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murtazaieppt-190820183045.pdf
1. PRESIDENTIAL ACTION PLAN 2018
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INFECTIVE ENDOCARDITIS IN CHILDREN
MURTAZA KAMAL
5TH JAN, 2019
2. PRESIDENTIAL ACTION PLAN 2018
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Definition
Epidemiology
Pathogenesis/ Pathology/ Microbiology
Clinical features
Diagnosis & Diagnostic criteria
Treatment
Preventive methods
Scope of the talk…
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Microbial infection of endocardial (endothelial) surface of heart
Native/ prosthetic valves: Most frequently involved
Can involve septal defects, mural endocardium, intravascular
foreign devices, intracardiac patches, surgically constructed
shunts, IV catheters
Disease classification on basis of etiologic agent involved:
Low virulence organisms (Alpha hemolytic streptococcai,
enterococci, CONS): Prolonged subacute form of illness
Virulent organisms (Staph aureus, strept pneumoniae, beta
hemolytic streptococci): Acute clinical course
Definition
Gewitz M, Taubert KA. IE and prevention. In: Heart disease in infant, children andadolescents. 9th ed. Philadelphia:
Wolter Kluwer; 2016: 1441-1453
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Less often in children than in adults
1: 1280 (0.78/1000) paediatric admissions/ year
Overall frequency among children and a shift towards those with
previous cardiac surgery: Increased Improved survival among
children who are at risk of IE, such as those with CHD (with/
without surgery) and hospitalised neonates
CHD: Predominant underlying condition in developed world (MC:
VSD, TOF, aortic valve abnormalities)
Post operative IE: Long term risk after correction of complex CHD,
esp those with residual defects/ surgical shunts/ prosthetic
materials
Epidemiology
Van Hare GF, Ben-Shachar G, Liebman J, Boxerbaum B, RiemenschneiderTA. Infective endocarditis in infants and children during the past 10 years:
a decade of change. Am Heart J. 1984;107:1235–1240.
Pasquali SK, He X, Mohamad Z, McCrindle BW, Newburger JW, Li JS,Shah SS. Trends in endocarditis hospitalizations at US children’s hospitals:
impact of the 2007 American Heart Association antibiotic prophylaxisguidelines. Am Heart J 2012;143:894–899.
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RHD: Before 1970s, 30-50% children with IE Decreased now as
prevalence of RHD decreased in developed countries
8-10% of pediatric cases: IE develops without structural heart
disease: Central indwelling venous catheters Mostly aortic or
mitral valves are involved by staph aureus
Neonates: 7.3% cases: Right sided heart structures involved
Factors associated with IE in adults like IV drug abuse and
degenerative heart diseases: Not common predisposing factor
Epidemiology Cont…
Baltimore RS. Infective endocarditis. In: Jenson HB, Baltimore RS,eds. Pediatric Infectious Diseases: Principles and Practice. 2nd ed.
Philadelphia, PA: Saunders; 2002.
Stull TL, LiPuma JJ. Endocarditis in children. In: Kaye D, ed. InfectiveEndocarditis. 2nd ed. New York, NY: Raven Press; 1992:313–327
Stockheim JA, Chadwick EG, Kessler S, Amer M, Abdel-Haq N, DajaniAS, Shulman ST. Are the Duke criteria superior to the Beth Israel criteria
for the diagnosis of infective endocarditis in children? Clin Infect Dis.1998;27:1451–1456.
