ENDOCARDITIS infecciosa

1. MIGUEL URINA-TRIANA MD, MSc, FACC
DIRECTOR FUNDACION BIOS

3. NEJM VOL 345 # 18, NOV 1-2001
PAG.1318

4. DEFINICION
— LA ENDOCARDITIS INFECCIOSA (EI) ES LA
INFECCION MICROBIANA DE LA SUPERFICIE
ENDOTELIAL DEL CORAZÒN
— LA VEGETACIÒN ES LA LESIÓN CARACTERÍSTICA
(FIBRINA,PLAQUETAS, MICROORGANISMOS Y CEL.
INFLAMATORIAS)

5. VEGETACIÓN VÁLVULAAÓRTICA

6. DEFINICION
LAS VÁLVULAS CARDÍACAS SON LAS MÀS
FRECUENTES COMPROMETIDAS, SIN EMBARGO,
LA INFECCIÒN PUEDE OCURRIR SOBRE EL
ENDOCARDIO MURAL

7. Trombo mural en hombre de 65 años

8. CLASIFICACION
AGUDA
TOXICIDAD SISTÉMICA
PROGRESIÓN DE DIAS A SEMANAS HACIA
LA DESTRUCCIÓN VALVULAR E INFECCIÓN
EN MÚLTIPLES SITIOS
TIPICA STAPHYLOCOCCUS.AUREUS

9. SUBAGUDA
MODESTA TOXICIDAD DE SEMANAS A MESES
Y OCASIONALMENTE INFECCIÓN MÚLTIPLE
— STREPTOCOCCUS VIRIDANS
— ENTEROCOCO
— STAPHYLOCOCUS COAGULASA NEGATIVO
— COCOBACILOS GRAM (-) DE CRECIMIENTO LENTO

10. FISIOPATOLOGIA
ENDOCARDITIS TROMBÓTICA NO
BACTERIANA (ETNB) PRODUCTO
DE LAHEMOSTASIS CON LA
FORMACIÓN DE COMPLEJOS DE
FIBRINA Y PLAQUETAS

11. Fibrina y plaquetas
(NEJM 1997;337:770-777)

13. ACTIVACIÓN PLAQUETARIA
BASALES
ACTIVADAS
AKKERMAN ET AL. HEMOSTASIS 1985:39

14. Bacterias en el endocardio por E. de whipple
NEJM 2000;342:620-625

15. INMUNOFLUORESCENCIA EN EL MISMO PACIENTE
NEJM 2000;342:620-625

16. FISIOPATOLOGIA
—“JET “ ENDOTELIAL CÁMARA DE
ALTA A BAJA PRESIÓN O FLUJO DE
ALTA VELOCIDAD POR ORIFICIO
ESTRECHO

17. FISIOPATOLOGIA
— EPISODIOS DE BACTEREMIA
— LA ETNB ES VISTA EN CANCER, CID,
UREMIA,QUEMADURAS, LES,VALVULOPATÍAS Y
CATÉTERES INTRACARDÍACOS
— DE LA ETNB A EI, SE PRODUCE LA ENTRADA DE
MICROORGANISMOS A LA CIRCULACIÓN COMO RESULTADO
DE INFECCIÓN LOCALIZADA O DE TRAUMA EN UNA
SUPERFICIE DEL ORGANISMO

18. EMBOLISMO SEPTICO
(ASPERGILLUS FUMIGATUS)
NEJM 2000;342:1015
HOMBRE,61A
CON VALVULA
PROTESICA
ISQUEMIA PIE
IZQUIERDO,
EMBOLECTO
MIA DE PEDIS
DORSALIS Y
TIBIAL.CULTI
VO POSITIVO
TEE VEG.AOR
TICAS

19. SITUACIONES CLINICAS
— ENDOCARDITIS DE VALVULAS NATIVAS
(LESIONES VALVULARES ADQUIRIDAS O
CONGENITAS) ALGUNOS PATOGENOS (S.AUREUS
O STREPTOCOCO PNEUMONIE) PUEDEN
CAUSARLAS SOBRE VALVULAS NORMALES
(ADICTOS)

