Infective endocarditis, etiology and pato.pptx

explabation about infective endocarditis,

1. Infective endocarditis DEWI TRISNAWATI Pembimbing : Dr. dr. An Aldia Asrial , Sp. JP, FIHA

2. DEFINISI presentation title 2 Penyakit yang disebabkan oleh mikroorganisme yang menginfeksi permukaan endocardium jantung termasuk lapisan endotel dari pembuluh darah . Bagian yang sering terlibat : Katup Jantung > Utamanya mitral ( Selain katup , bagian lain yang terlapisi endocardium juga dapat terinfeksi ) Bentuk Lesi > Vegetasi (Vegetation)

3. Epidemiology In 2019, the estimated incidence of IE was 13.8 cases per 100 000 subjects per year, and IE accounted for 66 300 deaths worldwide.2 Due to the associated high morbidity and mortality (1723.59 disability-adjusted life years and 0.87 death cases per 100 000 population, respectively), identification of the best preventive strategies has been the focus of research. 3 presentation title European Heart Journal (2023) 44, 3948–404; 2023 ESC Guidelines for the management of endocarditis

4. POPULATION AT RISK OF INFECTIVE ENDOCARDITIS Patients with previous IE Patients with surgically implanted prosthetic valves, with transcatheter implanted prosthetic valves, and with any material used for cardiac valve repair 4 presentation title 3. Patients with congenital heart disease (CHD) (not including isolated congenital valve abnormalities) are at increased risk of IE 4. Patients with ventricular assist devices as destination therapy are also considered at high risk because of associated morbidity and mortality, The groups of individuals at high risk of IE in whom antibiotic prophylaxis is recommended or should be considered include the following : European Heart Journal (2023) 44, 3948–404; 2023 ESC Guidelines for the management of endocarditis

5. POPULATION AT RISK OF INFECTIVE ENDOCARDITIS Patients at intermediate risk of IE include those with : 5 presentation title ( i ) rheumatic heart disease (RHD); (ii) non-rheumatic degenerative valve disease; (iii) congenital valve abnormalities including bicuspid aortic valve disease; (iv) cardiovascular implanted electronic devices (CIEDs); and (v) hypertrophic cardiomyopathy. European Heart Journal (2023) 44, 3948–404; 2023 ESC Guidelines for the management of endocarditis

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7. Situations and procedures at risk 1. Dental procedures Antibiotic prophylaxis is recommended in patients at high risk of IE undergoing at-risk dental procedures and is not currently recommended in other situations. At-risk dental procedures include dental extractions, oral surgery procedures (including periodontal surgery, implant surgery, and oral biopsies), and dental procedures involving manipulation of the gingival or periapical region of the teeth (including scaling and root canal procedures) 7 presentation title European Heart Journal (2023) 44, 3948–404; 2023 ESC Guidelines for the management of endocarditis

8. 8 presentation title The main target for antibiotic prophylaxis is oral streptococci. Table 6 summarizes the main regimens of antibiotic prophylaxis recommended before dental proce European Heart Journal (2023) 44, 3948–404; 2023 ESC Guidelines for the management of endocarditis

9. 2. Non-dental procedures Observational studies reported that, compared with patients with IE not undergoing an invasive procedure, several invasive non-dental medical procedures were associated with increased risk of IE, including cardiovascular interventions, skin procedures and wound management, transfusion, dialysis, bone marrow puncture, and endoscopic procedures, several invasive non-dental medical procedures were associated with increased risk of IE. For this reason, an aseptic operational environment should be ensured during all these procedures to minimize the risk of IE 9 presentation title Situations and procedures at risk(2) European Heart Journal (2023) 44, 3948–404; 2023 ESC Guidelines for the management of endocarditis

10. 3. Cardiac or vascular interventions In all patients undergoing implantation of a prosthetic valve, any type of prosthetic graft/ occluder device or CIED, peri-operative antibiotic prophylaxis is recommended due to the increased risk and adverse outcome of an infection. 10 presentation title Situations and procedures at risk(2) European Heart Journal (2023) 44, 3948–404; 2023 ESC Guidelines for the management of endocarditis

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13. DIAGNOSIS Th diagnosis of IE is based on a clinical suspicion supported by consistent microbiological data and the documentation of IE-related cardiac lesions by imaging techniques. Clinical features Infective endocarditis remains a diagnostic challenge due to its variable clinical presentation. The initial clinical assessment should include evaluation of cardiac and non-cardiac risk factors (Table 8), supportive clinical context, and physical examination findings including potential portals of entry. 13 presentation title European Heart Journal (2023) 44, 3948–404; 2023 ESC Guidelines for the management of endocarditis