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2 important factors:
Damaged area of endothelium and
Bacteremia (even transient)
Structural abnormalities of heart/ great arteries+ significant
pressure gradient/ turbulence Endothelial damage Thrombus
formation with deposition of sterile clumps of platelet and fibrin
Nonbacterial thrombus Nidus for bacteria to adhere and form
infected vegetation
Bacteremia from dental procedures
Bacteremia with activities such as chewing/ brushing teeth
Chewing with diseased teeth or gums frequent cause of bacteremia
Good dental hygiene very important in prevention
Pathogenesis
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Vegetation:
Usually on low-pressure side of defect
Either around defect or on opposite surface of defect where
endothelial damage is established by jet effect of defect
Vegetations found in PA in PDA or systemic-to-PA shunts
On atrial surface of mitral valve in MR
On ventricular surface of aortic valve and mitral chordae in
AR
On superior surface of aortic valve or at site of a jet lesion in
aorta in AS
Pathology
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Streptococcus viridans, Enterococci and Staphylococcus
aureus: 50%- 60%
Fungi+ HACEK organisms (Haemophilus, Actinobacillus,
Cardiobacterium, Eikenella, and Kingella spp.): 17% to 30%
α-Hemolytic streptococci (S. viridans): Dental procedures/
carious teeth/ periodontal disease
Enterococci: After GU/ GI surgery/ instrumentation
Staphyloccocci: Postoperative endocarditis
S. aureus: IV drug abusers
Fungal endocarditis (poor prognosis): Sick neonates/ long-
term antibiotic or steroid therapy/ after open heart surgery
Fungal endocarditis: Associated with very large friable
vegetations; emboli from these vegetations frequently
produce serious complications
Microbes: The Agent
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S. aureus/ CONS: Indwelling vascular catheters/ prosthetic material/
prosthetic valves
S. aureus/ CONS/ Candida: MCC among newborn infants
Culture-negative endocarditis: 5-7%
Patient has clinical or echo evidence of endocarditis but
persistently negative blood culture results
MCC: Current or recent antibiotic therapy or infection caused
by a fastidious organism that grows poorly in vitro
Fungal endocarditis: A rare cause of culture-negative
endocarditis
Diagnosis can be made only by removal of vegetation (during
surgery) sometimes
Microbes: The Agent…
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Most patients have history of underlying heart defect
Some patients with bicuspid aortic valve may not have been diagnosed
with defect before
History of a recent dental procedure/ tonsillectomy / toothache (from
dental or gingival disease)
Endocarditis: Rare in infancy; at this age, usually follows open heart
surgery
Onset usually insidious with prolonged low-grade fever and somatic
complaints, fatigue, weakness, loss of appetite, pallor, arthralgia,
myalgias, weight loss, and diaphoresis
Clinical Features: History
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Heart murmur: Universal (100%)
Appearance of new heart murmur/ Increase in intensity of an
existing murmur
Fever: 80%–90%; 101° and 103°F
Splenomegaly: 70%
Skin manifestations: 50%; Either secondary to microembolization or as
an immunologic phenomenon:
Petechiae on skin/ mucous membranes/ conjunctivae
Osler’s nodes: Tender, pea-sized red nodes at ends of fingers/
toes
Janeway’s lesions: Small, painless, hemorrhagic areas on palms/
soles
Splinter hemorrhages: Linear hemorrhagic streaks beneath
nails
Clinical Features: Examination
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Clinical Features: Examination
Embolic/ immunologic phenomena in other organs: 50%
Pulmonary emboli: VSD, PDA or a systemic-to-PA shunt
Seizures and hemiparesis: Embolization to CNS-20%
Hematuria and renal failure
Roth’s spots- 5%:
Oval, retinal hemorrhages
with pale centers located
near optic disc
From AAP. Red Book Online visual library, 2006
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Clinical Features: Examination
Clubbing of fingers in absence of cyanosis rarely in chronic cases
Heart failure as a complication of infection
Neonate:
Nonspecific and may be indistinguishable from septicemia or CHF
from other causes
Embolic phenomena (osteomyelitis, meningitis) common
Neurologic signs and symptoms (seizures,hemiparesis, apnea)
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Positive blood cultures:
90% in absence of previous antimicrobial therapy
50-60% pretreatment with antibiotics
CBC:
Anemia: 80%
Leukocytosis with a shift to the left
Patients with polycythemia preceding onset of IE may
have normal hemoglobin
ESR: Increased unless there is polycythemia.
