Guidelines on the prevention, diagnosis, and managment of Infective endocarditis

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guidelines in Focus, in the management of infective endocarditis

guidelines in Focus, in the management of infective endocarditis

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  • 1. GUIDELINES ON THE PREVENTION, DIAGNOSIS, AN D TREATMENT OF INFECTIVE ENDOCARDITIS European Society of Cardiology (version 2009)
  • 2. Prophylaxsis  Indications: IIa 1. 2. 3. 4. Prosthetic valves Previous IE Cyanotic Congenital heart disease, without surgical repair, or with residual defects Congenital heart disease with complete repair with prosthetic material up to 6 months after procedure
  • 3. Prophylaxsis  Recommendations: 1. 2. 3.  Dental procedures requiring manipulation of the gingiva or perforation of oral mucosa Respiratory tract procedures? Not indicated Gastrointestinal or urogenital procedures? Not indicated ANTIBIOTIC CHOICE:   Amoxicillin or ampicillin: 2g po/iv 30-60 min before procedure Allergy to penicillin: clindamycin 600mg po/iv 30-60 min before procedure
  • 4. Diagnosis Modified Duke’s Criteria  Major criteria 1. Blood Cultures: 1. 2. 3. 2. Typical microorganisms consistent with IE from two separate bottles Persistent positive blood cultures Single positive blood culture for Coxiella burnetii Echocardiography : 1. 2. Vegetation/abscess/ new partial dehiscence of prosthetic valve New valvular regurge
  • 5.  Minor Criteria: 1. 2. 3. 4. 5. Predisposition: heart disease/ IVDU Fever Vascular phenomena Immunologic phenomena Positive blood culture but does not meet major criteria
  • 6. Definite diagnosis of IE     2 MAJOR 1 MAJOR+ 3 MINOR 5 MINOR POSSIBLE DIAGNOSIS: 1 MAJOR+ 1 MINOR or 3 MINOR
  • 7. PREDICTORS OF POOR OUTCOME              Old age Prosthetic valve IDDM Heart failure Renal failure Stroke Septic shock S. Aureus Fungi Gram –ve bacilli Large vegetation Low ejection fraction Severe valve regurge
  • 8. Antimicrobial Treatment
  • 9. Oral Streptococci  Standard treatment: 1. 2. 3.  Two week treatment: 1. 2.  Penicillin G 12-18 million U/day in 6 divided doses (4 weeks) Amoxicillin 100-200mg/kg/day in 4-6 doses (4 weeks) Ceftriaxone 2g/d 1 dose (4 weeks) Penicillin G or Amoxicillin or Ceftriaxone (2 weeks) With Gentamicin 3mg/kg/day(2 weeks) Penicillin allergy:  vancomycin 30mg/kg/day in 2 doses
  • 10. Staphylococcus  Native valve: 1. 2. 3.  Flucloxacillin or Oxacillin 12g/d in 6 doses (4-6 weeks) PLUS Gentamicin (3-5 days) Penicillin allergy: vancomycin+gentamicin Prosthetic valve: 1. 2. 3. 4. Flucloxacillin or Oxacillin (6 weeks) PLUS Rifampicin 1200mg/d 2 doses (6 weeks) PLUS Gentamicin 3mg/kg/d (2 weeks) Vancomycin for penicillin allergy
  • 11. Enterococcus   Amoxicillin/ ampicillin 200mg/kg/d 4 doses (46 weeks) PLUS Gentamicin (4-6 weeks)
  • 12. Empirical treatment  NATIVE VALVE:  Ampicillin/sulbactam  OR Amoxicillin/clavulanate  WITH Gentamicin OR  Vancomycin with gentamicin with ciprofloxacin
  • 13.  PROSTHETIC VALVE: (within 12 months post surgery)  VANCOMYCIN (6 weeks)  WITH RIFAMPICIN  WITH GENTAMICIN (2 weeks)  Prothetic valve >12 months post surgery: follow same protocol for native valve
  • 14. Surgical Indications 1. 2. 3. Refractory heart failure Uncontrolled infection Prevention of embolism