Infective Endocarditis (IE) PDF

Infective endocarditis (IE) dr. Yusuf Galenta Sp.JP(K)FIHA Defenition Infective endocarditis (IE) is an inflammation of the endocardium.. inner of the heart muscle & the epithelial lining of heart valves Infective endocarditis (IE) is an inflammation of the endocardium.. inner o...

Infective endocarditis (IE) dr. Yusuf Galenta Sp.JP(K)FIHA Defenition Infective endocarditis (IE) is an inflammation of the endocardium.. inner of the heart muscle & the epithelial lining of heart valves Infective endocarditis (IE) is an inflammation of the endocardium.. inner of the heart muscle & the epithelial lining of heart valves.  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  Endophtalmitis Macula irregular erythe- matous tak nyeri, 1-4mm, di thenar/ hypothenar tangan/ kaki  vasculitis Janeway lesion Nodul kecil, lunak, merah- ungu, di terminal falangs jari tangan/kaki, telapak Retinal hemorrhages kaki, thenar/hypothenar with pale centers tangan Immune- Immune-mediated mediated vasculitis vasculitis Roth’s spot Osler node 3  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: Sulit membedakan vegetasi dg. trombi, prolaps cusp, tumor, myxoma, vegetasi non infectif (marantic endocarditis) Habib G, Heart 2006;92:124–130. 4  Definitions of Terms Used in the “Modified Duke Criteria” for the Diagnosis of IE MAJOR CRITERIA 1. 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 > 1:800 Circulation 1998;98;2936-2948 HACEK: Haemophylus aphrophilus, Actinobacillus actinomycetem- temcomitens, Cardiobacterium hominis, Eikenella corrodens, Kingella Circulation 2005;111;e394-e433 kingae 5  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  Definitions of Terms Used in the “Modified Duke Criteria” for the Diagnosis of IE 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-e433 7  Approach to The Diagnostic Use of Echocardiography Low initial patient risk IE SUSPECTED High initial patient risk Moderate to high clinical suspicion Low clinical suspicion Difficult imaging candidate Initial TTE Initial TEE - + - + Low Increased Rx High Look for other Rx suspicion suspicion suspicion source of persist during persist symptoms clinical course High risk No high risk Echo feature echo feature TEE Repeat TEE - + TEE for No TEE unless - + detection of complication clinical status deteriorates + - Alternative diagnosis established Look for Rx Rx Look for Look for other other other source source source Follow-Up TEE or TTE Reassess vegetation 8 Complication or Rx response Circulation 2005;111;e394-e433 As clinically indicated  The Use of Echocardiography During Dx and Rx of IE Early Echo as soon as possible ( 38.0°C 3. VASCULAR phenomena : major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions 4. IMMUNOLOGIC phenomena : glomerulonephritis, Osler’s nodes, Roth spots, and rheumatoid factor 5. MICROBIOLOGCAL evidance : positive blood culture but does not meet a major criterion as noted above or serological evidence of active infection with organism consistent with IE 6. ECHOCARDIOGRAFI findings : consistent with IE but do not meet a major criterion 10 Circulation 2005;111;e394-e433  Definition Diagnosisofof IEIE According to Duke According Criteria Duke Criteria” to “Modified 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 11 – Does not meet criteria for possible IE as above Circulation 2005;111;e394-e433 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 & sequelae 3) 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 12  OPERASI SEGERA BILA :  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) 13  Antimicrobial Therapy for Native Valves SUSCEPTIBLE / BAKTERIAL RESISTANT REGIMEN DOSAGE & ROUTE Durati on Streptococcus Penicillin G Sodium 12–18 million U/24 h IV either continuously or viridan Penicillin susceptible in 4 or 6 equally divided doses 4 wk Streptococcus Ceftriaxone Sodium* 2 g/24 h IV/IM in 1 dose 4 wk bovis + Gentamicin + 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 Streptococcus Relatively Penicillin Penicillin G Sodium 24 million U/24 h IV either continuously or in viridan Resistant 4–6 equally divided doses 4 wk Streptococcus Ceftriaxone Sodium 2 g/24 h IV/IM in 1 dose + bovis + Gentamicin 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 Oxacillin-susceptible Nafcillin or oxacillin 12 g/24 h IV in 4–6 equally divided doses 6 wk Staphylococci strains Optional addition of 3mg/kg/24h IV/IM in 2-3 equally divided doses 3-5 d gentamicin For penicillin allergic Cefazolin 6 g/24 h IV in 3 equally divided doses 6 wk Optional addition of 3 mg/kg/24 h IV/IM in 2-3 equally divide doses 3-5 d gentamicin * Ceftriaxone aloneOxacillin-resistant strains could be administrated for 4 weeksVancomycin HCl G instead of