Infective Endocarditis


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Infective Endocarditis

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Infective Endocarditis

  1. 1. Infective Endocarditis
  2. 2. occurs when microorganisms (bacteria or fungi) colonize the endocardial surface of the heart Classified into four groups:1. Native Valve IE2. Prosthetic Valve IE3. Intravenous drug abuse (IVDA) IE4. Nosocomial IE
  3. 3. Epidemiology The valves involved in IE:1. Mitral 28-45%2. Aortic 5-36%3. Both 0-35%4. Tricuspid 0-6%5. Pulmonary <1%
  4. 4. Males > femalesMay occur at any age and increasingly common inelderlyMortality 20-30%
  5. 5. Predisposing FactorsIV drug useCentral line Prosthetic valvePrevious IEDental procedureRheumatic heart disease
  6. 6. High Risk1. Prosthetic cardiac valve2. Prior episodes of endocarditis3. Complex congenital cardiac defect4. Surgical systemic-pulmonary shunts5. Intravenous drug abuse6. Intravascular catheters
  7. 7. Moderate Risk1. PDA, VSD, primum ASD2. Co-Aorta3. Bicuspid aortic valve4. Hypertrophic cardiomyopathy5. Acquired valvular dysfunction6. MVP with mitral regurgitation
  8. 8. Low Risk1. Isolated secundum atrial septal defect2. ASD, VSD, or PDA > 6 months past repair3. “Innocent” heart murmur by auscultation in the pediatric population
  9. 9. Pathophysiologya. Turbulent blood flow disrupts the endocardium making it “sticky”b. microorganisms infect the endocardial surface of the heart.c. Adherence of the organisms to the endocardial surfaced. Eventual invasion of the valvular leaflets
  10. 10. EtiologyCommon bacteria in children Strep. viridans–50% Staph aureus–40% Strep fecalis, Grp D Streptococcus(Enterococci)
  11. 11. Clinical Presentations High grade fever w/ chills SOB Arthralgias/myalgias Abdominal pain Pleuritic chestpain Backpain Anorexia Weight loss Fatigue
  12. 12. SignsFeverHeart murmurpetechiae, subungal or“splinter”hemorrhagesClubbingSplenomegalyNeurologic changesJaneway lesionsRoth Spots
  13. 13. Osler’s Nodes Janeway LesionsPainful ErythematousErythematousnodules BlanchingmaculesLocated on pulp of fingers and Nonpainfultoes Located in the palms and soles
  14. 14. DiagnosticsBlood Cultures: Minimum of 3 takings3 separate venipuncture sites: 5 - 10mLDetects >95% of cases
  15. 15. CBC Immunologic tests:ESR Increase inCRP gammaglobulinsUrinalysis Presence of cryoglobulin Low Complement levels(C3,C4) RF-positive
  16. 16. Imaging CXR: multiple focal infiltrates and calcification of heart valves ECG: Look for evidence of ischemia, conduction delay and arrhythmias Echocardiography: diagnostic tool for culture negative cases
  17. 17. Duke CriteriaClinical criteria for infective endocarditis requires:Two major criteria, orOne major and three minor criteria, orFive minor criteria
  18. 18. ManagementGive for 2 – 6 weeks1.Penicillin - susceptible strep on native cardiac valves: 4weeks Pen G or Ceftriaxone + Gentamicin for 2wks2.Penicillin - resistant strep on native cardiac valves:Penicillin, ampicillin, or ceftriaxone for 4weeks +gentamicin for the first 2 weeks
  19. 19. 5. Enterococcal infection on native valves - penicillin orampicillin + gentamicin for 4-6 weeks6. (MSSA) on native valves : Nafcillin or oxacillin for at least 6weeks + gentamicin for 3-5 days is optional7. (MRSA) on native valves: Vancomycin for at least 6 weekswith or without 3-5 days of gentamicin
  20. 20. 8. MSSA infection on prosthetic valve : Nafcillin or Oxacillin +Rifampin for at least 6 weeks, in combination with Gentamicinfor 2 weeks.9. MRSA infection on prosthetic valve: Vancomycin + Rifampinfor at least 6 weeks, in combination with Gentamicin for 2weeks10. Gram Negative endocarditis due to HACEK: Ceftriaxone orAmpicillin plus Gentamicin for 4 weeks