InfectIve endocardItIs


   MohaMed salIh azIz
defInItIon
 Life-thre te
           a ninginfe tio invo
                     c n      lvingthee o a ium
                 ...
epIdeMIology
 10 0 0 c s sp r ye r in theUS
     -2 ,0 0 a e e a
 Ma :Fe a ra 1.7:1
      le m le tio
 Ne tre s
     w ...
epIdeMIology
 Mitra va a ne2 -4 %
       l lve lo 8 5
 Ao va a ne5 6 (b us idva in 2 % o
    rtic lve lo -3 % ic p lve  ...
Classification
 Old :
    Sub c Ba te l End c rd
        a ute c ria   o a itis
       De th in 3 m nths
          a   ...
pathogenesIs
 Alte tio o theva
      ra n f      lvula e o lia s c
                       r nd the l urfa e
  le d tod p ...
pathogenesIs
 Lo p s ure(d w tre m s eo s tura le io
    w re s    o ns a ) id f truc l s n
    Atria s eo m l va (MR)
 ...
pathogenesIs
 Tra ie b c re ia
      ns nt a te m
    Tra a tio o m o a s
        um tiza n f uc s l urfa ec lo dw
     ...
MIcrobIology
 Staphylococcus aureus (3 -4 %)
                           0 0
 Virid nsg ups p c c i (18
       a ro tre t...
Streptococcus Viridans
 Ora o in
     l rig
 9 % c ra
   0 ure te
 3 % c m lic tio
   0 o p a ns
Strep. Gallolyticus (Bovis)
 GI le io
       s ns
 C c lo
    A o n
 c lo s o y o b riume m s uldb p rfo e
   o no c p ...
Strept. Pneumoniae
   Rare
   Typ a ha fulm nt c urs
       ic lly s     ina o e
   As o ia d ep riva
      s c te    e...
Group B strep ( agalactiae)
 Ris fa to ( DM, live fa
     k c rs           r ilure e c
                             , le ...
Enterococcus
   Affe tso e m n a r GU m nip tio
        c ld r e fte        a ula ns
   Affe ts yo e w m n a r o s Ma ul...
Staph aureus
 Fulm nt c urs .
      ina o e
 W es re d m ta ta infe tio e m c rd l
    id p a e s tic      c ns .g yo a ...
Gram –ve endocarditis
 E.gg m– b c ( HAC
       ra ve a illi       EK, e ro a te a ).
                               nte ...
Salmonella species
   Va lvula p rfo tio
            r e ra ns
   Atria thro b
         l    mi
   Myo a itis
         ...
Serrata marcescenses
 No d m inly in d a us rs
     te a          rug b e
 Typ a invo m l a a rticva
      ic lly    lve...
Pseudomonas
   Druga d ts
            d ic
   Affe tsno a va s
        c      rm l lve
   Ma r e b licp no e
       jo ...
Fungal endocarditis
 Inc a e ris in d a d ts im uno o ro is d b a
     re s d k     rug d ic , m c m m e , ro d
    s e t...
Q fever ( Coxiella burnetii)
   Mo t p tie ha und rlyinghe rt d e s .
        s a nts ve e             a is a e
   C nic...
Culture –ve endocarditis
 <5%
 Re e a m tra n o a io s
    c nt d inis tio f ntib tic .
 Slo g w e HAC
     w ro th .g ...
characterIstIcs of causatIve organIsMs
 Ad re efa to c a fo g w in the
    he nc c rs ritic l r ro th
 ve e tio
   g ta n...
rIsk factors
 Struc l he rt d e s
        tura a is a e
    Rhe a , c ng nita a ing
         um tic o e l, g
    P s ti...
clInIcal ManIfestatIons
 Sym to s
     p m
   Fe r, s e ts c
      ve w a , hills
   Ano xia m la e w ig lo s
       re...
cardIac pathologIc changes
 Ve e tio o va c s line
    g ta ns n lve lo ure s
 De truc n a p rfo tio o va le fle
    s t...
