTE may be sufficient in small children

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


Blood Culture Sampling & Treatment

If initiation of antimicrobial therapy is urgent, empiric antibiotic treatment can be started thereafter (blood culture). In all other cases it is recommended to post-pone therapy until blood cultures become positive.

If the patients has been on short term antibiotic, one should be wait, if possible, for at least 3 day.

Long term antibiotic treatment may not become positive until treatment has been discontinued for 6 - 7 days.

Conflicting data: artery vs. venous; high fever vs. constant bacteraemia.

5-15% of cases are culture negative endocarditis, the most frequent cause is previous antimicrobial treatment.

ESC guideline; European Heart J 2004;00, 1-37 6

Any patient suspected of having Native Valve Endocarditis (NVE) by clinical criteria should be screened by Transthoracic Echocardiography (TTE).

When images are of good quality and prove to be negative and there is only a low clinical suspicion of IE, endocarditis is unlikely and other diagnosis are to be considered.

If suspicion of IE is high, TransEsophageal Echocardiography (TEE) should be performed in all TTE-negative cases, in suspected Prosthetic Valve Endocarditis (PVE), and if TTE is positive but complications are suspected or likely and before cardiac surgery during active IE.

If TEE remains negative and there is still suspicion, it should be repeated within one week. A repeatedly negative study should virtually exclude the diagnosis.

ECHOCARDIOGRAPHY

Three echocardiographic findings are considered to be major critetria in the diagnosis of IE: A mobile, echodense mass attached to the

valvular or the mural endocardium or to implanted prosthetic material

Demonstration of abscesses or fistulas A new dehiscence of a valve prosthesis,

especially when occurring late after implantation

Bacteremia from daily activities (chewing food, tooth brushing and flossing, use of wooden toothpicks, use of water irrigation devices) is much more likely to cause IE than a dental procedure

Extremely small number of IE might be prevented by antibiotic prophylaxis, even if prophylaxis is 100% effective

AHA guideline: Prevention of Infective Endocarditis. Circulation 2007;115

New from AHA for IE prophylaxis

Limit prophylaxis only to conditions with high adverse outcome from endocarditis

Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics

AHA guideline: Prevention of Infective Endocarditis. Circulation 2007;115

Masalah yang dihadapi setelah diagnosis:

1) Dx IE sulit kerusakan katup progresif & irreparable

2) IE sering mengakibatkan kematian di RS (16–25%), kejadian emboli (10–49%) komplikasi & sequelae3) strategi terapi perlu ditetapkan, mungkin individual 4) beberapa pasien mungkin disertai komplikasi spesifik

manajemen spesifik

5) Operasi diperlukan pada + 50% kasus. Kalau pasien stabil operasi ditunda sampai terapi

antibotik selesai untuk mencegah prosthetic valve endocarditis yang terjadi dini

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Hemodinamik memburuk akibat kerusakan katup

Demam menetap meski telah mendapat antibiotik

Terbentuk abses/fistula ok invasi infeksi perivalvar

Organisme penyebab resisten (aggressive staphylococcal strains, Coxiella burnetti, Brucella species, fungi)

Prosthetic valve endocarditis (t.u. segera postop)

Vegetations besar yg berpotensi terjadi emboli ( > 10 mm atau melekat pada katup mitral)

OPERASI SEGERA BILA :

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An approach to diagnosis of IE with echocardiography

AHA Scientific Statement, 2005

Old clasiffication: acute/subacute/chronic Present classification, based on:

Activity and recurrence Diagnostic status Pathogenesis Anatomical site Microbiology

ESC Guidelines of IE. EHJ 2004; 25: 267 – 276

CLASSIFICATION

Activity 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


Classification based on ACTIVITY and RECURRENCE

Established IE: clinically and involvement of endocardium is established

Suspected IE: clinical strongly suspected, but no evidence of endocardium involvement

Possible IE: potential differential diagnosis


Classification Based on DIAGNOSIS

Native valve endocarditis (NVE) Prosthetic valve endocarditis (PVE)

Early PVE (<1 year since surgery) Late PVE (>1 year since surgery)

IE in iv drug abuse (IE in IVDA)


Classification based on PATHOGENESIS

Right side IE Left side IE Specific anatomical site (mitral, aortic,

mural, etc)


Classification bassed on ANATOMIC LOCATION

Culture, serological test, histological and/or molecular biology (PCR)

Culture negative, serological negative, histological negative, and/or PCR negative

If all negative microbiologically negative


Classification based on MICROBIOLOGY

Early PVE ( less than 12 months after surgery)

Late PVE with complication, particularly if staphylococci are the infecting organism

Postoperative antibiotic treatmentFull course of antimicrobial treatment should be

completed regardless duration treatment prior to surgery

Surgery In PVE

ECHOCARDIOGRAPHY

Major Duke Criteria

1. Blood culture positive for IE- Typical microorganism consistent with IE from 2

separate blood cultures: viridans streptococci, Streptococcus bovis, HACEK group, Staphylococcus aureus or community acquired enterococci in the absence of a primary focus; or

- Microorganism consistent with IE from persistently positive blood cultures defined as follows; At least 2 positive cultures of blood samples drawn > 12 hours apart; or all of 3 or a majority of > 4 separate cultures of blood (with first and last sample drawn at least 1 h apart)

- Single positive blood culture for Coxiella burnetti or anti-phase 1 IgG ntibody titer > 1:800

2. Evidence of endocardial involvementEchocardiogram positive for IE, defined as follows:- 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 abcess- or new partial dehiscence of prosthetic valve- or new valvular regurgitation

Rapid and effective antimicrobial treatment may help to prevent embolism.

If the patients is on longterm oral anticoagulation, coumarin therapy should be discontinued and replaced by heparin immediately after the diagnosis of IE has been established

After an embolic complication, the risk for recurrent episodes is high. After manifestation of a cerebral embolism, cardiac surgery to prevent a recurrent episode is not contraindicated if performed early (best within 72 hours) and cerebral haemorrhage has been excluded by cranial computed tomography immediately before the operation.

If surgery is not performed early it is advisable to be postponed for 3-4 weeks

MANAGEMENT OF COMPLICATIONS

Infective Endocarditis (IE) “a rising problem”

Insidens IE terus meningkat

di AS terdapat + 20.000 kasus baru pertahun

Berisiko tinggi terjadi morbiditas & mortalitas

(gagal jantung & emboli)Terus berkembang dalam hal:

risiko tinggi, prosedur diagnostik, jenis mikro-organisme penyebab dan terapi

Diperlukan : DIAGNOSIS CEPAT & TEPAT, TERAPI EFEEKTIF,

PENGENALAN KOMPLIKASI SEGERA

Circulation 1998;98;2936-2948, Circulation 2005;111;e394-e433 2

Most common: S aureus *, ** MRSA had been emerging (60-70% in

Europe)** Other organisms: P aeruginosa, Candida,

enterococci, streptococci *, ** Polymicrobial infection 5-10% **

* AHA guidelines IE. Circulation 2005;111;e394-e433

** ESC guidelines Infective Endocarditis 2004

IE IN INTRAVENOUS DRUG USER (IVDU)

Mandell, Bennett, & Dolin:

Principles and Practice of Infectious Diseases, 6th ed

Proposed scheme for the pathogenesis of infective endocarditis

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.

IE PREVENTIONAmerican Heart Association Guidelines (2007)

Guidelines From the American Heart Association. Published online Apr 19, 2007 18

Infective Endocarditis

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