ENDOKARDITIS INFEKTIF3

ENDOKARDITIS INFEKTIF

Definisi : infeksi mikroorganisme pada endokard atau katup jantung

Vegetasi katup (khas) Juga pada endokard dan pembuluh darah

besar Biasanya pada jantung yang rusak P.J. Bawaan atau yang didapat

ENDOKARDITIS INFEKTIF

Prof.dr.H. Saharman Leman, DTM&H. SpPD-KKV

Etio : bakteri, jamur, virus dll Pada jantung normal, E.I. dapat terjadi

pada katup sebab : misalnya pada penyalahgunaan narkoba

Perjalanan penyakit : bisa hiper akut, sub akut, khronik

Sub akut (bulan-2 tahun), hiper akut / akut fatal

Khronik tak didiagnosa

EPIDEMIOLOGI

Umur rata-rata 39-50 tahun Pria > wanita Bertambah banyak Tanda-tanda khas jarang ditemukan Insiden 6-7 dalam 100.000 penduduk

FAKTOR PREDISPOSISI / PENCETUS

1. Kelainan jantung organik (PJR, PJ kongenital, ASHD dll)

2. Tanpa kelainan jantung (akibat obat imunosuppresif, sitostatik, hemodialisa, sirosis hati, PPOK, ginjal, LE, Pirai, obat-obat IV)

PENCETUS : ekstraksi gigi, kateter urine dll

ETIOLOGI

Sub akut : Strept. Viridans (terbanyak) Akut : Staphy. aureus, Staphy. Fecalis,

gram (-) aerob, anaerob, jamur, virus, ragi, kandida

PATOGENESIS DAN PATOLOGI ANATOMI Port d’entre : saluran nafas, saluran kemih,

genital, saluran pencernaan, vena dan kulit. Endokard tidak rata / yang rusak

vegetasi trombosit dan fibrin Katub, abses miokard, aneurisma miokard,

ruptur chorda tendinea Trombus + kuman

7/98 medslides.com 8

IV Drug Use

Recurrent Polymicrobial Staph aureus accounts for the majority of

cases of endocarditis tricuspid valve, either alone or in

combination, us most often infected


Predisposing Factors Polymicrobial

Infective Endocarditis

Iv drug use

Central line

Prosthetic valve

Previous IE

Murmur

Dental procedure

Rheumatic disease

Miscellaneous


Polymicrobial Infective Endocarditisclinical features

IV drug use is the predominant risk factor younger age (mean 36.5 years) 2/3 were male right-sided cardiac involvement in > 60% streptococci more frequent than S. aureus 1/3 of patients died mortality rate is 4x higher for pure left-sides vs

pure right-sided endocarditis


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


Polymicrobial Infective Endocarditisclinical features

IV drug use is the predominant risk factor younger age (mean 36.5 years) 2/3 were male right-sided cardiac involvement in > 60% streptococci more frequent than S. aureus 1/3 of patients died mortality rate is 4x higher for pure left-sides vs

pure right-sided endocarditis



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



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



Major criteria– positive blood culture for IE

– evidence of endocardial involvement

Minor criteria– predisposition (heart condition or IV drug use)

– fever of 100.40F or higher

– vascular or immunologic phenomena

– microbiologic or echocardiographic evidence not meeting major criteria


Duke’s 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


Duke’s 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 pre-existing murmur not sufficient)


Duke’s 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)


Duke’s Minor Criteria

immunologic phenomena (glomerulonephritis, Osler’s 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)


Risk for Endocarditis

High risk– prosthetic cardiac valve– prior episodes of endocarditis– complex congenital cardiac defect– surgically constructed systemic-pulmonary

shunts or conduits



Moderate risk– patent ductus arteriosus– VSD, primum ASD– coarctation of the aorta– bicuspid aortic valve– hypertrophic cardiomyopathy– acquired valvular dysfunction– MVP with mitral regurgitation



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


Treatment

Pre-antibiotic era - a death sentence Antibiotic era

– microbiologic cure in majority of patients

KLASIFIKASI E.I

1.a. Endokarditis infektif bakterial sub akut (SBE)