S. Aureus mitral valve vegetation, anterior
leaflet
pathologIc changes
 Kid y
      ne
    Im unec m le g m rulo p
        m     o p x lo e ne hritis
    Em o w infa tio a...
pathologIc changes
 Sp nice rg m nt, infa tio
    le    nla e e      rc n
 Se tico b ndp o ry e b lis
    p    r la ulm ...
case defInItIon
   19 P lle r a P te d rf c ria
      77 e tie nd e rs o rite
   19 1 vo Re c ria
      8    n yn rite
...
ModIfIed duke crIterIa
 Ma r C ria
    jo rite
  P so itiveb o c
               lo d ulture w typ a o a m
              ...
ModIfIed duke crIterIa
 Mino C ria
       r rite
   P d p s n (va
      re is o itio    lvula d e s o IDU)
             ...
ModIfIed duke crIterIa
 De finiteIE
    P tho g c ria
      a lo ic rite
   C  linic l c ria
            a rite
      ...
blood cultures
 MULTIP BLOOD C
        LE      ULTURES BEFORE EMPIRIC
  THERAP    Y
 If no c a ill
       t ritic lly
  ...
“culture negatIve” Ie
 Le sc m o w im ro db o c
     s o m n ith p ve lo d ulturem tho s     e d
 Sp c l m d re uire
   ...
hacek
 Haemophilus aphrophilus, H. paraphrophilus,
    parainfluenzae
   Actinobacillus actinomycetemcomitans
   Cardio...
other MIcrobIologIc Methods
P R
  C
   Coxiella burnetii
   Tropheryma whipplei
   Bartonella henselae
 Se lo y
    r...
echocardIography
 Tra tho c
     ns ra ic
    Re tive lo s ns
       la ly w e itivity
    Go d s e ific
       o p c i...
When to go to tee fIrst?
 Lim dtho c w o s= TTE lo s ns
       ite   ra ic ind w       w e itivity
 P s ticva s
   ro th...
other tests
 Ele tro a io ra
      c c rd g m
    C nd tio d la
       o uc n e ys
    Is he iao infa tio
       c m r ...
treatMent of Ie
 Na tivevs P s ticVa
           . ro the     lve
 Ba te id l the p isne e s ry
     c ric a ra y        ...
antIMIcrobIal therapy
 Mo t p tie a a b in 3 d ys
      s a nts re fe rile    -5 a
 Lo d tio o the p (4 w e o m re
     ...
natIve valve Ie
 Virid nsStre to o c a S. bovis
         a      p c c i nd
    Aq o P nic
         ue us e illin G 12 0m...
natIve valve Ie
 Am g o id sfo s rg
      ino lyc s e r yne y
    Lo c nc ntra nsa a e ua (1-3m g l)
        w o e tio r...
natIve valve Ie
 Ente c c i, a p illin s ns
       ro o c m ic        e itive
    Hig ra so fa
         h te f ilure
   ...
natIve valve Ie
 S. aureus
    P nic
      e illina e s ta s m ynthe p nic
                s -re is nt e i-s    tic e il...
natIve valve Ie
 Me illin-re is nt S. aureus
    thic     s ta
   Va o yc isb c rio ta
       nc m in a te s tic
   Va ...
natIve valve Ie
 HAC   EK
    C ftria ne2gIV q 2 x 4 w e
      e xo               4 -6 e ks
 Fung l
       a
    Am ho...
natIve valve Ie
 Ind a nsfo s e
      ic tio     r urg ry
    Re c ry C
        fra to    HF
    Mo tha o s te ice b li...
prosthetIc valve Ie
 Sta hylo o c m s c m o
     p    c ci ot o mn
    C a ula ene a
      o g s g tives pta hylo o c
  ...
prosthetIc valve Ie
 Ris isg a s in thefirs 3m nthsa firs ye r (e rly
     k   re te t        t  o     nd t a a
 P IE)
  ...
prosthetIc valve Ie
 TEE s uldb us d firs
         ho    e e      t
 Sta hylo o c
     p     cci
    Va o yc o o c
    ...
prophylaxIs of Ie
 Unc rta
      e inty a c ntro rs
               nd o ve y
 No ra o ize tria
       nd m d ls
 Ind c ...
clInIcal case
   4 yrsm n ESRD, C d ve Re l Tra p nt 2 0
     3      a         a a ric na     ns la 0 4
   Re urre UTIs ...
 Urinew MRSA, 4 b o c
          ith        /4 lo d ulture w MRSA
                                   s ith
 Initia TTE: E...