Microscopic hematuria: 30%
Lab Studies
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Main modality for detection
Site of infection, extent of valvular damage and cardiac function
Baseline evaluation of ventricular function and cardiac chamber
dimension important for comparison later
Color Doppler: Sensitive modality for detection of valvular
regurgitation
Role of ECHOCARDIOGRAPHY
Vegetations on the aortic valve
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Echocardiographic findings included as major criteria in
modified Duke criteria:
Oscillating intracardiac mass on valves or supporting
structures, in path of regurgitation jets, or on
implanted material
Abscesses
New partial dehiscence of prosthetic valve
New valvular regurgitation
Role of ECHOCARDIOGRAPHY
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TEE superior to TTE:
Vegetations on prosthetic valves
Detecting complications of LV outflow tract endocarditis
Detecting aortic root abscess and involvement of sinus of
Valsalva
Absence of vegetations on echo: Does not rule out IE
False-negative: Vegetations are small or have embolized and they
may miss initial perivalvular abscess
Repeat examinations indicated if suspicion exists without
diagnosis of IE or worrisome clinical course during early
treatment of IE
Role of ECHOCARDIOGRAPHY
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False-positive:
An echogenic mass may represent a sterile
thrombus, sterile prosthetic material, normal
anatomic variation, an abnormal uninfected valve
(previous scarring, severe myxomatous changes),
or improper gain of echo machine
Echocardiographic evidence of vegetation may persist for
months or years after bacteriologic cure
Role of ECHOCARDIOGRAPHY
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Definite IE :
Pathological evidence of IE:
Demonstration of microorganism by culture
Histology in a vegetation or from an embolic sites or an
intracardiac abscess or histologic evidence of active
endocarditis demonstrated in vegetation or
intracardiac abscess
Fulfillment of clinical criteria:
2 major criteria
1 major+ 3 minor criteria
5 minor criteria
DIAGNOSIS: Modified Dukes Criteria
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Possible IE: When one of the following is present:
1 major+ 1 minor criterion
3 minor criteria
Rejected IE:
An alternative diagnosis is established
Clinical manifestations of IE have resolved within
4 days of antibiotic therapy
No pathological evidence is found on direct
examination of vegetation obtained from surgery
or autopsy after antibiotic therapy for < 4 days
Criteria for possible IE are not met
DIAGNOSIS: Modified Dukes Criteria
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1. Blood culture positive for IE:
Typical microorganisms consistent with IE from 2 separate
blood cultures: Viridans streptococci, Streptococcus bovis,
HACEK group, Staphylococcus aureus; or community-
acquired enterococci in absence of a primary focus or
Microorganisms consistent with IE from persistently positive
blood cultures defined as: at least 2 positive cultures of
blood samples drawn >12 h apart or all of 3 or a majority of 4
or more separate cultures of blood (with first and last sample
drawn at least 1 h apart)
Single positive blood culture for Coxiella burnetii or anti–
phase 1 IgG antibody titer >1:800
Modified Dukes: Major Criteria
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2. Evidence of endocardial involvement
Echocardiogram positive for IE (TEE recommended for
patients with prosthetic valves, rated at least “possible IE”
by clinical criteria, or complicated IE [paravalvular abscess];
TTE as first test in other patients) defined as follows:
Oscillating intracardiac mass on valve or supporting
structures, in path of regurgitant jets, or on implanted
material in absence of an alternative anatomic explanation
Abscess
New partial dehiscence of prosthetic valve
New valvular regurgitation (worsening or changing or
preexisting murmur not sufficient)
Modified Dukes: Major Criteria
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Predisposition, predisposing heart condition, or IDU
Fever, temperature >38°C
Vascular phenomena: Major arterial emboli, septic pulmonary
infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival
hemorrhages and Janeway’s lesions
Immunologic phenomena: Glomerulonephritis, Osler’s nodes,
Roth’s spots and rheumatoid factor
Microbiologic evidence: Positive blood culture but does not meet a
major criterion or serologic evidence of active infection with
organism consistent with IE
Modified Dukes: Minor Criteria
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Blood cultures: Indicated for all patients with fever of unexplained
origin and a pathologic heart murmur, a history of heart disease or
previous endocarditis
Usually 3 blood cultures are drawn by separate venipunctures over 24
hours unless patient is very ill
90% of cases, causative agent is recovered from 1st 2 cultures
If no growth by 2nd day of incubation, 2 more may be obtained
No value in obtaining >5 blood cultures over 2 days unless patient
received prior antibiotic therapy
Not necessary to obtain cultures at any particular phase of fever cycle
Adequate volume: 1-3 mL infants; 5-7 mL older children
Aerobic incubation alone sufficient
Management
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Recommended that consultation from local infectious disease
specialist be obtained when IE suspected/confirmed: Antibiotics of
choice continually changing, and there may be special situation
pertaining to local area
