Endocarditis Infecciosa Mr3 Gerald

ENDOCARDITIS INFECCIOSA Gerald Carlos Lévano Pachas MR 3 - Cardiología Hospital Arzobispo Loayza

1.- CONCEPTO ,[object Object],[object Object]

Sir William Osler (1849-1919) fue Catedrático de Medicina en la Universidad de Oxford (1905-1919), Profesor y Jefe de Departamento en la Facultad de Medicina Johns Hopkins (1888-1905) y Profesor de Medicina Clínica en la Universidad de Pensilvania (1884-1888). Fue autor de muchas obras de medicina y de ética médica. Introducción y Antecedentes históricos

Introducción y Antecedentes históricos ,[object Object],[object Object],[object Object],[object Object],Levy D. Centenary of William Osler’s 1885 gulstonian lectures and their place in the history of bacterial endocarditis. J R Soc Med 1985;78:1039-46

Introducción y Antecedentes históricos ,[object Object],[object Object],[object Object],Levy D. Centenary of William Osler’s 1885 gulstonian lectures and their place in the history of bacterial endocarditis. J R Soc Med 1985;78:1039-46

Introducción y Antecedentes históricos ,[object Object],[object Object],[object Object]

Predictores de mortalidad intrahospitalaria de la endocarditis infecciosa en la República Argentina: resultados del EIRA-II Epidemiología

[object Object],[object Object],[object Object],Epidemiología Unique Features of Infective Endocarditis in Childhood Copyright © 2002 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX 72514 DOI: 10.1161/01.CIR.0000013073.22415.90 Circulation 2002;105;2115-2126 American Heart Association Council on Cardiovascular Disease in the Young From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Matthew E. Levison, Thomas J. Pallasch, Tommy W. Gage, Kathryn A. Taubert and S. Dajani, Stanford T. Shulman, Walter Wilson, Ann F. Bolger, Arnold Bayer, Patricia Ferrieri, Michael H. Gewitz, Michael A. Gerber, Jane W. Newburger, Adnan

Epidemiología ,[object Object],[object Object],[object Object],[object Object],Karchmer A W. Infective endocarditis. In: Braunwald E, ed. Heart disease: a textbook of cardiovascular medicine. 7th ed. London: Saunders, 2005: 1633–56

Epidemiología ,[object Object],[object Object],[object Object],[object Object],[object Object],Ferrieri P, Gerwitz MH, Berger M, et al. Unique features of infective endocarditis in childhood. Pediatrics 2002;109:931 2 43.

[object Object],[object Object],[object Object],Unique Features of Infective Endocarditis in Childhood Copyright © 2002 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX 72514 DOI: 10.1161/01.CIR.0000013073.22415.90 Circulation 2002;105;2115-2126 American Heart Association Council on Cardiovascular Disease in the Young From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Matthew E. Levison, Thomas J. Pallasch, Tommy W. Gage, Kathryn A. Taubert and S. Dajani, Stanford T. Shulman, Walter Wilson, Ann F. Bolger, Arnold Bayer, Patricia Ferrieri, Michael H. Gewitz, Michael A. Gerber, Jane W. Newburger, Adnan

Infective endocarditis in patients with congenitally malformed hearts: characterization of the syndrome in a developing country Bilal K. Siddiqui, Muhammed Tariq, Atif Jadoon, Ghulam Murtaza, Asim Syed, M. Bilal Abid, Maria Qamaruddin, Mehnaz Atiq, Raymond A. Smego Accepted for publication 13 August 2007

Epidemiología ,[object Object],[object Object],[object Object],[object Object],Welton DE, Young JB, Gentry WO, et al. Recurrent infective endocarditis: analysis of predisposing factors and clinical features. Am J Med 1979;66:932 2 8.