 Re l a g ft re o dthefo w d y w a s e s
    na llo ra m ve       llo ing a ith b c s
 Re la e e o AV a MV a re e tio o ...
Infective Endocarditis
Infective Endocarditis
Infective Endocarditis
Infective Endocarditis
Infective Endocarditis
Infective Endocarditis
Infective Endocarditis
Infective Endocarditis
Infective Endocarditis
Infective Endocarditis
Infective Endocarditis
Infective Endocarditis
Infective Endocarditis
Infective Endocarditis
Infective Endocarditis
Infective Endocarditis
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Infective Endocarditis

  1. 1. InfectIve endocardItIs MohaMed salIh azIz
  2. 2. defInItIon  Life-thre te a ninginfe tio invo c n lvingthee o a ium nd c rd a thec rd cva s nd a ia lve .  Ma a oinvo s p l d fe ts y ls lve e ta e c .  Infe tivep fe dtob c ria c re rre a te l.
  3. 3. epIdeMIology  10 0 0 c s sp r ye r in theUS -2 ,0 0 a e e a  Ma :Fe a ra 1.7:1 le m le tio  Ne tre s w nd  Me n a ew s3 in 19 6 no > 5 % o p tie a a g a 0 2 , w 0 f a nts re o r6 ve 0  De linein inc e eo rhe a fe r c id nc f um tic ve  Mo p s ticva s re ro the lve  Mo no o o ia c s s inje te d re s c m l a e , c d ruguse  Mo s p re ta hylo o c l infe tio cca c n
  4. 4. epIdeMIology  Mitra va a ne2 -4 % l lve lo 8 5  Ao va a ne5 6 (b us idva in 2 % o rtic lve lo -3 % ic p lve 0 f a na va IE) ll tive lve  Bo m l a a rticva s0 6 th itra nd o lve -3 %  Tric p va 0 % us id lve -6  P o va <1% ulm nic lve  Rig a le s e 0 % ht nd ft id d -4
  5. 5. Classification  Old :  Sub c Ba te l End c rd a ute c ria o a itis  De th in 3 m nths a -6 o  Ac Ba te l End c rd ute c ria o a itis  De th in < 6w e a e ks  Ne : w  NativeVa End c rd lve o a itis  P s ticVa End c rd ro the lve o a itis
  6. 6. pathogenesIs  Alte tio o theva ra n f lvula e o lia s c r nd the l urfa e le d tod p s n o p te tsa fib a ing e o itio f la le nd rin  Ba te m w s e ingo no a te l c re ia ith e d f n-b c ria thro b ticve e tio (NBTE) mo g ta n  Ad re ea g w furthe p te t a fib he nc nd ro th, r la le nd rin dps n e o itio  Exte io toa ja e s ture ns n d c nt truc s  P p ry m c , a rticva ringa s e s c nd tio a illa us le o lve b c s , o uc n s te ys m
  7. 7. pathogenesIs  Lo p s ure(d w tre m s eo s tura le io w re s o ns a ) id f truc l s n  Atria s eo m l va (MR) l id f itra lve  Ve ntric r s eo a rticva (AR, AS w R) ula id f o lve ith  C ng nita a no a (MV p la s , b us idAV) o e l b rm lity ro p e ic p  Sc rringfro rhe a he rt d e s o s le s a a a m um tic a is a e r c ro is s c ns q nc o a ing o e ue e f g  P s ticva s ro the lve  Othe turb nc , hig r ule e h-ve c je lo ity ts  Ve ntric r s p l d fe t ula e ta e c  Ste ticva no lve  Dire t m c nic l d m g fro c the rs p c m ke le d c e ha a a a e m a te , a e a r a s
  8. 8. pathogenesIs  Tra ie b c re ia ns nt a te m  Tra a tio o m o a s um tiza n f uc s l urfa ec lo dw c o nize ith b c ria(o l, GI) a te ra  Lo g d , c a d in 15 0m w ra e le re -3 inute s  Sus e tib c p ility toc m le e o p m nt-m d te b c ria killing e ia d a te l  Le d to c nc p o p p a s o e t f ro hyla xis