1.b. Endokarditis infektif akut (ABE)2.a. Native valve endokarditis (NVE)2.b. Endokarditis katup prostetik (PVE)

KLASIFIKASI KLINIS :I. S.B.EII. A.B.E

S B E

KELUHAN Tak jelas kapan timbul, Sesudah cabut gigi,

Infeksi saluran nafas, Tindakan lain Demam, lemah, letih, lesu, keringat malam

banyak, anereksia, BB turun, sakit sendi Bila emboli (+) : paralisis, sakit dada, sakit

perut, hematuria, buta mendadak, sakit jari kaki

S B E

GEJALA

1. Gejala umum toksemia : demam remitten, intermitten, menggigil, keringat banyak, anemia, hepatosplenomegali

2. Gejala jantung : penting, kelainan katup dll (SM, IM, IA, PDA, VSD), dispneu, takikardi, aritmia, sianosis, perubahan bising penting

S B E

GEJALA

3. Gejala emboli dan vaskular : ptekhie, Roth’s spot, splinter hemorrhage, Osler’s nodes, abses kulit, aneurisma mikotik, GNA, GG, splenommegali

ENDOKARDITIS INFEKTIF AKUT

Pada jantung normal Akut, panas tinggi Splenomegali, clubbing finger, osler’s node,

ptekhie dll Dst = SBE

PEMERIKSAAN PENUNJANG

LABORATORIUM Leukositosis (neutrofilia), Ig serum , g

globulin (+), C3 , total hemolitik

Biakan mikroorganisme : tiap hari (2-5 hari), dalam media serum, sebelum antibiotik

EKG


EKOKARDIOGRAFI

1. Vegetasi

2. Dilatasi / hipertrofi

3. Katup-katup

RADIOLOGI

1. Gagal jantung

2. Infiltrat paru

DIAGNOSIS

Tidak mudah Kelainan katup, kelainan jantung Demam, biakan darahD/ SBE : Septikemia Kelainan jantung bawaan dll Demam lama + bising +/- Respon pengobatan (+)

DIAGNOSIS

DD/ Demam rematik Pneumonia Sepsis lain ; thromboplebitis, meningitis TBC milier LE GNA, PNA Reaksi Obat

KOMPLIKASI

1. GAGAL JANTUNG

2. EMBOLI

3. ANEURISMA NEKROTIK

4. GANGGUAN NEUROLOGI

PENGOBATAN Antibiotika, sesuai uji kuman Penisilin G ²,4 – 6 juta unit/hari, selama 4

minggu, parenteral 2 minggu, kemudian oral penisilin

+ Streptomisin 2 x 0,5 gr, 2 minggu Pada orang tua (+), gentamisin 3-5 mg /

kgBB, ²-3 dosis/hari, 4-6 minggu Sefalotin, oksasilin, vankomisin,

aminoglikosid Gagal jantung

PROGNOSIS

Buruk pada : Gagal jantung Resistensi mikroorganisma Pengobatan terlambat Bakteremia Orang tua Penderita dengan katup buatan

ENDOKARDITIS INFEKTIF PADA PENYALAHGUNAAN OBAT INTRA VENA

Def. End. Inf. : infeksi mikrobial pada lapisan endotel jantung dengan vegetasi pada daun katup dan dapat meluas ke chorda tendinea, muskulus papilaris, bahkan endokardium ventrikel dan atrium

Terbanyak di katup trikuspid dan pulmonal, jarang pada mitral dan aorta

PATOGENESIS Tidak jelas Diduga kerusakan mekanik karena obat-

oatan tercampur dengan partikel kontamisasi

ETIO Akut : S. aureus Sub akut : S. epidermis, S. viridans

MANIFESTASI KLINIS :

Demam 80-100% Lelah Anoreksia BB menurun Sesak nafas, sakit nkepala, mialgia, mual,

muntah

PEMERIKSAAN FISIK

Lesi ptekhie Osler’s node Lesi Janewey, abnormalitas kulit, emboli

septik, deposisi komplek immunTANDA SPESIFIK Murmur pada katup Di trikuspid : holosistolik. Blowing Kk : gagal jantung kongestif, splenomegali,

emboli paru


Kultur darah : 3 x terpisah Ekokardiogradfi T.E.E 98% (+)