[object Object],[object Object],Unique Features of Infective Endocarditis in Childhood Copyright © 2002 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX 72514 DOI: 10.1161/01.CIR.0000013073.22415.90 Circulation 2002;105;2115-2126 American Heart Association Council on Cardiovascular Disease in the Young From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Matthew E. Levison, Thomas J. Pallasch, Tommy W. Gage, Kathryn A. Taubert and S. Dajani, Stanford T. Shulman, Walter Wilson, Ann F. Bolger, Arnold Bayer, Patricia Ferrieri, Michael H. Gewitz, Michael A. Gerber, Jane W. Newburger, Adnan

[object Object],[object Object],[object Object],[object Object]

Epidemiología ,[object Object],[object Object],[object Object],Bayer A S, Bolger A F, Taubert K A et al. Diagnosis and management of infective endocarditis and its complications. Circulation 1998; 98: 2936–48 .

Epidemiología ,[object Object],[object Object],Fowler V G Jr, Li J, Corey G R et al. Role of echocardiography in evaluation of patients with Staphylococcus aureus bacteremia: experience in 103 patients. J Am Coll Cardiol 1997; 30: 1072–8

Epidemiología ,[object Object],[object Object],Karchmer A W. Infective endocarditis. In: Braunwald E, ed. Heart disease: a textbook of cardiovascular medicine. 7th ed. London: Saunders, 2005: 1633–56

Epidemiología ,[object Object],[object Object],[object Object],[object Object],[object Object],Karchmer A W. Infective endocarditis. In: Braunwald E, ed. Heart disease: a textbook of cardiovascular medicine. 7th ed. London: Saunders, 2005: 1633–56

Epidemiología ,[object Object],[object Object],[object Object],Gonzalez Quintela A, Candela H J, Vidal C et al. Non-bacterial thrombotic endocarditis in cancer patients. Acta Cardiol 1991; 46: 1–9.

Patogénesis de la endocarditis

Patogénesis de la endocarditis ,[object Object],[object Object],Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed

Enlace de daños ,[object Object],[object Object],[object Object],[object Object],[object Object],Patogénesis de la endocarditis

Patogénesis de la endocarditis ,[object Object],[object Object],Martin-Davila P, Fortun J, Navas E, et al: Nosocomial endocarditis in a tertiary hospital: An increasing trend in native valve cases. Chest 2005; 128:772-779

Patogénesis de la endocarditis ,[object Object],[object Object],[object Object],[object Object],Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed

Patogénesis de la endocarditis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed

Sitios de Vegetación por Flujo

Patogénesis de la endocarditis ,[object Object],[object Object],[object Object],[object Object],Martin-Davila P, Fortun J, Navas E, et al: Nosocomial endocarditis in a tertiary hospital: An increasing trend in native valve cases. Chest 2005; 128:772-779.

Patogénesis de la endocarditis ,[object Object],[object Object],[object Object],Moreillon P, Que YA, Bayer AS. Pathogenesis of streptococcal and staphylococcal endocarditis. Infect Dis Clin North Am 2002;16:297

Patogénesis de la endocarditis ,[object Object],[object Object],[object Object],[object Object],Moreillon P, Que YA, Bayer AS. Pathogenesis of streptococcal and staphylococcal endocarditis. Infect Dis Clin North Am 2002;16:297 .

P Moreillon,Que Y. Infective endocarditis Lancet 2004; 363: 139–49

Patogénesis de la endocarditis ,[object Object],[object Object],[object Object],Moreillon P, Que YA, Bayer AS. Pathogenesis of streptococcal and staphylococcal endocarditis. Infect Dis Clin North Am 2002;16:297 .

Adhesinas de S. aureus (MSCRAMMs) que participan en la patogénesis de IE Infect. Dis. Clin. North Am. 2002; 16:297

ETA/ETNB Colonización Endocarditis Infecciosa Velo valvular Fibrina Lesión Endotelial Agregación Plaquetaria Endocarditis infecciosa (vegetación) Bacteriemia Cicatrización

Endocarditis infecciosa Lesión endotelial por factores -hemodinámicos traumáticos Presencia de inmunocomplejos Depósito de fibrina Endocarditis trombótica no bacteriana Maniobras que producen traumatismo de piel y/o mucosas:drogadicción foco séptico Bacteriemia transitoria Adherencia y colonización VEGETACION SÉPTICA Destrucción valvular Bacteriemia persistente Embolia pulmonar o sistémica MANIFESTACIONES CARDÍACAS MANIFESTACIONES EXTRACARDÍACAS Aneurismas micóticos Inmunocomplejos vasculitis glomerulonefritis Metástasis sépticas Esplenomegalia Fisiopatología

Las complicaciones de la endocarditis

Las complicaciones de la endocarditis ,[object Object]

Las complicaciones de la endocarditis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Las complicaciones de la endocarditis “ Ballpark” estimates of the incidence of complications in the modern era. Adapted from Textbook of Cardiovascular Medicine.22 AI, aortic insufficiency; MR, mitral regurgitation; TR, tricuspid regurgitation.