  9. 9. MIcrobIology  Staphylococcus aureus (3 -4 %) 0 0  Virid nsg ups p c c i (18 a ro tre to o c %)  Ente c c i (11%) ro o c  C a ula e g tives p o g s -ne a ta hylo o c (11%) c ci  Streptococcus bovis (7%)  Othe s p c c i (5 r tre to o c %)  No n-HAC Gra ne a s(2 EK m g tive %)  HAC Org nis s(2 EK a m %)  Fung (2 i %)  “ ulturene a ” -2 %) C g tive (2 0
  10. 10. Streptococcus Viridans  Ora o in l rig  9 % c ra 0 ure te  3 % c m lic tio 0 o p a ns
  11. 11. Strep. Gallolyticus (Bovis)  GI le io s ns  C c lo A o n  c lo s o y o b riume m s uldb p rfo e o no c p r a ne a ho e e rm d
  12. 12. Strept. Pneumoniae  Rare  Typ a ha fulm nt c urs ic lly s ina o e  As o ia d ep riva s c te e lvula a s e s r bcs  As o ia d ep ric rd s c te e a itis  Ao va typ a invo d rtic lve ic lly lve  H/O a o l a us lc ho b e  C nc nt m ning in ~ 70 o urre e itis %
  13. 13. Group B strep ( agalactiae)  Ris fa to ( DM, live fa k c rs r ilure e c , le tivea o n, b rtio c rc m , a o lis a d a us ) a ino a lc ho m nd rug b e  As o ia d w villo a e m o thec lo s c te ith us d no a f o n  Mo lity is5 % rta 0
  14. 14. Enterococcus  Affe tso e m n a r GU m nip tio c ld r e fte a ula ns  Affe ts yo e w m n a r o s Ma ula ns c ung r o e fte b t. nip tio  4 % no o vio und rlyinghe rt d e s . 0 b us e a is a e  9 % d ve p ahe rt m ur. 5 e lo a urm  P rip ra s m taa unc m o e he l tig a re o m n.
  15. 15. Staph aureus  Fulm nt c urs . ina o e  W es re d m ta ta infe tio e m c rd l id p a e s tic c ns .g yo a ia a s es s p b c s e , urule p ric rd , va ringa s e s s a nt e a itis lve b c s e , nd p rip ra a s e s sin b in, kid ys s le n. e he l b c s e ra ne , p e  4 % c nc o d a 0 ha e f e th.  1/3ne lo ic l m nife ta nse he ip g . uro g a a s tio .g m le ia  Them s c m o c us tiveo a min d a d ts ot o mn a a rg nis rug d ic .  Le ss ve in a d tstha no d ic . s e re d ic n n-a d ts  C a ula e– s p C m o in p s ticva o g s ve ta h. o m n ro the lve e o a itis nd c rd .
  16. 16. Gram –ve endocarditis  E.gg m– b c ( HAC ra ve a illi EK, e ro a te a ). nte b c ric e  Inc a e ris in d a d ts e e p s ticva s re s d k rug d ic , ld rly, ro the lve a c nd irrho . tic  C isc m o HF o m n  P g s isp o ro no is o r  Mo lity ~ 8 % rta 0
  17. 17. Salmonella species  Va lvula p rfo tio r e ra ns  Atria thro b l mi  Myo a itis c rd  p ric rd e a itis
  18. 18. Serrata marcescenses  No d m inly in d a us rs te a rug b e  Typ a invo m l a a rticva ic lly lve itra nd o lve  La e ve e tio a ne r to l o c io o theva rg g ta n nd a ta c lus n f lvular o e rific  Ab e eo s nific nt und rlyingva s nc f ig a e lvula d s tio r e truc n
  19. 19. Pseudomonas  Druga d ts d ic  Affe tsno a va s c rm l lve  Ma r e b licp no e jo m o he m na  Ina ility tos rilizeva s b te lve  Ne lo icc m lic tio uro g o p a ns  Ringa and nnula a s e s s r b c se  Sp nica s e s s le b c se  P g s iveC ro re s HF  As o ia d w theus o P nta c a s c te ith e f e zo ine nd Trip le m le nna ine
