1. Echography
   1. TEE
      1. More sensitive
         1. 인공판막환자, Possible 임상진단, 합병증(vegetation)
   2. TTE
2. 사용의 원칙
   1. 병합요법
      1. Betalactam + Aminoglycoside
   2. 경구용법
      1. IVDU에서 Rt. IE
3. 치료 반응 평가
   1. Defervescence(해열)
      1. <1 week (75%)
         1. S. aureus
      2. <2 week (90%)
   2. Persistant fever
      1. Cardiac complication
         1. Myocardial abscess
      2. Extracardiac complication
         1. Splenic infarction
         2. Systemic embolism
      3. Drug fever
      4. Nosocomial infection
4. Staphylococcal IE
   1. Treatment
      1. NVE
         1. MSSA, MSCNS
            1. Nafcillin(+/- Gentamicin) = 6w
         2. MRSA, MRCNS
            1. Vancomycin = 6w
      2. PVE
         1. MSSA, MSCNS
            1. Nafcillin or Oxacillin = ≥6w
            2. +Rifampin = ≥6w
            3. +Gentamicin = 2w
         2. MRSA, MRCNS
            1. Vancomycin = ≥6w
            2. +Rifampin = ≥6w
            3. +Gentamicin = 2w
            4. Linezolid(Vancomycin failure시)
5. Streptococcal IE
   1. Treatment
      1. NVE
         1. Penicillin Highly susceptible(MIC≤0.12)
            1. Penicillin G = 2w
         2. Penicillin Relatively resistant(MIC >0.12~≤0.5)
            1. Vancomycin = 4w
         3. Penicillin Fully resistant(MIC > 0.5)
            1. Enterococci와 같이 치료
      2. PVE
         1. Penicillin Highly susceptible(MIC≤0.12)
            1. Penicillin G = 6w
         2. Penicillin Relatively or Fully resistant(MIC >0.12)
            1. Vancomycin = 6w
6. Enterococcal IE
   1. PCN-R, VANC-S
      1. Betalactamase producing strain
         1. Ampicillin-sulbactam = 6w
      2. Intrinsic penicillin resistance
         1. Vancomycin = 6w
   2. PCN, AG-R, VRE
      1. E. faecium
         1. Linezolid = ≥8w
      2. E. faecalis
         1. Imipenem/cilastatin(Ceftriaxone) = ≥8w
7. HACEK
   1. NVE or PVE
      1. Ceftriaxone, Ampicillin-sulbactam, Ciprofloxacin = 4w
8. Complication
   1. Predictor of Death
      1. Low serum albumin
      2. S. aureus IE
      3. Heart failure
      4. DM
      5. Apache 2 score
      6. Embolic events
         1. Size>10mm
         2. MV의 Ant. leaflet
         3. 1~2nd weeks
      7. Paravalvular abscess
      8. Vegetation size
      9. Female sex
   2. 수술 적응증
      1. Heart failure
      2. Fungal, ARO
      3. Persistent bacteremia
      4. Embolic episode
      5. Valve
         1. dehiscence, perforation, rupture, fistula, large perivalvular abscess
      6. Vegetation of ant. leaflet MV
         1. Size > 10mm
         2. Persistent vegetation after embolisation
      7. Vegetation size ↑
9. Epidemiology
   1. Male>Female
   2. 50대 이상
   3. 소아에서는 드뭄
   4. Mitral valve(주로)>Aortic valve>Tricuspid valve(드뭄)
10. 시기적분류
    1. Acute
       1. S. aureus
       2. Normal valve
       3. Produces metastatic foci
    2. Subacute
       1. viridans streptococci
       2. Damaged valve
       3. not produce metastatic foci
11. Culture Negative IE(CNE)
    1. Cause
       1. Fastidious slow frowing organisms(Coxiella burnetti, Chlamydia species)
       2. Non-bacterial(Fungi)
       3. Prior administration of Abscess
       4. Subacute Rt. side IE
       5. Permanent pace maker
12. 1. Inadequate diagnostic techniques 2. Less rigidly defined Dx Criteria
13. Definition
    1. Microbial infection of the endocardial surface
       1. valve
