Update on Infective Endocarditis - FK UWKS 2012 C

Update on Infective Endocarditis - FK UWKS 2012 C

ENDOKARDITIS INFEKTIF (EI) B. Rudy Utantio, MD University of Wijaya Kusuma 14/02/20 Rudy Utantio DEFINISI Endokarditis infeksiosa (EI) adalah infeksi mikroba pada lapisan endotel jantung didapatkan lesi spesifik, berupa vegetasi yang merupakan masa dengan ukuran bervariasi, yang dibentuk oleh platelet, fibrin, mikroba dan sel-sel inflamasi yang saling berikatan satu sama lain.

Infeksi paling banyak mengenai katup jantung (terutama katup abnormal),namun dapat juga terjadi pada lokasi defek septal (pada ASD atau VSD), arteriovenous shunt, arterioarterial (PDA) atau koartasio aorta 14/02/20 Rudy Utantio 2 ENDOKARDITIS INFEKTF Angka kematian tinggi, karena itu sangat penting untuk mengingat dan melaksanakan tiga hal berikut : 1. EI harus dicurigai pada semua pasien

dengan demam / septikemia dan murmur 2. Pemeriksaan ekokardiografi harus dilakukan dengan segera pada penderita yang dicurigai EI 3. Ahli jantung, ahli mikrobiologi dan ahli bedah jantung harus bekerja sama . 14/02/20 Rudy Utantio 3 Mikroba Penyebab EI 1. Bakteri Gram positif :

Streptokokus viridans, Stafilokokus Aureus, Pneumokokus dll 2. Bakteri Gram negatif : Escherichia coli, salmonela dll 3. Jamur 4. Lain-lain, misalnya Riketsia burnetti, Brucella abortus 14/02/20 Rudy Utantio 4 Predisposisi terjadinya EI Gangguan katup-katup jantung merupakan penyebab dasar

terjadinya endokarditis infektif: Demam Rheuma Akut tejadi pada beberapa tahun yang lalu Mitral valve prolapse Penyakit Jantung Bawaan Bakteremia yang dapat terjadi pada pemeriksaan / terapi dental, manipulasi genitourinaria, persalinan, kateterisasi jantung, penyuntikan IV terutama pada kecanduan obat parenteral dan tindakan bedah 14/02/20 Rudy Utantio 5

Tindakan diagnostik / terapi yang dapat menyebabkan bakteremia Bronkoskopi Sistoskopi pada infeksi saluran kemih (ISK) Biopsi saluran kemih / prostat Tindakan / operasi gigi dengan risiko trauma gingival / mukosa Tonsilektomi / adenoidektomi Dilatasi esophagus / skleroterapi

Instrumentasi pada obstruksi traktus biliaris 14/02/20 Rudy Utantio 6 Tindakan diagnostik / terapi yang dapat menyebabkan bakteremia Reseksi prostat transurethral Instrumentasi / dilatasi uretra Tindakan ginekologi dalam keadaan infeksi Kateterisasi jantung tidak memerlukan profilaksis 14/02/20

Rudy Utantio 7 Mitral Valve Prolapse Resiko terjadinya endocarditis infeksiosa 5x-8x x-8x Terjadi mitral regurgitasi yang meningkatkan risiko Daun katup mitral sering mengalami degenerasi miksomatous Umur <20 , predominan wanita Umur >20 , predominant pria 14/02/20

Rudy Utantio 9 Number of cases Mitral Valve Prolapse and Infective Endocarditis 14/02/20 20 18 16 14

12 10 8 6 4 2 0 Male Female <19 20-29

30-39 40-49 50-59 Rev Infect Dis 1986;8:117-137 Rudy Utantio >60 10 Prosthetic Heart Valve Kultur darah yang positif pada pasien dengan katup

buatan merupakan petunjuk adanya endokarditis 43% penderita dengan infeksi bakteri atau jamur yang nosokomial Merupakan komplikasi yang serius 14/02/20 Rudy Utantio 11 Penyalahgunaan obat-obat IV Sering kambuh Polimikroba Yang paling sering menyebabkan endokarditis

adalah Staph aureus Yang paling sering terinfeksi adalah katup trikuspid 14/02/20 Rudy Utantio 12 Faktor Predisposisi Endokarditis Infektif Polimikroba Iv drug use Central line Prosthetic valve

Previous IE Murmur Dental procedure Rheumatic disease Miscellaneous 14/02/20 Rudy Utantio 13 Diagnosis EI Anamnesis Riwayat penyakit : - sering gejala non spesifik / asimptomatik

lemah, panas yang hilang timbul, mirip flu - 75x-8x % penderita mempunyai riwayat kelainan jantung atau kelainan katup - 20% penyalahgunaan obat iv Pemeriksaan fisik Pemeriksaan EKG Pemeriksaan Pemeriksaan Radiologi penunjang Pemeriksaan Ekokardiografi Pemeriksaan gigi 14/02/20 Rudy Utantio 14

Pemeriksaan Fisik Didapatkan tanda-tanda inflamasi umum, peningkatan temperatur, anemia, berkeringat, menggigil, anoreksia, penurunan berat badan dll. Pemeriksaan fisik khusus, sangat tergantung pada komplikasinya, misalnya sesak nafas, batuk, tanda-tanda neurologi misalnya hemiparese dll 14/02/20 Rudy Utantio 15