  20. 20. Fungal endocarditis  Inc a e ris in d a d ts im uno o ro is d b a re s d k rug d ic , m c m m e , ro d s e truma io s C c the rs pc ntib tic , V a te .  C nd ap rp ilo isa c nd atro ic lisp d m tein a id a s s nd a id p a re o ina inje tingd a us rs c rug b e .  C nd aa ic nsa a p rg a id lb a nd s e illusno ruga d ts n-d d ic  P o p g s d to o r ro no is ue  La e b rg , ulky ve e tio , inva io o m c rd g ta ns s n f yo a ium  W es re d s p e b li id p a e tic m o  P o p ne tio o a o r e tra n f ntifung l a e into ve e tio a g nts g ta ns  -veb o c lo d ulures  Mo lity >8 % fo m ld a > 4 % fo ye s rta 0 r o s nd 0 r a ts
  21. 21. Q fever ( Coxiella burnetii)  Mo t p tie ha und rlyinghe rt d e s . s a nts ve e a is a e  C nicp s nta n. hro re e tio  Exp s toa a a itsp d ts o ure nim ls nd ro uc .  H/O influe -likeillne s6 m nthsp vio ly. nza s -12 o re us  m jo o c s so c in p s ticva s a rity f a e c ur ro the lve  C m o a c a rticva o m nly ffe ts o lve  As o ia d w he a s le m g ly, thro b c p nia s c te ith p to p no e a m o yto e , hyp rg m a lo ule m a im unec m le e a m g b ne ia nd m o p x g m rulo p lo e ne hritis .
  22. 22. Culture –ve endocarditis  <5%  Re e a m tra n o a io s c nt d inis tio f ntib tic .  Slo g w e HAC w ro th .g EK  Fung l e o a itis a nd c rd .  No ultura leintra e r m ro rg nis s(e n-c b c llula ic -o a m .g Ba ne s e ie , c m ia T. w p i). rto lla p c s hla yd , hip le  Ma ntice o a itis ra nd c rd .
  23. 23. characterIstIcs of causatIve organIsMs  Ad re efa to c a fo g w in the he nc c rs ritic l r ro th ve e tio g ta n  C n a he to d m g d va s(Sta h, Stre a a d re a a e lve p p nd Ente c c i ha a he instha m d tea c e ro o c ve d s t e ia tta hm nt)  Sta h a he in b sfib p d s ind rino e a fib ne tin g n nd ro c  Ba te trig e tis ue c r p d tio fro lo a c ria g r s -fa to ro uc n m c l m no yte a ind ep te t a g g tio s the o c s nd uc la le g re a n o o a m b c m e lo e in theve e tio rg nis s e o e nve p d g ta n  P te tio fro im unec a nc le d to la e ro c n m m le ra e a s rg num e o b c ria(10 -10 p r go tis ue b rs f a te 9 10 e f s )
  24. 24. rIsk factors  Struc l he rt d e s tura a is a e  Rhe a , c ng nita a ing um tic o e l, g  P s tiche rt va s ro the a lve  Inje te d us c d rug e  Inva ivep c d s(? s ro e ure )  Ind e w llingva c r d vic s s ula e e  Othe infe tio w b c re ia(e . p um nia r c n ith a te m .g ne o , m ning ) e itis  His ry o infe tivee o a itis to f c nd c rd
  25. 25. clInIcal ManIfestatIons  Sym to s p m  Fe r, s e ts c ve w a , hills  Ano xia m la e w ig lo s re , a is , e ht s  Signs  Ane ia(no o hro ic no o ytic m rm c m , rm c )  Sp no e a le m g ly  Mic s o iche a ro c p m turia p te , ro inuria  Ne o c ng w r ha inghe rt m ur, C a urm HF  Em o o im uno g d rm to g s ns b lic r m lo ic e a lo ic ig  Hyp rg m a lo uline ia e va d ESR, C , RF e a mg b m , le te RP
  26. 26. cardIac pathologIc changes  Ve e tio o va c s line g ta ns n lve lo ure s  De truc n a p rfo tio o va le fle s tio nd e ra n f lve a t  Ruptureo c rd ete ina , intra ntric r s p , f ho a nd e ve ula e tum p p ry m c s a illa us le  Va ringa s e s lve bcs  Myo a ia a s e s c rd l b c s  C nd tio a no a s o uc n b rm litie