DIAGNOSIS

KRITERIA DUKE UNIVERSITY 1994

1. EI DEFINITE

2. EI POSSIBLE

3. EI REJECTED

E.I. DEFINITE

KRITERIA PATOLOGIS Mikrorganisme : kultur darah, histologis vegetasi

emboli Ditemukan vegetasi diatas, abses intrakardial

histologis

KRITERIA KLINIS 2 kriteria mayor 1 mayor dan 3 kriteria minor 5 kriteria minor

E.I. POSSIBLE

DIANTARA DEFINITE DAN REJECTED

E.I. REJECTED

DIAGNOSIS ALTERNATIF TIDAK DITEMUKAN :

1. MANIFESTASI ENDOKARDITIS SELAMA 2-4 HARI

2. BAKTERI PATOLOGIS EI PADA SPESIMEN / OTOPSI KURANG DARI 4 HARI

KRITERIA MAYOR

1. KULTUR DARAH (+) UNTUK EIa. Mikroorganisme khas EI dari kultur darah

terpisah1. Strep. Viridans, Bovis / HACEK2. Staph. Aureus, enteerococci, tanpa vokus primer

b. Mikroorganisme konsisten EI dari kultur darah (+) persisten sebagai :

1. > 2 kultur darah yang diambil terpisah > 12 jam2. Semua dari 3 atau 4 kultur darah terpisah (atau

sampel awal dan akhir lebih dari 1 jam)

KRITERIA MAYOR

2. BUKTI KETERLIBATAN ENDOKARDIAL

a. EKOKARDIOGRAM1. Massa intrakardial oscilating pada katup atau

struktur lain pada aliran regurgitasi2. Abses3. Tonjolan pada katup prostetik

b. REGURGITASI VALVULAR YANG BARU ATAU MEMBURUK / BERUBAH DARI SEMULA

KRITERIA MINOR

PREDISPOSISI : KONDISI JANTUNG ATAU PENGGUNAAN OBAT IV

DEMAM LEBIH DARI 38 C FENOMENA VASKULAR

– Emboli arteri besar– Infark pulmonal septik– Aneurisma mikotik, perdarahan intra kranial,

konjungtiva dan lesi Janeway

KRITERIA MINOR

FENOMENA IMUNOLOGIS :– Glomerulonefritis, nodul Osler, Roth spots

dan faktor rematoid

BUKTI MIKROBIOLOGIS– Kultur darah (+)– Serologis infektif akut

TEMUAN EKOKARDIOGRAFI– Konsisten dengan EI tetapi tidak yang diatas


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


SBE Prophylaxis

Standard general prophylaxis amoxicillin

Unable to take oral meds ampicillin

Allergic to penicilin clindamycin

cephalexin

azithromycin

clarithromycin

Allergic to penicillin and unable clindamycin

to take oral medications cefazolin

TERAPI

EMPIRIS SAMBIL MENUNGGU KULTUR DARAH

PERTIMBANGAN AKUT ATAU SUB AKUT

Gram (-) (M.SSA)– Penisilin 6 x 3 juta U IV atau Ampisilin 6 x 2

gram + Gentamisin 3 x 50 mg– Terapi lain Seftriakson 1 x 2 gram– Semuanya diberikan minimal 4 minggu

TERAPI

Bila M.RSA– Vankomisin 2 x 1 gr IV– Terkoplamin 2 x 400 mg IV dibagi 3 dosis– Selama 4 minggu

TERAPI SURGICAL

INDIKASI

1. VEGETASI MENETAP

2. DISFUNGSI KATUP AI, MI AKUT GAGAL JANTUNG YANG TIDAK

RESPON DENGAN MEDIS PERFORASI / RUPTUR KATUP

3. EKSISTENSI PERIVALVULAR

ENDOKARDITIS INFEKTIF3

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