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/ /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
Periferal abscesess (kidney, spleen, brain, vertebral column)

11. roadmap Definitions Clinical symptoms Diagnosis Treatment basics
Duke criteria
Blood cultures
Echocardiography
Treatment basics
Complications
Prophylaxis
Summary

12. Duke criteria Major criteria Minor criteria
Blood culture positive for typical IE-causing microorganism
Evidence of endocardial involvement
Predisposition – heart condition or i.v. drug abuse
Fever – temp. >38 °C
Vascular phenomena – arterial emboli etc.
Immunologic phenomena – glomerulonephritis, Osler’s nodes, Roth’s spots
Microbiological evidence – positive blood cultures but do not meet major criteria
Diagnosis
2 major criteria
1 major and 3 minor
5 minor criteria

13. roadmap Definitions Clinical symptoms Diagnosis Treatment basics
Duke criteria
Blood cultures
Echocardiography
Treatment basics
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 Clinical symptoms Diagnosis Treatment basics
Duke criteria
Blood cultures
Echocardiography
Treatment basics
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 % vs % )
TEE is first choice to find IE complications

17. Echocardiography Echocardiographic findings in IE Vegetation Abscess
Pseudoaneurysm
Perforation
Fistula
Valve aneurysm
Dishence of prosthetic valve

18. roadmap Definitions Clinical symptoms Diagnosis Treatment basics
Duke criteria
Blood cultures
Echocardiography
Treatment basics
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 - 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

21. roadmap Definitions Clinical symptoms Diagnosis Treatment basics
Duke criteria
Blood cultures
Echocardiography
Treatment basics
Complications
Prophylaxis
Summary

22. Complications Congestive heart failure Uncontrolled infection
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
Neurologic events
Acute renal failure
Rheumatic problems
Myocarditis

24. roadmap Definitions Clinical symptoms Diagnosis Treatment basics
Duke criteria
Blood cultures
Echocardiography
Treatment basics
Complications
Prophylaxis
Summary

25. 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 min prior to intervention

26. roadmap Definitions Clinical symptoms Diagnosis Treatment basics
Duke criteria
Blood cultures
Echocardiography
Treatment basics
Complications
Prophylaxis
Summary

27. Summary IE is rare but serious disease, with high mortality rate
Every case of fever of unknown origin should be suspected for IE
Blood cultures are essential for diagnosis
TTE/TEE is the best method to monitor and follow-up of IE
Antibiotics are main treatment
CHF is the most common complication
Pharmacological prophylaxis is reserved for a narrow group of high risk patients