  27. 27. S. Aureus mitral valve vegetation, anterior leaflet
  28. 28. pathologIc changes  Kid y ne  Im unec m le g m rulo p m o p x lo e ne hritis  Em o w infa tio a s e s b li ith rc n, b c s  Ao m o a urys s rtic yc tic ne m  C re ra e b lis e b l mo m  Infa tio a s e s m o a urys s rc n, b c s , yc tic ne m P urule m ning isra nt e itis re
  29. 29. pathologIc changes  Sp nice rg m nt, infa tio le nla e e rc n  Se tico b ndp o ry e b lis p r la ulm na m o m  Skin  P te hia e c e  Os r no e : d le d s iffus infiltra o ne p , a e te f utro hils nd m no yte in thed rm l ve s lsw im unec m le o c s e a s e ith m o p x d p s n. Te e a e e o itio nd r nd rythe a us m to  J ne a le io : s p e b li w b c ria a w y s ns e tic m o ith a te , ne p a S.C he o g a ne ro is utro hils nd m rrha e nd c s . Bla hinga no nd r. P lm a s le nc nd n-te e a s nd o s
  30. 30. case defInItIon  19 P lle r a P te d rf c ria 77 e tie nd e rs o rite  19 1 vo Re c ria 8 n yn rite  19 4Dukec ria 9 rite  2 0 Mo ifie Dukec ria 00 d d rite
  31. 31. ModIfIed duke crIterIa  Ma r C ria jo rite P so itiveb o c lo d ulture w typ a o a m s ith ic l rg nis s  P rs te e is ntly p so itiveb o c lo d ultures  Evid nc o End c rd l invo m nt e e f o a ia lve e  P s o itiveEc c rd g m ho a io ra  Os illa c tingintra a ia m s c rd c a s  Ab c s s es  De c nc o p s ticva his e e f ro the lve  Ne Va w lvula re urg tio r g ita n
  32. 32. ModIfIed duke crIterIa  Mino C ria r rite  P d p s n (va re is o itio lvula d e s o IDU) r is a e r  Fe r ve  Va c r p no e (Arte l e b li, s p p s ula he m na ria m o e tic ulm na o ry infa ts intra ra l he o g , Os r, J ne a rc , c nia m rrha e le a w y)  Im uno g p no e (GN, Os r, Ro s o , m lo ic he m na le th p ts Rhe a idFa to um to c r)
  33. 33. ModIfIed duke crIterIa  De finiteIE  P tho g c ria a lo ic rite C linic l c ria a rite  2Ma r C riaOR jo rite  1 Ma r a 3m r C riaOR jo nd ino rite  5Mino C ria r rite  P s ib IE o s le  1 Ma r a 1 Mino OR jo nd r  3Mino r  Re c dIE je te
  34. 34. blood cultures  MULTIP BLOOD C LE ULTURES BEFORE EMPIRIC THERAP Y  If no c a ill t ritic lly  3b o c lo d ulture o r 12 4ho p rio s ve -2 ur e d  ?De y the p until d g s c nfirm d la ra y ia no is o e  If c a ill ritic lly  3b o c lo d ulture o r o ho s ve ne ur  No m retha 2fro s m ve unc o n m a e nip ture  Re tive c ns nt b c re ia la ly o ta a te m
  35. 35. “culture negatIve” Ie  Le sc m o w im ro db o c s o m n ith p ve lo d ulturem tho s e d  Sp c l m d re uire e ia e ia q d  Bruc lla Myc p s a C m ia His p s a e , o la m , hla yd , to la m , Le io lla Ba ne g ne , rto lla  Lo e inc a n m y b re uire ng r ub tio a e q d  HAC EK  Coxiella burnetii (Q Fe r), Trophyrema whipplei w ve ill no g win c ll-fre m d t ro e e e ia
  36. 36. hacek  Haemophilus aphrophilus, H. paraphrophilus, parainfluenzae  Actinobacillus actinomycetemcomitans  Cardiobacterium hominis  Eikenella corrodens  Kingella kingae
  37. 37. other MIcrobIologIc Methods P R C  Coxiella burnetii  Tropheryma whipplei  Bartonella henselae  Se lo y ro g  Coxiella burnetii  Bartonella  Brucella  Legionella  Chlamydophila psittaci