20. SITUACIONES CLINICAS
— ENDOCARDITIS INFECCIOSA EN NIÑOS
— VALVULA TRICUSPIDE (CATETERES) ALTA
MORTALIDAD S.AUREUS,S.COAGULASA
NEGATIVO,STREPTOCOCO GRUPO B, BACILOS
GRAM -, CANDIDA
— ENF. CONGENITAS(AORTICA, FALLOT,CIV)

21. SITUACIONES CLINICAS
EI EN LOS ADULTOS
— PROLAPSO V.MITRAL E INSUFICIENCIA(RIESGO
RELATIVO DE 3.4 A 8.2)
— VALVULOPATÍA REUMÁTICA (VM,VA)
— CARDIOPATIAS CONGENITAS (PCA,CIV Y AORTA
BICUSPIDE)

22. SITUACIONES CLINICAS
— EI EN ADICTOS ADROGAS IV
— 2-5 %/ANUAL HOMBRE 5.4:MUJER 1
— VALVULAS DERECHAS
— 50 % S. AUREUS,P.AUREUGINOSA
— DOLOR TORACICO PLEURITICO, TOS Y
HEMOPTISIS, SOPLO DE I.TRICUSPIDEA

23. SITUACIONES CLINICAS
— EI VALVULAS PROTESICAS
— PRIMEROS 6 MESES >RIESGO (6SEMANAS)
0,2-0.35/AÑO.
— ESTREPTOCOCOS,S.AUREUS,
ENTEROCOCO,COCO BACILOS DEL GRUPO
HACEK :HAEMOPHILUS,ACTINOBACILLUS
ACTINOMYCETEMCOMITANS,CARDIOBACTERIU
M HOMINIS, EIKENELLAY KINGELLA

24. SITUACIONES CLINICAS
— EI NOSOCOMIAL
— POR CATETERES IV, INTRUMENTACIÓN DEL
TRACTO URINARIO O GASTROINTESTINAL,
PROCEDIMIENTOS QUIRURGICOS

25. SITUACIONES CLINICAS
— EI CON CULTIVOS NEGATIVOS
— 5 %
— EN NUESTRO MEDIO >50 % SON NEGATIVOS POR
TTO PREVIO
— LAS TECNICAS NO SON LAS MEJORES

26. MANIFESTACIONES
— EFECTOS LOCALES
DESTRUCTIVOS
— EMBOLIZACION DE
FRAGMENTOS
— SIEMBRA
HEMATOGENA
— RESPUESTA
INMUNOLOGICA
MEDIADA POR
CITOQUINAS Y ACS
(depositos de
complejos inmunes)

27. LESIONES PIEL Y UÑAS EN ENDOCARDITIS
HEMORRAGIA
TIPICA SUBUNGUEAL
Y PETEQUIAS EN LA
PIEL DEL ABDOMEN
EN ENDOCARDITIS
POR STAFILOCOCO

28. HALLAZGOS AL EXAMEN FISICO Y SINTOMAS
MANCHAS DE ROTH
ARTRALGIAS,
MIALGIAS. ARTRITIS,
DOLOR LUMBAR,
EMBOLISMOS
SITEMICOS NODULOS DE OSLER
LESIONES DE JANEWAYPETEQUIAS CONJUNTIVA

29. RMI MULTIPLES EMBOLOS
NEJM 1997;337:770-777

30. EXAMEN
— ABCESO ESPLENICO-ESPLENOMEGALIA
— SINTOMAS NEUROLOGICOS
— ANEURISMAS MICOTICOS (INTRACRANEAL O
EXTRACRANEAL)