Predictores de mortalidad intrahospitalaria de la endocarditis infecciosa en la República Argentina: resultados del EIRA-II

Predictores de mortalidad intrahospitalaria de la endocarditis infecciosa en la República Argentina: resultados del EIRA-II JUAN C. MODENESI†, ERNESTO R. FERREIRÓS*, SANDRA SWIESZKOWSKI, FRANCISCO M. NACINOVICH, CLAUDIA CORTÉS, HERNÁN COHEN ARAZI, LUCÍA KAZELIAN, SERGIO VARINI*, MARIO CIRUZZI†, JOSÉ HORACIO CASABÉ*, en representación de los Investigadores del estudio EIRA-II, del Área de Investigación y del Consejo de Cardiología Clínica de la Sociedad Argentina de Cardiología

Las complicaciones de la endocarditis ,[object Object],[object Object],[object Object]

Las complicaciones de la endocarditis ,[object Object],[object Object],Stewart WJ, Carabello BA. Aortic valve disease. In: Topol EJ, editor. Textbook of Cardiovascular Medicine. Philadelphia, PA: Lippincott Williams and Wilkins, 2002. p. 509-28

Las complicaciones de la endocarditis ,[object Object],[object Object],[object Object],Heiro M, Nikoskelainen J, Engblom E, et al. Neurologic manifestations of infective endocarditis: a 17 year experience in a teaching hospital in Finland. Arch Intern Med 2000;160:2781-7.

Gran hemorragia frontal en un paciente con endocarditis de la válvula mitral S. aureus. aneurismas micóticos (flechas) a lo largo del curso de las ramas de la arteria cerebral media

Fenómenos embólicos ,[object Object],[object Object],[object Object],[object Object],PEDIATRICS Vol. 109 No. 5 May 2002

Endocarditis Infecciosa: Complicaciones

[object Object],[object Object],[object Object],Las complicaciones de la endocarditis Mathew J, Addai T, Anand A, et al. Clinical features, site of involvement, bacteriologic findings, and outcome of infective endocarditis in intravenous drug users. Arch Intern Med 1995;155(15):1641-8.

Fenómenos embólicos Endocarditis complicada con Infarto pulmonar con embolos sépticos

Las complicaciones de la endocarditis ,[object Object],[object Object],[object Object],[object Object],Majumdar A, Chowdhary S, Ferreira MA, et al. Renal pathological findings in infective endocarditis. Nephrol Dial Transplant 2000;15(11):1782-7 .

Las complicaciones de la endocarditis ,[object Object],[object Object]

Endocarditis Infecciosa: Complicaciones Infect Dis Clin N Am 16 (2002) 507–521

Endocarditis Infecciosa: Complicaciones Heart 2005;91;795-800 Int J of Card 78 (2001) 175–182

El diagnóstico de endocarditis infecciosa

El diagnóstico de endocarditis infecciosa ,[object Object],[object Object],[object Object],Pelletier L, Petersdorf R. Infective endocarditis: a review of 125 cases from the University of Washington Hospitals, 1963-72. Medicine 1977;56(4):287-313.

El diagnóstico de endocarditis infecciosa ,[object Object],[object Object],von Reyn CF, Levy BS, Arbeit RD, et al. Infective endocarditis: analysis based on strict definitions. Ann Intern Med 1981;94:505-18.

Endocarditis Infecciosa DIAGNÓSTICO Alta sospecha clínica Nuevo soplo regurgitante Embolia de origen desconocida Sepsis de origen desconocido Hematuria, glomerulonefritis.