  38. 38. echocardIography  Tra tho c ns ra ic  Re tive lo s ns la ly w e itivity  Go d s e ific o p c ity  Tra e o ha e l ns s p g a  De c n o va ringa s e s(8 te tio f lve b c s 7% vs 2 % s ns . 8 e itivity for TTE)  De c n o p s ticva IE te tio f ro the lve
  39. 39. When to go to tee fIrst?  Lim dtho c w o s= TTE lo s ns ite ra ic ind w w e itivity  P s ticva s ro the lve  P r va rio lvula a no a r b rm lity  S. aureus b c re iaa s p c dIE a te m nd us e te  Ba te m w o a m like toc us IE c re ia ith rg nis s ly a e = hig p r p b b h rio ro a ility o IE f
  40. 40. other tests  Ele tro a io ra c c rd g m  C nd tio d la o uc n e ys  Is he iao infa tio c m r rc n  C s X-ra he t y  Se tice b li in rig id d IE p mo ht-s e  Va c lc a n lve a ific tio C HF
  41. 41. treatMent of Ie  Na tivevs P s ticVa . ro the lve  Ba te id l the p isne e s ry c ric a ra y c sa  Era ic tio o b c riain theve e tio d a n f a te g ta n  Ma b m ta o a ina tive(s tio ry p s ) y e e b lic lly c ta na ha e  Ma ne d hig r c nc ntra nso a y e he o e tio f ntim ro ia a e ic b l g nts
  42. 42. antIMIcrobIal therapy  Mo t p tie a a b in 3 d ys s a nts re fe rile -5 a  Lo d tio o the p (4 w e o m re ng ura n f ra y -6 e ks r o )  C m ina n the p m s im o nt fo o b tio ra y o t p rta r  Sho r c urs re im ns rte o e g e  Ente c c a e o a itis ro o c l nd c rd  P s ticva infe tio ro the lve c ns
  43. 43. natIve valve Ie  Virid nsStre to o c a S. bovis a p c c i nd  Aq o P nic ue us e illin G 12 0m n units a c ntinuo ly -2 illio /d y o us o d e q o q fo 4w e r ivid d 4 r 6 r e ks  If inte e ia s c p ility to p nic rm d te us e tib e illin, a ue us q o p nic e illin G 2 m n unitso c ftria ne2gq 4 4 illio r e xo 2 P LUS a ino lyc s efo thefirs 2w e m g o id r t e ks
  44. 44. natIve valve Ie  Am g o id sfo s rg ino lyc s e r yne y  Lo c nc ntra nsa a e ua (1-3m g l) w o e tio re d q te c /m  Ge m in 3m /kgd nta ic g ivid dq o q e 12 r 8  Littled tafo q 4d s a r 2 o ing
  45. 45. natIve valve Ie  Ente c c i, a p illin s ns ro o c m ic e itive  Hig ra so fa h te f ilure  β-la ta sa b c rio ta , m t c m inew c m re a te s tic us o b ith a ino lyc s efo o tim l the p m g o id r p a ra y  Hig h-le l g nta ic re is nc o c in 3 % ve e m in s ta e c urs 5  Hig o ea p illin fo 8 w e h-d s m ic r -12 e ks  Ente c c i, a p illin re is nt ro o c m ic s ta  Va o yc p g nta ic nc m in lus e m in  Ente c c i, va o yc re is nt ro o c nc m in s ta  Line lid o d p m in zo r a to yc  P nic e illin + va o yc + g nta ic ? nc m in e m in
  46. 46. natIve valve Ie  S. aureus  P nic e illina e s ta s m ynthe p nic s -re is nt e i-s tic e illin (o c xa illin o na illin) 1.5 gIV q o c p lo p rin r fc -2 4 r e ha s o (c fa lin 1-2gIV q ) fo 4 w e e zo 8 r -6 e ks  Am g o id s rg ticb d e no a c s ino lyc s e yne is ut o s t ffe t urviva l, no re o m nd d t cm e e  Sho c urs in rig id d IE rt o e ht-s e  2w e o s m ynthe p nic e ks f e i-s tic e illin a a ino lyc s e nd m g o id
