INFECTIVE ENDOCARDITIS

Riyani WikaningrumBag. Mikrobiologi

Fak. Kedokteran Univ. Yarsi

ANATOMI

PENDAHULUAN

• Keadaan infeksi yang jarang tapi berat.• Ditandai dengan kolonisasi atau invasi

katup jantung dan endokardium oleh agen mikroba.

• Terbentuk “vegetasi” yang terdiri atas fibrin, platelet dan mikroorganisme lepas ke sirkulasi memberikan gejala dan tanda berupa demam, gejala sistemik non-spesifik, bising jantung dan emboli.

Gambaran Histopatologi

Tipe Infective endocarditis

• Akut– Paling sering disebabkan oleh S. aureus– Jarang terjadi, menyerang katup normal

maupun abnormal• Subakut

– Paling sering disebabkan oleh S. viridans– Lebih sering terjadi Sub-acute bacterial

endocarditis (SBE)– Menyerang katup abnormal

Tipe Infective endocarditis (cont)

• Prostetik– Terjadi sesudah operasi penggantian katup– Bisa terjadi awal (< 60 hari sesudah operasi)

atau lambat (> 60 hari sesudah operasi)• Right sided endocarditis

– Terjadi akut, pada pemakai obat iv dan penderita penurunan kekebalan

– 5% kasus endokarditis– Katup tricuspidal

Faktor resiko

• Kelainan kongenital jantung• Abnormalitas vaskuler• Penyalah gunaan obat iv• Aborsi• Operasi penggantian katup• Kateterisasi urin dan jantung• Prosedur diagnostik dan operasi invasif:

– Gigi; Saluran nafas atas; traktus urinarius; traktus digestivus bawah

Organisme penyebab

• Gol. Streptokokus viridans:– S. sanguis; S. mitis; S. mutans; S. milleri

• Gol. Enterokokus:– Enterococcus faecalis, E. faecium

• Gol. Stafilokokus:– S. aureus; S. epidermidis

• Fungi:– Candida; Aspergillus; Histoplasma; T.

glabrata

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Streptococcus (Gram stain)

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Viridans streptococciViridans streptococci• diverse species diverse species • oral oral • dental cariesdental caries• α hemolytic and negative for other tests hemolytic and negative for other tests • non-groupable.non-groupable.• includes includes S. mutansS. mutans

– occassional endocarditis after tooth extractionoccassional endocarditis after tooth extraction

Streptococcus viridans isolated from bacterial endocarditis case (Gram stain)

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EnterococciEnterococci

• distantly related to other streptococcidistantly related to other streptococci• genus genus EnterococcusEnterococcus • gut floragut flora

– urinary tract infection urinary tract infection • fecal contaminationfecal contamination

– opportunistic infectionsopportunistic infections• particularly endocarditisparticularly endocarditis

• most common most common E. (S.) faecalisE. (S.) faecalis

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EnterococciEnterococci• resistant to many antibiotics resistant to many antibiotics

– including vancomycinincluding vancomycin• terminal D-ala replaced by D-lactate terminal D-ala replaced by D-lactate

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STAPHYLOCOCCISTAPHYLOCOCCI

• Gram positiveGram positive• Facultative anaerobesFacultative anaerobes• Grape like-clustersGrape like-clusters• Catalase positiveCatalase positive• Major components Major components of normal flora of normal flora

- skinskin- nose nose

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Staphylococcus aureusStaphylococcus aureus

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One of commonest opportunistic One of commonest opportunistic infections - hospital and communityinfections - hospital and community:

• pneumonia• osteomyelitis• septic arthritis• bacteremia• endocarditis• abscesses/boils• other skin infections

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IdentificationIdentification• Sheep blood agarSheep blood agar– β hemolytic β hemolytic – yellow pigmentedyellow pigmented (aureus(aureus))

• mannitol fermentationfermentation• coagulase-positivecoagulase-positive

• reference laboratories reference laboratories – phage-typing phage-typing

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Staphylococcus epidermidisStaphylococcus epidermidis• major member, skin floramajor member, skin flora

• opportunistic infectionopportunistic infection - less common than S.aureus- less common than S.aureus

• nosomial infections nosomial infections - shunts, cathetersshunts, catheters

• artificial heart valves/joints artificial heart valves/joints

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IdentificationIdentification• Sheep blood agarSheep blood agar

– non-hemolyticnon-hemolytic– Non-pigmentedNon-pigmented

• Does not ferment mannitolDoes not ferment mannitol• Coagulase negativeCoagulase negative

Organisme penyebab

• Lain-lain:– Coxiella burnetti– Legionella sp.– Chlamydia psittaci– Bartonella henselae; B. quintana– HACEK group (Haemophilus sp.,

Actinobacillus actinomycetecomitans, Cardiobacterium hominis, Eikenella corrodens dan Kingella kingae)

Sumber infeksi

• Karies dentis• Kateterisasi urin• Penyalahgunaan obat iv• Kateter vena• Gangguan kolon• Dekubitus• Operasi dan perawatan gigi• Septisemia

Gejala

• Demam• Malaise, anorexia dan BB turun• Gejala gagal jantung• Gejala emboli• Gangguan kesadaran

Tanda-tanda• Pyrexia• Bising jantung• Tanda-tanda emboli• Tanda-tanda gagal jantung• Osler’s Nodes, splinter haemorrhages, lesi

Janeway• Anemia, LED meningkat, AL umunya normal• Splenomegali• Clubbing fingers

Splinter hemorrhage

Conjunctival petechiae

Osler’s nodes

Janeway’s lesion

Splinter hemorrhage

Osler’s Node

Pemeriksaan• Kultur darah:

– Standar baku– Apabila hasil negatif, kemungkinan:

• Pemeriksaan sesudah pemberian antibiotik• Mikroorganisme penyebab gol yang sukar tumbuh dengan

cara kultur biasa• Serologi utk patogen penyebab• Imunoglobulin; total komplemen dan komplemen C3• Echocardiografi• Pemeriksaan urin, darah• Foto thorax, ECG

Manajemen

• Manajemen pasien sakit akut• Pemberian antibiotik

– Blind therapy kombinasi penisilin dan gentamisin atau vancomisin dan gentamisin

– Berdasarkan hasil kultur dan tes sensitivitas mikroba thd antibiotik

• Operasi

Sumber Bacaan

• Bahan kuliah Riyani Wikaningrum:– Infective Endocarditis– Chlamydia– Rickettsiae

• Brooks GF et al. (2004) Jawetz, Melnick, & Adelberg’s Medical Microbiology. 21st ed.

• Prendergast BD (2004) Diagnostic criteria and problems in infective endocarditis, Heart; 90: 611-613