Endocarditis en el neonato ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],An Pediatr Contin. 2007;5(2):69-76

Síntomas ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],La aparición de los síntomas suele ser 2 semanas o menos desde el inicio de la bacteriemia

Presentación de signos en 73 niños con 76 episodios de EI Pediatrics in Review Vol.26 No.11 November 2005

Signos ,[object Object],[object Object],[object Object],[object Object]

Fiebre ,[object Object],[object Object],[object Object],[object Object],Current Treatment Options in Cardiovascular Medicine 2000, 2: 481–487 PEDIATRICS Vol. 109 No. 5 May 2002

De imagen y los criterios de Duke ,[object Object],[object Object],[object Object],Hoen B, Selton-Suty C, Danchin N, et al. Evaluation of the Duke criteria versus the Beth Israel criteria for the diagnosis of infective endocarditis. Clin Infect Dis 1996;21(4):905-9.

Endocarditis Infecciosa CRITERIOS DE DURACK (Am J Med 1994;96:200) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Modificacion de los criterios de Durack (Li JS et al. Proposed modification to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis 2000; 30:633-8)

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Criterios mayores Criterios menores

An Pediatr (Barc) 2005; 63: 383 - 389

Criterios de Duke ,[object Object],[object Object],Clin Ped Emerg Med 6:266-272 ª 2005 Heart 2006;92:124–130

Pediatrics in Review Vol.26 No.11 November 2005

HEMOCULTIVO ,[object Object],[object Object],[object Object],Current Treatment Options in Cardiovascular Medicine 2000, 2:481–487

[object Object],[object Object],[object Object],Hemocultivos 2004 The European Society of Cardiology Current Paediatrics (2002) 12, 212^219

Hemocultivo ,[object Object],[object Object],[object Object],Current Paediatrics (2002) 12, 212- 219

Valvulitis ,[object Object],[object Object],[object Object],Current Treatment Options in Cardiovascular Medicine 2000, 2: 481–487 Rev. chil. pediatr. v.71 n.2 Santiago mar. 2000

Respuestas Inmunologicas ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Rev. chil. pediatr. v.71 n.2 Santiago mar. 2000 Current Treatment Options in Cardiovascular Medicine 2000, 2: 481–487

Petequias ,[object Object],[object Object]

Las hemorragias en astilla ,[object Object],[object Object],[object Object]

Nódulos de Osler ,[object Object],[object Object],[object Object],[object Object],American College of Rheumatology

Las lesiones de Janeway ,[object Object],[object Object],[object Object],[object Object]

La consideración de múltiples evaluaciones ecocardiográficas ,[object Object],[object Object],Rohmann S, Erbel R, Darius H, et al. Prediction of rapid versus prolonged healing of infective endocarditis by monitoring vegetation size. J Am Soc Echocardiogr 1991;4:465-74.

QUE BUSCAMOS EN ECO? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

ESC Guideline. The Task Forse on IE of the European Society of Cardiology. European Heart Journal (2004) OO, 1-37 Sospecha de EI ETT sin demora Material protésico involucrado + - Imagen de buena calidad + - ETE ETT”positivo” + Sospecha o complicación documentada, o cirugía durante IE activa - + - Sospecha BAJA ALTA

La endocarditis de válvula nativa ,[object Object],[object Object],[object Object],[object Object],Sanfilippo AJ, Picard MH, Newell JB, et al. Echocardiographic assessment of patients with infectious endocarditis. J Am Coll Cardiol 1991;18:1191-9.

[object Object],[object Object],[object Object],La endocarditis de válvula nativa Di Salvo G, Habib G, Pergola V, et al. Echocardiography predicts embolic events in infective endocarditis. J Am Coll Cardiol 2001;37(4):1069-76.

Cuando operar la endocarditis infecciosa

Cuando operar la endocarditis infecciosa ,[object Object],[object Object],Vikram HR, Buenconsejo J, Hasbun, R, et al. Impact of valve surgery on 6-month mortality in adults with complicated, left-sided native valve endocarditis. JAMA 2003;290(24):3207-14.

[object Object],[object Object],[object Object],[object Object],Hasbun R, Vikram HR, Barakat LA, et al. Complicated left-sided native valve endocarditis in adults: risk classification for mortality. JAMA 2003;289(15): 1933-40.