       2. septal defect
       3. chordae tendineae
       4. mural endocardium
    2. Vegetation(고름집)
       1. platelet
       2. fibrin
       3. microorganism
       4. inflammatory cells
14. Pathology
    1. (1)Bacteremia
       1. (2)Colonization(Adherence)
          1. Damaged endothelium(Rheumatic HD)
             1. Streptococcal IE
          2. Inflamed endothelium(Intact valve)
             1. Staphylococcus aureus IE
       2. (3)Bacterial Growth
          1. (4)Vegetation
15. 진단
    1. 확실한 IE
       1. 병리기준
       2. 임상기준
          1. M 2개
          2. M 1개 + m3개
          3. m 5개
    2. 가능성 있는 IE
       1. M 1개 + m 1개(또는 2개까지)
       2. m 3개
    3. 진단을 부정할 수 있는 경우
       1. 분명한 다른 진단
       2. 4일 미만 항균요법으로 치유
       3. 위의 possible의 기준 충족 x
    4. Modified Duke criteria
       1. Major criteria
          1. 혈액배양 양성결과
             1. 전형적 미생물 2회 이상 양성
             2. 그외 미생물 지속적 양성
             3. Coxiella burnetti 1회이상 양성, 또는 anti-phase IgG > 1:800
          2. 심내막 침범의 근거(초음파소견)
             1. 와류가 닿는 판막 또는 지지구조에 진동하는 심장 내 종물
             2. 이상한 구조의 삽입물 종물
             3. Abscess
             4. 인공판막 suture 부위에 dehiscence(벌어진 부분)
             5. 새로운 판막폐쇄부전
       2. Minor criteria
          1. >38℃ Fever
          2. 원 심장질환, 정맥주사남용자
          3. 혈관계현상
             1. 동맥색전증
             2. 패혈성 폐경색
             3. 감염성 대동맥염
             4. 두개강내출혈
             5. 결막출혈
             6. 그림3.jpg
             7. Janeway 병변
             8. 그림1.jpg
             9. 그림1.jpg
             10. Splinter hemorrhages
             11. 그림2.jpg
          4. 면역학적 현상
             1. 토리콩팥염
             2. Osler결절
             3. 그림5.jpg
             4. 그림6.jpg
             5. 그림4.jpg
             6. Roth 반점
             7. 그림7.jpg
             8. 그림8.jpg
             9. Rheumatoid factor 양성
          5. 미생물학적 근거
16. Epidemiology
    1. Usually Heart valve
    2. Sex : M>F = 2:1
    3. Increase Age of Onset (30~40 -> 47~69)
    4. Streptococcus -> Staphylococcus
    5. Normal valve 발생감소, Prosthetic valve 발생증가(Staphylococcus)
       1. 급성으로 발현되는 경우 많다
    6. Culture negative 5%
    7. Early valve surgery 49%
17. Classification
    1. Native Valve IE(NVE)
       1. Streptococci
          1. viridans streptococci(75%)
          2. Streptococcus bovis(20%)
             1. mainly in elderly(>60 yrs old)
             2. >1/3에서 underlying GI malignancy
       2. Enterococci
          1. 60대 남자
             1. 선행인자
             2. GU tract manipulation 의 최근 history
             3. trauma
             4. disease
             5. cystoscopy
             6. urethral catheterization
             7. prostatectomy
             8. abortion
             9. pregnancy
             10. cesarean section
       3. Staphylococci
          1. Normal or Damaged valve 이환
       4. HACEK
       5. Fungi
          1. subacute course
          2. 자주 glucocorticoid 치료받는 intravascular catheter를 가진 환자
          3. broad spectrum antimicrobial drug
          4. cytotoxic agents
    2. Prosthetic Valve IE(PVE)
       1. aortic valve
       2. 봉합부위
       3. Staphylococcus epidermidis가 주로 infection
    3. Nosocomial IE
    4. IE IN IVDU
       1. S. aureus(>50%)
       2. tricuspid valve에 주로
       3. murmur는 없다
18. Treatment
    1. Antibiotics
       1. Bactericidal activity
       2. Adequate concentration
       3. Optimal Duration
       4. Combination Tx