14. In the European Infective Endocarditis Registry (EURO-ENDO), fever (77.7%), cardiac murmur (64.5%), and congestive HF (27.2%) were the most frequent clinical presentations. Embolic complications were detected in 25.3% of patients and cardiac conduction abnormalities were found in 11.5%. 14 presentation title European Heart Journal (2023) 44, 3948–404; 2023 ESC Guidelines for the management of endocarditis

15. 15 presentation title Vascular Phenomena Petechiae, microembolization of small vessels in the skin or mucous membrane Coetaneous purpura European Heart Journal (2023) 44, 3948–404; 2023 ESC Guidelines for the management of endocarditis

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18. 2. Laboratory findings Laboratory investigations and biomarkers typically yield non-specific result The degree of anaemia , leucocytosis / leucopaenia , the number of immature white cell forms, concentrations of C-reactive protein and procalcitonin, erythrocyte sedimentation rate, and markers of end-organ dysfunction (serum lactate, serum creatinine, bilirubin, thrombocytopaenia , cardiac troponin, and natriuretic brain peptides) can be used to estimate the severity of sepsis, but none is diagnostic of IE. 18 presentation title European Heart Journal (2023) 44, 3948–404; 2023 ESC Guidelines for the management of endocarditis

19. LABORATORY FINDING 19 presentation title European Heart Journal (2023) 44, 3948–404; 2023 ESC Guidelines for the management of endocarditis

20. 3. Blood culture-positive infective endocarditis Positive blood cultures remain the cornerstone of IE diagnosis and provide live bacteria for both identification and susceptibility testing. At least three sets of blood cultures should be obtained at 30-minute intervals prior to antibiotic therapy, each containing 10 mL of blood, and should be incubated in both aerobic and anaerobic atmosphere 20 presentation title European Heart Journal (2023) 44, 3948–404; 2023 ESC Guidelines for the management of endocarditis

21. 4. Blood culture-negative infective endocarditis Blood culture-negative infective endocarditis (BCNIE) refers to IE in which no causative microorganism can be grown using the usual blood culture methods. Blood culture-negative IE most commonly arises as a consequence of previous antibiotic administration, underlying the importance of performing blood cultures prior to antibiotic therapy, particularly in patients with known risk factors for IE. Blood culture-negative IE can also be caused by fungi or fastidious bacteria, notably obligatory intracellular bacteria. Isolation of these microorganisms requires culturing on specialized media, and their growth is relatively slow 21 presentation title European Heart Journal (2023) 44, 3948–404; 2023 ESC Guidelines for the management of endocarditis

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23. Microbiological diagnostic algorithm in culture positive and bcnie 23 presentation title

24. 5. Imaging Techniques Evidence of lesions characteristic of IE are major diagnostic criterion. Echocardiography is the first-line imaging technique to diagnose IE and to assess the structural and functional damage of cardiac structures. In some clinical scenarios, other imaging modalities, such as CT, nuclear imaging, and MRI, are needed to confirm or exclude the diagnosis of IE, to characterize the extent of the cardiac lesions, and to diagnose extracardiac complications. 24 presentation title European Heart Journal (2023) 44, 3948–404; 2023 ESC Guidelines for the management of endocarditis

25. 25 presentation title Indikasi Echocardiography 1. Transthoracic echocardiography (TTE) First line if suspected IE Native valves 2. Transesophageal echocardiography (TEE) Prosthetic valves Intracardiac complications Inadequate TTE Fungal or S. aureus or bacteremia European Heart Journal (2023) 44, 3948–404; 2023 ESC Guidelines for the management of endocarditis

26. DIAGNOSTIC CRITERIA 26 presentation title European Heart Journal (2023) 44, 3948–404; 2023 ESC Guidelines for the management of endocarditis

27. 27 presentation title DIAGNOSTIC CRITERIA European Heart Journal (2023) 44, 3948–404; 2023 ESC Guidelines for the management of endocarditis

28. Algorithm for diagnosis of native valve infective endocarditis 28 presentation title European Heart Journal (2023) 44, 3948–404; 2023 ESC Guidelines for the management of endocarditis

29. Algorithm for diagnosis of PROSTHETIC valve infective endocarditis 29 presentation title European Heart Journal (2023) 44, 3948–404; 2023 ESC Guidelines for the management of endocarditis

30. Algorithm for diagnosis of CARDIAC DEVICE RELATEDinfective endocarditis 30 presentation title European Heart Journal (2023) 44, 3948–404; 2023 ESC Guidelines for the management of endocarditis