Baddour et al.Circulation 2005;111:394-433 Ecocardiografía Potencial necesidad de tratamiento quirúrgico Vegetación Persistencia de vegetación luego de embolizacion >10 mm valva anterior de mitral Aumento de tamaño a pesar de tratamiento ATB adecuado Disfunción valvular Insuficiencia mitral o aórtica con falla ventricular Perforación valvular o ruptura Extensión perivalvular Dehiciencia valvular, ruptura o fístula BAV nuevo Grandes abscesos o aumento de tamaño a pesar de tratamiento ATB adecuado.

Cirugía en la endocarditis infecciosa activa sobre válvula nativa Guías ACC/AHA 2006 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Endocarditis infecciosa IC III-IV Tratamiento médico Respuesta No respuesta Curso completo Sustitución valvular según situación hemodinámica SUSTITUCION VALVULAR URGENTE Insuficiencia aórtica aguda severa IC<II Tratamiento médico Estable Empeoramiento Hongos Tratamiento quirurgico

Microbiología de la Endocarditis Infecciosa

Microbiología de la Endocarditis Infecciosa: Cocos gram-positivos ,[object Object],[object Object],[object Object],[object Object],Kim EL, Ching DL, Pien FD. Bacterial endocarditis at a small community hospital. Am J Med Sci 1990;299(2):87-93.

[object Object],[object Object],Baddour LM. Infective endocarditis caused by beta-hemolytic streptococci. The Infectious Diseases Society of America’s Emerging Infections Network. Clin Infect Dis 1998;26(1):66-71.

Estafilococos ,[object Object],[object Object],Fowler VG Jr, Olsen MK, Corey GR, et al. Clinical identifiers of complicated Staphylococcus aureus bacteremia. Arch Intern Med 2003;163(17):2066-72.

[object Object],[object Object],[object Object],[object Object],Rev Esp Cardiol 2001; 54: 111-113

[object Object],[object Object],[object Object],O’Callaghan C, McDougall P. Infective endocarditis in neonates. Arch Dis Child 1988;63(1):53-7.

Bacilos gram-negativos ,[object Object],[object Object],Fernandez Guerrero ML, Aguado JM, Arribas A, et al. The spectrum of cardiovascular infections due to Salmonella enterica: a review of clinical features and factors determining outcome. Medicine 2004;83(2):123-38.

[object Object],[object Object],Bacilos gram-negativos Fernandez Guerrero ML, Aguado JM, Arribas A, et al. The spectrum of cardiovascular infections due to Salmonella enterica: a review of clinical features and factors determining outcome. Medicine 2004;83(2):123-38.

HACEK y otros inusuales Bacterias Gram-negativas ,[object Object],[object Object],Ellner JJ, Rosenthal MS, Lerner PI, et al. Infective endocarditis caused by slow-growing, fastidious, Gram-negative bacteria. Medicine 1979;58(2):145-58.

Los bacilos Gram-positivos ,[object Object],[object Object],Tiley SM, Kociuba KR, Heron LG, et al. Infective endocarditis due to nontoxigenic Corynebacterium diphtheriae: report of seven cases and review. Clin Infect Dis 1993;16:271 .

Bacterias anaerobias ,[object Object],[object Object],[object Object],[object Object],Nastro LJ, Finegold SM. Endocarditis due to anaerobic gram-negative bacilli. Am J Med 1982;54:482.

Hongos ,[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],Herbrecht R, Denning DW, Patterson TF, et al. Voriconazole versus amphotericin B for primary therapy of invasive aspergillosis. N Engl J Med 2002;347(6):408-15.

[object Object],[object Object],Carrizosa J, Levinson ME, Lawrence T, et al. Cure of Aspergillus ustus endocarditis. Arch Intern Med 1974;133:486.

[object Object],[object Object],[object Object],Peter O, Flepp M, Bestetti G, et al. Q fever endocarditis: diagnostic approaches and monitoring of therapeutic effects. Clin Invest 1992;70:932.