  47. 47. natIve valve Ie  Me illin-re is nt S. aureus thic s ta  Va o yc isb c rio ta nc m in a te s tic  Va o yc p a ino lyc s eo rifa p nc m in lus m g o id r m in  Da to yc p m in  Line lid zo
  48. 48. natIve valve Ie  HAC EK  C ftria ne2gIV q 2 x 4 w e e xo 4 -6 e ks  Fung l a  Am ho ric p te in  Fluc na le o zo  Cso a p fung littled ta in, a  Surg ry us lly ne e s ry 1-2w e into tre tm nt e ua c sa e ks a e
  49. 49. natIve valve Ie  Ind a nsfo s e ic tio r urg ry  Re c ry C fra to HF  Mo tha o s te ice b lice nt re n ne ys m m o ve  Unc ntro d infe tio o lle c n  P io g a s nific nt va hys lo ic lly ig a lvula d func n r ys tio  Ine c ffe tiveantim ro ia the p (e . fung l) ic b l ra y .g a  Lo a s p tivec m lic tio c l up ura o p a ns  Myc tica urys o ne m
  50. 50. prosthetIc valve Ie  Sta hylo o c m s c m o p c ci ot o mn  C a ula ene a o g s g tives pta hylo o c cci  Ente c c us ro o c  Nutrito lly va nt s p c c i na ria tre to o c  Fung i
  51. 51. prosthetIc valve Ie  Ris isg a s in thefirs 3m nthsa firs ye r (e rly k re te t t o nd t a a P IE) V  C a ula e g tives p o g s -ne a ta hylo o c in e rly e o a itis S. cci a nd c rd , aureus  La -o e m res ila to na te ns t o im r tiveva d e s in lve is a e m ro io g b m rec a ula e g tives p ic b lo y ut o o g s -ne a ta hylo o c c c i. Va ise o lia d lve nd the lize
  52. 52. prosthetIc valve Ie  TEE s uldb us d firs ho e e t  Sta hylo o c p cci  Va o yc o o c nc m in r xa illin p rifa p in fo a le s s lus m ic r t a t ix w e , g nta ic fo thefirs tw w e (3m /kgq 4 e ks e m in r t o e ks g 2)  Rifa p in s rte a le s 2d ysa r 2o r a e to m ic ta d t a t a fte the g nts a idre is nc vo s ta e
  53. 53. prophylaxIs of Ie  Unc rta e inty a c ntro rs nd o ve y  No ra o ize tria nd m d ls  Ind c e e e(unc ntro dc ire t vid nc o lle linic l s rie , c s - a e s ae c ntro s ie ) o l tud s  De is n a lys c io na is
  54. 54. clInIcal case  4 yrsm n ESRD, C d ve Re l Tra p nt 2 0 3 a a a ric na ns la 0 4  Re urre UTIs p c m nt o ne hro to y tub c nt , la e e f p s m e  Fe rs c , a re m nta s tus s p iss ro e ve , hills lte d e l ta , e s ynd m  Bra yc rd to3 a inc a e P d a ia 5 nd re s d R
  55. 55.  Urinew MRSA, 4 b o c ith /4 lo d ulture w MRSA s ith  Initia TTE: EF 3 -4 %, thic ne AV w m d ra AS, l 5 5 ke d ith o e te thic ne o c lc dMV m MR ke d r a ifie ild  “ m a d w la t p vio e ho the isno s nific nt c ng . Co p re ith s re us c , re ig a ha e In thep s nc o va re e e f lvula thic ning c nno ruleo e o a itis r ke , a t ut nd c rd .  Ne d y TEE xt a  thic ne AV, m to m d ra AS, no AR. 2ve e tio ~1 c ke d ild o e te g ta ns m o ve n ntric r s e ula id  Ma d thic ne MV, la em b ve e tio >4 mo a l rke ly ke d rg o ile g ta n c n tria s ea rio le fle p s ib s c nd ve e tio o p s rio le fle id nte r a t, o s le e o g ta n n o te r a t, m MR ild
  56. 56.  Re l a g ft re o dthefo w d y w a s e s na llo ra m ve llo ing a ith b c s  Re la e e o AV a MV a re e tio o le p c m nt f nd nd s c n f ft ventric r a s e sc vity tw d ysla r ula b c s a o a te

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