EKG tidak khas PR interval memanjang atau blok AVyang bisa merupakan petanda adanya abses Pemeriksaan Radiologi : Foto thorax Pembesaran otot jantung yang progresif, edema paru dan adanya abses paru pada pasien penyalahgunaan obat iv Pemeriksaan Laboratorium Penting biakan darah Hematologis didapatkan anemia, LED yang meningkat, lekosit pada umumnya meningkat

14/02/20 Rudy Utantio 17 Pemeriksaan Ekokardiografi Menunjukkan adanya kelainan jantung yang mendasari Penting vegetasi katup jantung 14/02/20 Rudy Utantio

18 DIAGNOSIS EI Risk for Endocarditis High risk prosthetic cardiac valve prior episodes of endocarditis complex congenital cardiac defect surgically constructed systemic-pulmonary shunts or conduits 14/02/20 Rudy Utantio

22 Risk for Endocarditis Moderate risk patent ductus arteriosus VSD, primum ASD coarctation of the aorta bicuspid aortic valve hypertrophic cardiomyopathy acquired valvular dysfunction MVP with mitral regurgitation 14/02/20 Rudy Utantio

23 Risk for Endocarditis Low risk isolated secundum atrial septal defect ASD, VSD, or PDA >6 months past repair innocent heart murmur by auscultation in the pediatric population innocent heart murmur by echocardiography in adult patients 14/02/20 Rudy Utantio

24 PENGOBATAN Antibiotika disesuaikan dengan sensitivitas dari mikroba yang dilakukan kultur Pengobatan gagal jantung : digitalis, diuretika dan vasodilator Pengobatan komplikasi yang lain 14/02/20 Rudy Utantio 25

New Treatments Right-sided infective endocarditis due to methicillinsusceptible S aureus (MSSA) in IV drug users 2-wk therapy with a penicillinase-resistant penicillin and an aminoglycoside 2-wk monotherapy with IV cloxacillin short-term therapy is inappropriate if complicated by ostomyelitis, meningitis, myocardial abscess, or concomitant left-sided involvement 14/02/20 Rudy Utantio 26

New Treatments Highly penicillin-susceptible Streptococcus viridans or bovis Once-daily ceftriaxone for 4 wks cure rate > 98% easily administered as outpatient, avoid hospitalization, offers significant cost savings Once-daily ceftriaxone 2 g for 2wks followed by oral amoxicillin qid for 2 wks Once-daily ceftriazone and netilmicin for 2 wks 14/02/20 Rudy Utantio

27 New Treatments Prosthetic valve endocarditis due to fluconazole-susceptible Candida species many are due to bloodstream invasion chronic oral suppressive therapy with fluconazole for inoperable disease 14/02/20 Rudy Utantio 28

SBE Prophylaxis Standard general prophylaxis Unable to take oral meds Allergic to penicilin amoxicillin ampicillin clindamycin cephalexin azithromycin clarithromycin Allergic to penicillin and unable clindamycin to take oral medications cefazolin

14/02/20 Rudy Utantio 29 Diagnostic (Duke) Criteria Definitive infective endocarditis pathologic criteria microorganisms or pathologic lesions: demonstrated by culture or histology in a vegetation, or in a vegetation that has embolized, or in an intracardiac abscess clinical criteria (see below)

two major criteria, or one major and three minor criteria, or five minor criteria 14/02/20 Rudy Utantio 30 Diagnostic (Duke) Criteria Major criteria evidence of endocardial involvement positive blood culture for IE Minor criteria predisposition (heart condition or IV drug use) fever

vascular or immunologic phenomena microbiologic or echocardiographic evidence not meeting major criteria 14/02/20 Rudy Utantio 31 Diagnostic (Duke) Criteria Possible infective endocarditis findings consistent of IE that fall short of definite, but not rejected Rejected

firm alternate Dx for manifestation of IE resolution ofmanifestations of IE, with antibiotic therapy for 4 days no pathologic evidence of IE at surgery or autopsy, after antibiotic therapy for 4 days 14/02/20 Rudy Utantio 32 Dukes Major Criteria positive blood culture for IE

typical microorganism (strep viridans, strep bovis, HACEK group, staph aureus or enterococci in the absence of a primary locus) for endocarditis from two separate blood cultures persistently positive blood culture from: blood cultures drawn more than 12 hr apart, or all of 3 or a majority of 4 or more separate blood cultures, with first and last drqwn at least 1 hr apart 14/02/20 Rudy Utantio 33

Dukes Major Criteria Evidence of endocardial involvement positive echocardiogram for endocarditis oscillating intracardiac mass on valve or supporting structure, or in the path of regurgitant jets, or on implanted material, in the absence of an alternate anatomic explanation abscess new partial dehiscence of prosthetic valve new valvular regurgitation (increase or change in preexisting murmur not sufficient) 14/02/20 Rudy Utantio

34 Dukes Minor Criteria predisposition (predisposing heart condition or iv drug use) fever of 100.40F or higher vascular phenomena (major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctive hemorrhages, Janeway lesions) 14/02/20 Rudy Utantio

35 Dukes Minor Criteria immunologic phenomena (glomerulonephritis, Oslers nodes, Roth spots, rheumatoid factor) microbiologic evidence (positive blood culture not meeting major criteria or serologic evidence of active infection with organism consistent with IE) echocardiogram (consistent with IE but not meeting major criteria) 14/02/20 Rudy Utantio

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