31. Antimicrobial therapy: principles and methods 31 presentation title European Heart Journal (2023) 44, 3948–404; 2023 ESC Guidelines for the management of endocarditis

32. PATIENT SELECTION FOR OPAT Careful patient selection into an OPAT program is critical to minimize treatment failure and complication rates (Table 2). Patients contraindicated to OPAT are those with IE complications, such as heart failure, renal failure, septic shock, neurological complications, or those who participate in active illicit drug use 32 presentation title MDPI Journal 2023 ; Outpatient Parenteral Antimicrobial Therapy for Infective Endocarditis—Model of Care Dylan Rajaratnam 1 and Rohan Rajaratnam

33. 33 presentation title MDPI Journal 2023; Outpatient Parenteral Antimicrobial Therapy for Infective Endocarditis—Model of Care Dylan Rajaratnam 1 and Rohan Rajaratnam

34. MDPI Journal 2023 ; Outpatient Parenteral Antimicrobial Therapy for Infective Endocarditis—Model of Care Dylan Rajaratnam 1 and Rohan Rajaratnam

35. Models of Delivery OPAT It can be administered in multiple different ways either through an outpatient clinic or ambulatory care setting, or via home visit treatment or self-administration. OPAT through an outpatient clinic/ambulatory care setting is very common, involving a peripherally inserted central catheter (PICC), with patients presenting to the healthcare service, being monitored for symptoms or signs of complications and having vital signs taken and laboratory investigations or an ECG taken if indicated. 35 presentation title MDPI Journal 2023 ; Outpatient Parenteral Antimicrobial Therapy for Infective Endocarditis—Model of Care Dylan Rajaratnam 1 and Rohan Rajaratnam

36. Patients receive their therapy by appropriately trained nursing staff . Home visit treatment involves administration of antibiotics via a PICC within a patient’s place of residence (hospital in the home). This requires daily visits by appropriately trained nursing staff, with patients being monitored for symptoms or signs of complications and having vital signs taken . This cohort must be monitored closely with a low threshold to refer to the hospital. 36 presentation title MDPI Journal 2023 ; Outpatient Parenteral Antimicrobial Therapy for Infective Endocarditis—Model of Care Dylan Rajaratnam 1 and Rohan Rajaratnam

37. Finally, self-administration treatment is where patients self-administer their antibiotics through a PICC or orally if utilizing a hybrid intravenous/oral regimen . This cohort must have strict patient selection with patients having direct access/contact with the OPAT team. This cohort must be reviewed regularly in an outpatient clinic/ambulatory care setting to conduct necessary monitoring of symptoms or signs of complications, laboratory investigations and an ECG where required. 37 presentation title MDPI Journal 2023 ; Outpatient Parenteral Antimicrobial Therapy for Infective Endocarditis—Model of Care Dylan Rajaratnam 1 and Rohan Rajaratnam

38. Monitoring during OPAT During the OPAT program patients should be monitored regularly. Weekly laboratory investigations should be performed, Renal and hepatic function Ensuring a decrease in/normalization of inflammatory markers (leucocytes, c-reactive protein) Close monitoring of circulating levels of aminoglycosides and glycopeptides is vital to ensure patients on these antimicrobials have appropriate dose adjustments to avoid inefficacy or toxicity . The AHA recommends repeating TTE and/or TEE for re-evaluation of patients with IE who have a change in clinical signs or symptoms. 38 presentation title

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51. Empirical therapy Treatment of IE should be started promptly. Three sets of blood cultures should be drawn at 30-minute intervals before initiation of antibiotics.391 The initial choice of empirical treatment depends on several consideration : Previous antibiotic therapy. IE in a native valve or a prosthesis (and if so, when surgery was performed [early vs. late PVE]). The place of the infection (community, nosocomial, or nonnosocomial healthcare-associated IE) and knowledge of the local epidemiology, especially for antibiotic resistance and specific genuine culture-negative pathogens. Cloxacillin/cefazolin administration is associated with lower mortality rates than other beta-lactams, including amoxicillin/clavulanic acid or ampicillin/sulbactam,392 and vancomycin for empirically treating MSSA bacteraemia /endocarditis. 51 presentation title European Heart Journal (2023) 44, 3948–404; 2023 ESC Guidelines for the management of endocarditis

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53. Indications for surgery and management of main infective endocarditis complications 53 presentation title European Heart Journal (2023) 44, 3948–404; 2023 ESC Guidelines for the management of endocarditis

54. Thank you