Infective endocarditis occurs when bacteria or fungi colonize the heart valves. It is classified into four groups depending on the valve affected and cause. The most common predisposing factors are intravenous drug use, prosthetic valves, previous endocarditis and dental procedures. Clinical presentations include fever, heart murmur, petechiae and neurological changes. Diagnosis involves blood cultures, echocardiography and application of the Duke Criteria. Treatment involves antibiotics for 2-6 weeks depending on the causative organism and affected valve.

1. Infective Endocarditis
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2. occurs when microorganisms (bacteria or fungi)
colonize the endocardial surface of the heart
Classified into four groups:
1. Native Valve IE
2. Prosthetic Valve IE
3. Intravenous drug abuse (IVDA) IE
4. Nosocomial IE

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. Males > females
May occur at any age and increasingly common in
elderly
Mortality 20-30%

5. Predisposing Factors
IV drug use
Central line Prosthetic valve
Previous IE
Dental procedure
Rheumatic heart disease

6. High Risk
1. Prosthetic cardiac valve
2. Prior episodes of endocarditis
3. Complex congenital cardiac defect
4. Surgical systemic-pulmonary shunts
5. Intravenous drug abuse
6. Intravascular catheters

7. Moderate Risk
1. PDA, VSD, primum ASD
2. Co-Aorta
3. Bicuspid aortic valve
4. Hypertrophic cardiomyopathy
5. Acquired valvular dysfunction
6. MVP with mitral regurgitation

8. Low Risk
1. Isolated secundum atrial septal defect
2. ASD, VSD, or PDA > 6 months past repair
3. “Innocent” heart murmur by auscultation in the
pediatric population

9. Pathophysiology
a. 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
surface
d. Eventual invasion of the valvular leaflets

10. Etiology
Common bacteria in children
 Strep. viridans–50%
 Staph aureus–40%
 Strep fecalis, Grp D Streptococcus(Enterococci)

11. Clinical Presentations
 High grade fever w/ chills
 SOB
 Arthralgias/myalgias
 Abdominal pain
 Pleuritic chestpain
 Backpain
 Anorexia
 Weight loss
 Fatigue

12. Signs
Fever
Heart murmur
petechiae, subungal or“splinter”hemorrhages
Clubbing
Splenomegaly
Neurologic changes
Janeway lesions
Roth Spots

13. Osler’s Nodes Janeway Lesions
Painful Erythematous
Erythematousnodules Blanchingmacules
Located on pulp of fingers and Nonpainful
toes
Located in the palms and soles

14. Diagnostics
Blood Cultures: Minimum of 3 takings
3 separate venipuncture sites: 5 - 10mL
Detects >95% of cases

15. CBC Immunologic tests:
ESR Increase in
CRP gammaglobulins
Urinalysis Presence of cryoglobulin
Low Complement
levels(C3,C4)
RF-positive

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. Duke Criteria
Clinical criteria for infective endocarditis requires:
Two major criteria, or
One major and three minor criteria, or
Five minor criteria

19. Management
Give for 2 – 6 weeks
1.Penicillin - susceptible strep on native cardiac valves: 4
weeks Pen G or Ceftriaxone + Gentamicin for 2wks
2.Penicillin - resistant strep on native cardiac valves:
Penicillin, ampicillin, or ceftriaxone for 4weeks +
gentamicin for the first 2 weeks

20. 5. Enterococcal infection on native valves - penicillin or
ampicillin + gentamicin for 4-6 weeks
6. (MSSA) on native valves : Nafcillin or oxacillin for at least 6
weeks + gentamicin for 3-5 days is optional
7. (MRSA) on native valves: Vancomycin for at least 6 weeks
with or without 3-5 days of gentamicin

21. 8. MSSA infection on prosthetic valve : Nafcillin or Oxacillin +
Rifampin for at least 6 weeks, in combination with Gentamicin
for 2 weeks.
9. MRSA infection on prosthetic valve: Vancomycin + Rifampin
for at least 6 weeks, in combination with Gentamicin for 2
weeks
10. Gram Negative endocarditis due to HACEK: Ceftriaxone or
Ampicillin plus Gentamicin for 4 weeks