31. ANEURISMA MICOTICO ANTES CMI

32. CLINICA
— ICC
— EXTENSIÓN PERIANULAR
— INSUFICIENCIA RENAL

33. DIAGNOSTICO
— PARACLINICOS
— HEMOCULTIVOS
— ECOCARDIOGRAFIA
— OTROS LABORATORIOS

34. ECO TTE Y ESPECIMEN POSTQUIRURGICO

35. ECOCARDIOGRAMA TRANSESOFAGICO

36. ECOCARDIOGRAMA TRANSTORACICO

37. Ecocardiografía TT vs TEE

38. Table 1. Criteria for Clinical Diagnosis of Infective
Endocarditis
High probability
Persistently positive blood cultures1 plus one of the
following: New regurgitant murmur2,Predisposing
heart disease3 and vascular phenomena4 or
Negative or intermittently positive blood
cultures5 plus all of the following: Fever6,New
regurgitant murmur,Vascular phenomena
Criterios de probabilidad

39. Medium probability
Persistently positive blood culture plus one of the
following: Predisposing heart disease,Vascular
phenomena orNegative or intermittently positive blood
cultures plus all of the following: Fever,Predisposing
heart disease,Vascular phenomena orViridans group
streptococcus only: at least two positive blood cultures
without an extracardiac source and fever
Low probability
None of the above classifications applicable
orAlternative diagnosis generally apparent but
endocarditis not excluded

40. 1 At least two blood cultures obtained with two of two
positive, three of three positive, or at least 70% of
cultures positive if four or more cultures obtained.
2 Not previously noted during current hospitalization,
past hospitalizations, or past outpatient clinic visits.
3 Definite valvular or congenital heart disease or a
cardiac prosthesis (excluding permanent pacemakers).
4 Petechiae, splinter hemorrhages, conjunctival
hemorrhages, Roth's spots, Osler's nodes, Janeway
lesions, aseptic meningitis, glomerulonephritis, and
pulmonary, central nervous system, coronary, or
peripheral emboli.
5 Any rate of blood culture positivity that does not meet
the definition above of persistently positive.
6 Fever >38.0°C.

41. Reprinted from Durack et al,5 American Journal of Medicine
Definite IE
Pathological criteriaMicroorganisms: demonstrated by culture or
histology in a vegetation, in a vegetation that has embolized, or in an
intracardiac abscess, or Pathological lesions: vegetation or
intracardiac abscess present, confirmed by histology showing active
endocarditisClinical criteria, using specific definitions listed in Table
2,2 major criteria, or 1 major and 3 minor criteria, or 5 minor criteria
Possible IE
Findings consistent with IE that fall short of "Definite" but not
"Rejected" Rejected Firm alternate diagnosis for manifestations
of endocarditis, or Resolution of manifestations of endocarditis with
antibiotic therapy for 4 days, or No pathological evidence of IE at
surgery or autopsy, after antibiotic therapy for 4 days
Table 1. Duke Clinical Criteria for Diagnosis of IE

42. Table 2. Definitions of Terms Used in the Duke Criteria for the Diagnosis of IE
Major criteria
1. Positive blood culture for IE
A. Typical microorganism consistent with IE from 2 separate blood
cultures as noted below:
(i) viridans streptococci,1 Streptococcus bovis, or HACEK group, or
(ii) community-acquired Staphylococcus aureus or enterococci, in the
absence of a primary focus, or
B. Microorganisms consistent with IE from persistently positive blood
cultures defined as
(i) 2 positive cultures of blood samples drawn >12 hours apart or
(ii) all of 3 or a majority of 4 separate cultures of blood (with first and
last sample drawn 1 hour apart)

43. CRITERIOS DE DUKE
2. Evidence of endocardial involvement
A. Positive echocardiogram for IE 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)
not cause endocarditis

44. Minor criteria
1. Predisposition: predisposing heart condition or intravenous
drug use
2. Fever: temperature 38.0°C
3. Vascular phenomena: major arterial emboli, septic pulmonary
infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival
hemorrhages, and Janeway lesions
CRITERIOS DE DUKE

