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INFECTIVE
ENDOCARDITIS
Eka Fithra Elfi
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REFFERENCES

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PERHATIAN

Bahan ajar ini hanya sebagai panduan dan rangkuman dasar dari
materi kuliah pakar. Sebagai sumber pengetahuan dan bahan
untuk ujian silahkan membaca referensi tersebut diatas.

Eka Fithra Elfi

Penulis

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TUJUAN PEMBELAJARAN

TIU
• Mampu menjelaskan prinsip diagnosis dan penatalaksanaan
penyakit infeksi jantung, dan penyakit katup jantung dengan
pendekatan dokter keluarga

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TUJUAN PEMBELAJARAN
TIK
Mahasiswa mampu:
• Menjelaskan etiologi dan faktor risiko penyakit infeksi jantung (perikarditis, miokarditis,
endokarditis), penyakit katup (demam rheumatik akut) dan penyakit katup lainnya
• Menjelaskan klasifikasi dan komplikasi penyakit infeksi jantung (perikarditis, endokarditis),
penyakit katup (demam rheumatik akut) dan penyakti katup lainnya
• Menjelaskan patogenesis dan patofisiologi penyakit infeksi jantung (perikarditis,
endokarditis), penyakit katup (demam rheumatik akut) dan penyakti katup lainnya
• Menjelaskan manifestasi klinis dan pemeriksaan penunjang lainnya penyakit infeksi jantung
(perikarditis, endokarditis), penyakit katup (demam rheumatik akut) dan penyakti katup
lainnya
• Menjelaskan penatalaksanaan komprehensif dari penyakit infeksi jantung (perikarditis,
endokarditis), penyakit katup (demam rheumatik akut) dan penyakti katup lainnya
• Menjelaskan komplikasi penyakit infeksi jantung (perikarditis, endokarditis), penyakit katup
(demam rheumatik akut) dan penyakti katup lainnya
• Menjelaskan prognosis penyakit infeksi jantung (perikarditis, endokarditis), penyakit katup
(demam rheumatik akut) dan penyakti katup lainnya
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INTRODUCTION

• The incidence of infective endocarditis (IE) continues to rise, with

a yearly incidence of 20.000 new cases.
• The incidence of IE range from 1.9-6.2 annual infection per
100.000 population
• IE carries a high risk of morbidity and mortality and represents
the fourth leading cause of life-threatening infectious disease with
mortality rate 20%.

• Rapid diagnosis, effective treatment, and prompt recognition of

complications are essential to good patient outcome.

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DEFINITION

• Infection of the endocardial surface of heart

• Characterized by colonization or invasion of the
heart valves (native or prosthetic) or the mural
endocardium by a microbe, leading to formation of
bulky, friable vegetation composed of thrombotic
debris and organisms.
• Often associated with destruction of underlying
cardiac tissue.

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NORMAL FLOW

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ETIOLOGY

Portal of entry:
◦ Dental / Surgical
Procedures
◦ Contamination by IV drug
use
◦Obvious infections
(RS/Skin)
◦ Occult source from gut,
oral cavity
◦ Trivial injuries.
◦ Intravascular catheter
infection
◦ Nosocomial wounds
◦ Chronic invasive
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PREDISPOSING FACTORS

CARDIAC AND VASCULAR HOST FACTORS

ABNORMALITIES
• Neutropenia
• Rheumatic Heart Disease
• Myxomatous mitral valve • Immunodeficiency
• Degenerative calcific valvular • Malignancy
stenosis
• Therapeutic
• Bicuspid aortic valves
immunosuppression
• Prosthetic valves
• Diabetes mellitus

• Alcohol

• IV drug abuse
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MICROBIOLOGY

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PATHOGENESIS

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PATHOGENESIS

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CLINICAL FEATURE
Symptoms
• Damage to intracardiac
structures
• Embolization of
vegetation fragments
• Hematogenous
infection
• Immune complex

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CLINICAL FEATURE
• Fever
• Constitutional symptoms
• New signs of valve
dysfunction
• Heart failure
• Embolic Stroke
• Peripheral arterial
embolism
• Other features
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MODIFIED DUKES CRITERIA

Definitive Endocarditis if,

• Two major or,
• One major and three minor or,
• five minor

Possible Endocarditis if,

• One major and one minor or,
• Three minor
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MAJOR CRITERIA

• Positive blood culture

◦Typical organism from two cultures
◦Persistent positive blood cultures taken > 12 hours apart
◦Three or more positive cultures taken over more than 1 hour.
• Endocardial involvement
◦Positive echocardiographic findings of vegetations
◦New valvular regurgitation
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MINOR CRITERIA

• • Predisposition: Predisposing valvular or cardiac abnormality

• • Intravenous drug misuse
• • Pyrexia ≥38°C (≥100.4°F)
• • Embolic phenomenon
• •Vasculitic/ immunologic phenomenon
• • Blood cultures suggestive: -organism grown but not achieving
• major criteria
• • Suggestive echocardiographic findings
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Splinter hemmorrhage Roth spot

Osler node
Janeway lesion
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MYCOTIC
ANEURYSM

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INVESTIGATION

Echocardiography Microbiology
• Vegetation : oscilating Positive blood culture of
intracardiac mass on valve, streptococci strain
supporting structure, or
implanted material Samples drawn from ≥ 2
venipuncture sites over 24 hrs
• Abcess
• Prostethic valve dehiscence
• New valvular regurgitation

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ECHOCARDIOGRAPHY

Normal heart Vegetation

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INVESTIGATION

Laboratorium Other
• Serology : in negative culture ECG
results (coxiella, legionella,
Chest X Ray
bartonella
Brain CT scan
• Inflammatory marker (CRP,
WBC) CT angiography

• Renal function and urinalysis

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MANAGEMENT
• Antimicrobial therapy
• Empirical therapy started as soon as possible followed with
pathogen specific antibiotics (correlate with blood culture)
• Ampicillin (2 g 4 hourly) 4-6 weeks, and Gentamicin (1mg/kg 8-12 hourly)

• Surgical procedure
• Indicated in
• Patients with direct extension of infection to myocardial structures.
• Prosthetic valve dysfunction and badly damaged native valves.
• Congestive heart failure.
• IE caused by fungi or gram negative or resistant organisms.
• Large vegetations on echocardiography
• Recurrent embolic attacks.

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PROPHYLAXIS

High risk category

• Prosthetic cardiac valves
• Previous bacterial endocarditis,even in absense of
• heart disease.
• Complex cyanotic congenital heart
disease(TGA,TOF)
• Surgically constructed systemic pulmonary shunts.
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Moderate risk category

• Rheumatic and other valvular dysfunction
• Congenital cardiac malformations
• Hypertrophic cardiomyopathy
• Mitral valve prolapse with valvular regurgitation
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REGIMEN FOR IE PROPHYLAXIS

STANDARD ORAL REGIME
• Amoxicillin 2 g 1hr before procedure
• Inability to take oral medication
 Ampicillin 2g IV or IM 1hr before procedure
Penicillin allergy
 Clindamycin 600 mg
Clarithromycin 500 mg
Cephalexin 2 g.
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HOME ASSIGNMENT

Read about MYOCARDITIS and PERICARDITIS

• Etiology
• Pathogenesis and pathophysiology
• Clinical features
• Diagnosis
• Management

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