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2015 ESC Guidelines for the management of infective endocarditis
THE TASK FORCE FOR THE MANAGEMENT OF INFECTIVE ENDOCARDITIS OF THE EUROPEAN SOCIETY OF CARDIOLOGY (ESC)
DR RISHI A BHARGAVA
INFECTIVE ENDOCARDITIS
Infection of the endocardial surface of the heart, which may include one or more heart valves, the mural endocardium, or a septal defect.
Varieties of IE that were uncommon in the early antibiotic era have become prominent.
Cases of NIE, IVDA IE, and PVE have markedly increased. Valvular infections have entered the era of IE caused by
intravascular devices and procedures.
Definitions
Prophylaxis
Patients requiring antibiotic prophylaxis:-
Non specific prevention measures in high and intermediate risk patient
Procedure requiring antibiotics prophylaxis
Contd….
Recommended prophylaxis for high risk procedures in high risk patients
Recommendations for cardiac and vascular procedures
ECHOCARDI- OGRAPHY IN DIAGNOSIS
Use of TTE and TEE:-
Follow up during treatment
Intra op during cardiac surgery
After completion of therapy
Indication For Echocardiography In I.E.
CAUSATIVE ORGANISMS
The etiologic agents
•Streptococci: 60%-80% . •Viridans streptococci: 30%-40% . •Other streptococci: 15%-25%. •Enterococci: 5%-18% . •Coagulase-positive organisms: 10%-27%•Coagulase-negative organisms: 1 %-3%•Gram-negative aerobic bacilli: 1% -13% •Fungi: 2%-4% Staphylococci: 20%-35%
Also more commonly seen -Pseudomonas aeruginosa , esp in pentazocine addictCandida is commonly implicated in heroin addict
The most common etiologic agent of infective endocarditis - S. aureus
IV drug users
In patients with prosthetic valves, the microbiology is somewhat dependent on early (<12 months after valve replacement) versus late (>I2 months) endocarditis.
Staphylococci- 40% to 60% of the cases of early onset prosthetic valve endocarditis.
Coagulase-negative staphylococci - 30% to 35% of cases, S. Aureus - 20% to 25%.
Late onset PVE – organisms same as native valve disease.
• Fungal endocarditis -• IV drug users,• Recently undergonecardiovascular surgery,• Received prolonged IV antibiotic therapy.
HACEK organisms
HACEK is an acronym for a group of fastidious, slow-growing, gram-negative bacteria
Account for approximately 5% to 10% of cases of community-acquired endocarditis.
•H: Haemophilus parainfluenzae, Haemophilus aphrophilus, Haemophilus paraphrophilus, .Haemophilus influenzae .•A : Actinobacillus actinomycetemcomitans .•C : Cardiobacterium hominis .•E : Eikenella corrodens •K: Kingella kingae, Kingella denitrificans
Investigation of rare causes of I.E.(blood culture -ve)
DIAGNOSTIC CRITERIA
Modified Duke’s criteria
Definition Of Different Criteria
ESC Algorithm For Diagnosis Of I.E.
PROGNOSTIC FACTORS
Predictors of poor outcome in patient with infective endocardiris
ANTIBIOTIC TREATMENT
Streptococcal bovis and oral streptococci
Penicillin susceptible – standard treatment – 2wk vs 4wk beta lactam allergicPenicillin aresistant Standard treatment Beta lactam allergic
Antibiotic treatment - oral streptococci and streptococci bovis- penicillin susceptible
Penicillin resistance :
Antibiotic treatment - staphylo-cocci
Native valve – Methicilin susceptible /methicillin resistant or pencilillin allergic Prosthetic valveMethicilin susceptible /methicillin resistant or pencilillin allergic
No role of gentamicin in native valve staph infection.Rifampicin is added 3-5 days after starting antibiotics in prosthetic valve endocarditis.
Antibiotic treatment - staphylo-cocci
Antibiotic treatment - staphylo-cocci – prosthetic valve
Antibiotic treatment - entero-cocci – prosthetic valve
Antibiotic treatment of blood culture negative infective endocarditis
Antibiotic treatment of blood culture negative infective endocarditis
Empirical treatment
Empirical treatment of acutely severe ill patient
Outpatient Parenteral Antibiotic Therapy(OPAT)
SURGICAL MANAGEMENT
Indication and timing of surgery in left sided valve infective endocarditis
Indication for surgical treatment of right sided infective endocarditis
Factors associated with increase rate of relapse
Cardiac device related infective endocarditis (CDRIE)
Diagnosis
Principles of Treatment
Mode of device removal
Re-implantation
Prophylaxis
I.E. In congenital heart diseases
Fewer systematic studies. Incidence is lower in children(o.o4% per year ) than in
adult(0.1%) CHD with multiple lesion is at higher risk than simple lesion. Mortality of 4-10 %. Prognosis is better than other forms. Surgical repair of CHD reduces the risk, provided there is no
residual shunt. Artificial valve substrate may increase the risk.
I.E. during pregnancy
Incidence – 0.006%. Higher inpatients with cardiac disease and further
more in pt with prosthetic valves. Maternal mortality is approximately 33% ,with most
death relating to HF or an embolic event. Foetal mortality is about 29%. Rapid detection and appropriate treatment is
important. Despite the high foetal mortality , urgent surgery
should be performed in pt who present with HF due to acute regurgitation.
“……..not to forget, they originated millions of years before us ; and how to survive, probably know better than us!! “