Penicillin 30 mg/kg/ 1424 h IV in 2 equally divided doses 6 wk Circulation 2005;111;e394-e433  Antimicrobial Therapy for Prosthetic Valves BAKTERIAL SUSCEPTIBLE / REGIMEN DOSAGE & ROUTE Dura- RESISTANT tion Streptococ Penicillin G Sodium 24 million U/24 h IV either continuously or in 4 or 6 6 wk viridan Penicillin susceptible equally divided doses Streptococ Ceftriaxone Sodium + 2 g/24 h IV/IM in 1 dose + 6 wk + bovis Gentamicin 3 mg/kg per 24 h IV/IM in 1 dose 2 wk Vancomycin HCl 30 mg/kg.24 h IV in 2 equally divided dose 6 wk Streptococ Relatively Penicillin Penicillin G Sodium 24 million U/24 h IV either continuously or in 4–6 6 wk viridan Resistant equally divided doses Streptococ Ceftriaxone Sodium + 2 g/24 h IV/IM in 1 dose + 6 wk bovis Gentamicin 3 mg/kg per 24 h IV/IM in 1 dose Vancomycin HCl 30 mg/kg/24 h IV in 2 equally divided dose 6 wk Staphylo- Oxacillin-susceptible Nafcillin or oxacillin + 12 g/24 h IV in 6 equally divided doses + > 6 wk cocci Rifampin 900 mg/24 h IV/PO in 3 equally divided doses Gentamicin 3 mg/kg/24 h IV/IM in 2 or 3 equally divide dose 2 wk Vancomycin + 30 mg/kg/24 h IV in 2 equally divided doses + Oxacillin-resistant strains Rifampin 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 2 wk doses 15 Circulation 2005;111;e394- Antimicrobial Therapy for Native or Prosthetic Valves Bacterial Susceptible/Resistant Regimen Dosage and route Duration Entero - Penicillin, Genytamycin, cocci Vancomycin Susceptible Ampicillin sodium 12 g/24 h IV in 6 equally divided doses 4-6 wk Penicilin G 18–30 million U/24 h IV either continuously or in 6 equally divided doses+3 sodium+Gentamicin mg/kg per 24 h IV/IM in 3 equally divided doses 4-6 wk 30 mg/kg per 24 h IV in 2 equally divided doses+3 mg/kg per 24 h IV/IM in Vancomycin+Gentamicin 3 equally divided doses 6 wk Penicillin, Streptomycin, Ampilin sodium 12 g/24 h IV in 6 equally divided doses 4-6 wk 24 million U/24 h IV continuously or in 6 equally in divided doses+15 Vancomycin Susceptible, Penicillin G +Streptomycin mg/kg per 24 h IV/IM in 2 equally divided 4-6 wk Gentamicin Resistant 30 mg/kg per 24 h IV in 2 equally divided doses+15 mg/kg per 24 h IV/IM Vancomicin+Streptomycin in 2 equally divided doses 6 wk Vancomycin, aminoglycoside Susceptible, Penicillin Ampicillin- 12 g/24 h IV in 4 equally divided doses+3 mg/kg per 24 h IV/IM in 3 Resistant Sulbactam+Gentamicin equally divided doses 6 wk 30 mg/kg per 24 h IV in 2 equally divided doses+3 mg/kg per 24 h IV/IM in Intrinsic Penicillin resistant Vancomycin+Gentamicin 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 2 g/24 h IV in 4 equally divided doses+12 g/24 h IV in 6 equally divided Resistant E faecalis Imipenem/cilastatin+Ampicillin 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 16 Antimicrobial Therapy for Native or Prosthetic Valves 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 Anti Bacterial Therapy for Culture negative BACTERIA VALVES REGIMEN DOSAGE & ROUTE DURATION Culture Native Valve Ampicillin-sulbactam + 12 g/24 h IV in 4 equally divided doses+ 4-6 wk Negative Gentamicin 3mg/kg/24 h IV/IM in 3 equally divided doses Vancomycin + 30 mg/kg/24 h IV in 2 equally divided doses+ Gentamicin 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 4-6 wk divided doses Culture Prosthetic Vancomycin + 30 mg/kg/24 h IV in 2 equally divided doses+ 6 wk Negative Valve Gentamicin 3 mg/kg/24 h IV/IM in 3 equally divided doses 2 wk plus Cefepim + 6 g/24 h IV in 3 equally divided doses+900 mg/24 6 wk Rifampin h PO/IV in 3 equally divided doses 17 Circulation 2005;111;e394-e433  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 18  Regimens for a Dental Procedure Regimen: Situation Agent Single Dose 30 to 60 minute Before Procedure Adults Children Oral Amoxicillin 2g 50 mg/kg Unable to take oral Ampicillin or 2 g IM or IV 50 mg/kg IM or IV medicine Cefazolin or Ceftriaxone 1 g IM or IV 50 mg/kg IM or IV Allergic to Penicillin Cephalexin*† or 2g 50 mg/kg or Ampicillin  oral Clindamycin or 600 mg 20 mg/kg Azithromycin or 500 mg 15 mg/kg Clarithromycin Allergic to Penicillin Cefazolin or Ceftriaxone† 1 g IM or IV 50 mg/kg IM or IV or Ampicillin and or 600 mg IM or IV 20 mg/kg IM or IV unable to take oral Clindamycin medicine 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. 19 Guidelines From the American Heart Association. Published online Apr 19, 2007  KESIMPULAN  IE terus mengalami perubahan, dari infeksi klasik akibat infeksi streptococcal, hingga IE nosokomial pada pasien yang berisiko tinggi, dan infeksi pada materi artifisial.  Manifestasi IE yang beraneka ragam menyulitkan diagnosis dan mengurangi efisiensi upaya preventif  Perlu terapi agresif pada pasien paling berisiko, disertai penanganan multidisiplin. 20