45. 4. Immunologic phenomena: glomerulonephritis, Osler's nodes,
Roth spots, and rheumatoid factor
5. Microbiological evidence: positive blood culture but does not
meet a major criterion as noted above2 or serological evidence of
active infection with organism consistent with IE
6. Echocardiographic findings: consistent with IE but do not meet
a major criterion as noted above
Reprinted from Durack et al,5 American Journal of Medicine,
with permission from Excerpta Medica Inc.
1 Includes nutritionally variant strains (Abiotrophia species).
2 Excludes single positive cultures for coagulase-negative
staphylococci and organisms that do
CRITERIOS DE DUKE

46. Table 4. Clinical Situations Constituting
High Risk for Complications for IE
•Prosthetic cardiac valves
•Left-sided IE
•S aureus IE
•Fungal IE
•Previous IE
•Prolonged clinical symptoms (3 months)
•Cyanotic congenital heart disease
•Patients with systemic to pulmonary shunts
•Poor clinical response to antimicrobial therapy

47. •Valvular dysfunction
•Acute aortic or mitral insufficiency with signs of
ventricular failure3
•Heart failure unresponsive to medical therapy3
•Valve perforation or rupture3
•Perivalvular extension
•Valvular dehiscence, rupture, or fistula3
•New heart block3
•Large abscess, or extension of abscess despite appropriate
antimicrobial therapy3
1 See text for more complete discussion of indications for surgery based on
vegetation characterizations.
2 Surgery may be required because of risk of embolization.
3 Surgery may be required because of heart failure or failure of medical
therapy.

48. TRATAMIENTO
— ERRADICACION DEL MICROORGANISMO
— ANTIBIOTICOS
— ANTIMICOTICOS
— POR PERIODOS LARGOS
— TRATAMIENTO QUIRURGICOS

49. •
Table 5. Echocardiographic Features
Suggesting Potential Need for Surgical
Intervention1
•Vegetation
•Persistent vegetation after systemic embolization:
•Anterior mitral leaflet vegetation, particularly with
size >10 mm2 One or more embolic events during first
2 weeks of antimicrobial therapy2
•Two or more embolic events during or after
antimicrobial therapy2
•Increase in vegetation size after 4 weeks of
antimicrobial therapy2 3

50. PRONOSTICO— 16-27 % MORTALIDAD, SOBREVIDA DE EI
VALVULAS NATIVAS 80% A 10 AÑOS
FACTORES DE MAL PRONOSTICO:
>65AÑOS
ENF. SUBYACENTES
E.VÁLVULA AÓRTICA
ICC
COMPROMISO DEL SNC
COMPLICACIONES INTRACARDIACAS
INFECC. POR S.AUREUS,S.NO VIRIDANS GRUPO B,C Y G
C.BURNETTI,P.AERUGINOSA,ENTEROBACTERIACEAE,HONG
OS Y ENTEROCOCOS

51. PREVENCION
— EVALUAR EL RIESGO Y PROFILAXIS AHA
— PROC.DENTALES CON HEMORRAGIA
— AMIGDALECTOMÍA O DENOIDECTOMÍA
— CIRUGÍA DEL TRACTO SUPERIOR RESPIRATORIO
— BRONCOSCOPIA CON BRONCO RIGIDO
— ESCLEROTERAPIA,CIRUGÍA TRACTO URINARIO (PROSTATA)
— DILATACION DE ESOFAGO, SONDA VESICAL EN IU
— COLECISTECTOMIA, CISTOSCOPIA
— HISTERECTOMÍA VAGINAL
— PARTO VAGINAL COMPLICADO POR INFECCIÓN
— INCISION Y DRENAJE DE TEJIDO INFECTADO

52. PROFILAXIS
PROCEDIMIENTOS DENTALES Y TR
— AMOXICILINA 3.GR VO 1 HORA PRE Y LUEGO 1.5 6
HORAS DESPUES DE LA 1A DOSIS
— ERITROMICINA,CLINDAMICINA,AMPICILINA
PROCEDIMIENTOS URINARIOS Y
GASTROINSTESTINALES
— AMPICILINA, GENTAMICINA, VANCOMICINA,
AMOXICILINA