[object Object],[object Object],[object Object],[object Object],Fernandez-Guerrero ML, Muelas JM, Aquado JM. Q fever endocarditis on porcine bioprosthetic valves. Ann Intern Med 1988;108:209-13.

Chlamydia psittaci ,[object Object],[object Object],[object Object],Jones RB, Priest JB, Kuo C-C. Subacute chlamydial endocarditis. JAMA 1982;247:655.

Tropheryma whippelii ,[object Object],Raoult D, Birg ML, La Scola B, et al. Cultivation of the bacillus of Whipple’s disease [comment]. [erratum appears in N Engl J Med 2000 May 18;342(20):1538.] N Engl J Med 2000;342(9):620-5.

Cultivo negativo" Endocarditis ,[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],Pesanti EL, Smith IM. Infective endocarditis with negative blood cultures. Am J Med 1979;66:43.

Endocarditis polimicrobiana ,[object Object],[object Object],[object Object],[object Object]

Manejo de la endocarditis infecciosa ,[object Object],[object Object],[object Object]

Tratamiento antimicrobiano ,[object Object],[object Object],[object Object],[object Object],Durack DT, Beeson PB. Experimental bacterial endocarditis. I. Colonization of a sterile vegetation Br J Exp Pathol 1972;53(1):44-9.

Endocarditis Infecciosa: Consideraciones Iniciales ,[object Object],[object Object],Current of Pediatrics. 2007

[object Object],[object Object],Endocarditis Infecciosa: Consideraciones Iniciales Advances In Medical And Antibiotic Management Of Infective Endocarditis. Cardiology Clinics. Volume 14 Number 3 August 1996

Endocarditis Infecciosa : Terapia ATB Inicial ,[object Object],[object Object],[object Object],Infective Endocarditis: Diagnosis and Management Guideline. AHA. Circulation. 2005; 111:e394-e433

Endocarditis Infecciosa : Terapia ATB específica

Heart 2005;91;795-800 Am Heart J 2006;151:545-52

German guidelines for the diagnosis and management of infective endocarditis. International Journal of Antimicrobial Agents 29 (2007) 643–657

[object Object],[object Object],[object Object],Endocarditis Infecciosa : Terapia ATB específica ,[object Object]

Endocarditis Estreptococcica: ,[object Object],[object Object],[object Object],[object Object],Infective Endocarditis. Current of Pediatrics. 2006

Infective Endocarditis: Diagnosis and Management Guideline. AHA. Circulation. 2005; 111:e394-e433

Endocarditis por Stafilococo ,[object Object],[object Object],[object Object],[object Object],Infective Endocarditis. Current of Pediatrics. 2006

Endocarditis por Enterococcus ,[object Object],[object Object],[object Object],Infective Endocarditis. Current of Pediatrics. 2006

Endocarditis por Gram Negativos ,[object Object],Infective Endocarditis. Current of Pediatrics. 2006

Endocarditis Fúngica ,[object Object],[object Object],[object Object],[object Object],Infective Endocarditis. Current of Pediatrics. 2006

Endocarditis Cultivo Negativo ,[object Object],Infective Endocarditis. Current of Pediatrics. 2006

Endocarditis Infecciosa: Tratamiento Ambulatorio ,[object Object],[object Object],[object Object],Infective Endocarditis. Current of Pediatrics. 2006

Endocarditis Infecciosa: Profilaxis Prevention of Infective Endocarditis. Guidelines From the American Heart Association. Circulation published online Apr 19, 2007

Prevention of Infective Endocarditis. Guidelines From the American Heart Association. Circulation published online Apr 19, 2007

Endocarditis Infecciosa: Profilaxis ¿Tiene Sentido? ,[object Object],[object Object],[object Object],[object Object],Guntheroth, Am J Cardiol 1984;54:797-801 Cumulative risk from daily events is 5.6 million times greater over 1 year than that resulting from a single tooth extraction Pallasch, Dent Clin North Am 2003;47:623-639

Endocarditis Infecciosa: Profilaxis AHA Guidelines 2007 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Circulation 2007. Published online 4/19/07

Endocarditis Infecciosa: Profilaxis ¿Tiene Sentido?

Endocarditis Infecciosa Mr3 Gerald

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