Initial empirical therapy:
Usual initial regimen: Antistaphylococcal semisynthetic
penicillin (nafcillin,oxacillin or methicillin)+ aminoglycoside
(gentamicin)
Covers against S. viridans, S. aureus, and gram-negative
organisms
Vancomycin:
Methicillin-resistant S. aureus suspected
Penicillin-allergic patients
Management
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Depends on organism isolated+ results of antibiotic sensitivity test
Streptococcal IE:
Native cardiac valve IE caused by highly sensitive S. viridans:
IV penicillin (or ceftriaxone OD) X 4 weeks
Alternatively penicillin, ampicillin or ceftriaxone+
gentamicin for 2 weeks
IE caused by penicillin-resistant streptococci:
4 weeks of penicillin, ampicillin or ceftriaxone+
gentamicin for 2 weeks
Final antibiotic selection
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Staphylococcal endocarditis:
Drug of choice native valve IE by methicillin-susceptible
staphylococci: Semisynthetic β-lactamase–resistant penicillins
(nafcillin, oxacillin or methicillin) X minimum of 6 weeks (±
gentamicin X 3–5 days)
Methicillin-resistant native valve IE: Vancomycin X 6 weeks (±
gentamicin X 3–5 days)
Enterococcus:
IV penicillin/ ampicillin+ gentamicin X 4 to 6 weeks
Allergic to penicillin: Vancomycin +gentamicin x 6 weeks
HACEK organisms:
Ceftriaxone/ another 3rd generation cephalosporin alone or
ampicillin+ gentamicin x 4 weeks
Final antibiotic selection
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IE by other gram-negative bacteria (E coli, Pseudomonas
aeruginosa, or Serratia marcescens):
Piperacillin/ ceftazidime together+ gentamicin X 6 weeks
Amphotericin B: Most effective agent for most fungal infections
Culture-negative endocarditis:
Treatment directed against staphylococci, streptococci and
HACEK organisms using ceftriaxone+ gentamicin
When staphylococcal IE suspected, nafcillin should be
added to the above therapy
Final antibiotic selection
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Should be treated for 6 weeks based on organism isolated
and results of sensitivity test
Operative intervention may be necessary before antibiotic
therapy is completed if clinical situation warrants:
Progressive CHF
Significant malfunction of prosthetic valves
Persistently positive blood cultures after 2 weeks of
therapy
Bacteriologic relapse after an appropriate course of
therapy
Prosthetic valve Endocarditis
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Overall recovery rate: 80%- 85%
90% or better: S. viridans and enterococci
50%: Staphylococcus organisms
Fungal endocarditis: Very poor outcome
Prognosis
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Prevention
Emphasis should be on maintaining good oral hygiene and
eradicating dental disease to decrease frequency of
bacteremia from routine daily activities
Recommended for tonsillectomy and adenoidectomy only in
high-risk patients
Prophylaxis no longer recommended:
For routine bronchoscopy
For GI or genitourinary procedures, such as diagnostic
esophagogastroduodenoscopy or colonoscopy
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Patients with prosthetic cardiac valve/ material used for cardiac valve
repair
Patients with previous IE
Patients with CHD:
Unrepaired cyanotic CHD, including palliative shunts/ conduits
Completely repaired CHD with prosthetic material/ device,
whether placed by surgery or catheter intervention, during 1st
6 months after procedure
Repaired CHD with residual defects at site or adjacent to site
of a prosthetic patch/ device (which inhibits
endothelialization)
Cardiac transplantation recipients with valve regurgitation caused by
a structurally abnormal valve
Cardiac conditions for which prophylaxis
With dental procedures is recommended
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Dental procedures:
Involving manipulation of gingival tissue of periapical region
or perforation of oral mucosa
Respiratory tract procedures:
Procedures that involve incision/ biopsy of respiratory mucosa
Not recommended for bronchoscopy
GI or GU procedures:
No prophylaxis for diagnostic esophagogastroduodenoscopy/
colonoscopy
Reasonable in patients with infected GI/GU tract
Skin, skin structure or musculoskeletal tissue:
Surgical procedures that involve infected skin, skin structure,
or musculoskeletal tissue
Procedures for which IE
Prophylaxis is recommended
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Prophylactic regimens for
Dental procedures
Park. Pediatric cardiology for practitioners; 6th edition
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Special Considerations
Patients already receiving antibiotics:
Rheumatic fever prophylaxis: Use other antibiotics, such as
clindamycin, azithromycin or clarithromycin
Delay a procedure until 10 days after completion of antibiotic
Patients who undergo cardiac surgery:
Careful preoperative dental evaluation so that required dental
treatment may be completed whenever possible before surgery
Prophylaxis at time of surgery: Primarily against staphylococci
Prophylaxis should be initiated immediately before surgery,
repeated during prolonged procedures to maintain serum
concentrations intraoperatively, and continued for no more
than 48 hours postoperatively
38. PRESIDENTIAL ACTION PLAN 2018
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IE in children is not uncommon
Common in children with CHD
Neonates: Poor outcome
Blood culture + ECHO has important role in diagnosis
Treatment adherence necessary
Prognosis not bad if treated properly
Knowledge of conditions requiring prophylaxis and drugs for it
necessary
Take Home Message