Endocarditis

1. Dr. Abdiwahid Ahmed
Infective Endocarditis

3. Infective Endocarditis
A 6-year-old boy has had high intermittent fevers
for 3 weeks, accompanied by chills. He has a
past history of bicuspid aortic valves and recently
had dental work

4. Infective Endocarditis
General characteristics
 Infection of endocardium, valves, and related
structures and most commonly the valves.
 classifications: acute vs. subacute, native valve vs.
prosthetic valve, right sided vs. left sided
 Most cases of noninfectious endocarditis are immune
mediated
 Rheumatic fever
 Children often have preexisting condition such as
an indwelling catheter or congenital heart disease
 frequency of valve involvement MV>>aortic valve
(AV)>tricuspid valve (TV)>pulmonary valve (PV )

5. classifications
 acute vs. subacute,
 native valve vs. prosthetic valve,
 right sided vs. left sided

6. Risk factor:
 predisposing conditions
 High risk: prosthetic cardiac valve, previous IE,
congenital heart disease, cardiac transplant
 moderate risk: other congenital cardiac defects,
acquired valvular dysfunction, hypertrophic
cardiomyopathy
 low/no risk: secundum atrial septal defect (ASD)
or surgically repaired ASD

7. Etiology/epidemiology
 Most are Streptococcus viridans (alpha
hemolytic) and Staphylococcus aureus
Organism associations
 S. viridans—after dental procedures
 Group D streptococci—large bowel or
genitourinary manipulation
 Pseudomonas aeruginosa and Serratia
marcescens: intravenous drug users
 Fungi—after open heart surgery
 Coagulase-negative Staphylococcus—
indwelling intravenous catheters

9. Pathophysiology
 Turbulent blood flow leads to endocardial surface
injury
 Thrombus develops at injury site
 During transient bacteremia, thrombus becomes
infected
 Subsequent local tissue damage, embolic
phenomena, and secondary autoimmune
sequelae

10. Clinical features
Historical findings(symptoms)
 In subacute infection symptoms include
 prolonged low-grade fever
 weight loss
 Fatigue
 Myalgias
 nausea, vomiting, and abdominal pain
 In acute infection: child may be ill-appearing
with high fever or sepsis

11. Cont..
Physical exam findings (signs):
 New or changing heart murmur
 Janeway lesions: nontender, small nodules or
macules on palms/soles
 Roth spots: retinal hemorrhages with pale center that
are caused by immune complex-mediated vasculitis
 Osler nodes: tender, erythematous nodules on hands
and feet
 Splinter hemorrhages: tiny lines located under nail
 Signs of embolic phenomena: cerebral infarction or
hemorrhage, pulmonary embolism, and renal
infarction
 Splenomegaly
 Petechiae

16. Clinical Features
 systemic :
 fever (80-90%), chills, weakness, rigors, night
sweats, weight loss, anorexia
 cardiac :
 Dyspnea
 chest pain
 clubbing (subacute)
 regurgitant murmur (new onset or increased
intensity)
 signs of CHF (secondary to acute mitral
regurgitation (MR), atrial regurgitation (AR))

17.  embolic/vascular :
 petechiae over legs, splinter hemorrhages (linear,
reddish-brown lesion within nail bed)
 Janeway lesions (painless, 5 mm, erythematous,
hemorrhagic pustular lesions on soles/palms)
 focal neurological signs (CNS emboli),
 splenomegaly (subacute)
 microscopic hematuria, flank pain (renal emboli)

18.  immune complex :
 Osler’s nodes (painful, raised, red/brown, 3-15
mm on digits)
 glomerulonephritis
 arthritis
 Roth’s spots (retinal hemorrhage with pale centre)

19. Janeway lesions

20. Diagnosis
 Duke criteria:
 Definite diagnosis requires 2 major criteria or 1
major criterion and 3 minor criteria or 5 minor
criteria
 Possible diagnosis requires 3 minor criteria or 1
major criterion and 1 minor criterion

22.  Laboratory data
 Patients with endocarditis have persistent
bacteremia;
 Repeat blood cultures (at least 2 sets) after 48-72
h of appropriate antibiotics to confirm clearance
 ESR and CRP are elevated
 Rheumatoid factor is positive in 25%-50% of
cases
 Low complement, hematuria, and proteinuria
suggest immune complex glomerulonephritis,
which occurs with bacterial endocarditis
 Anemia of chronic disease is often present

23.  Echocardiography (echo)
 Identifies vegetations, valvular regurgitation,
and pericardial effusion; ventricular function
can also be assessed

24. Treatment
Medical therapy :
 Usually non-urgent and can wait for confirmation
of etiology before initiating treatment unless
patient is septic
 Empiric antibiotic therapy if patient is unstable;
administer ONLY after blood cultures have been
taken.
 first line empiric treatment for native valve:
vancomycin + gentamicin OR ceftriaxone
 first line empiric treatment for prosthetic valve:
vancomycin + gentamicin + rifampin

25. Cont..
 targeted antibiotic therapy: antibiotic and
duration (usually 4-6 wk)
 monitor for complications of IE (e.g. heart failure
(HF), conduction block, new emboli) and
complications of antibiotics (e.g. renal disease)
 post-treatment prophylaxis only recommended
for high-risk individuals listed above with
dental procedures that may lead to bleeding
OR invasive procedure of the respiratory tract
that involves incision or biopsy of the respiratory
mucosa, such as tonsillectomy and
adenoidectomy OR procedures on infected skin,
skin structure, or musculoskeletal tissue

26.  dental/respiratory: amoxicillin single dose 30-60
min prior; clindamycin if truly penicillin-allergic
 skin/soft tissue: cephalexin single dose 30-60
min prior; clindamycin if truly penicillin-allergic
(modify based on etiology of skin/soft tissue
infection)
surgical therapy:
 indications include: valve ring abscess, fungal
etiology, valve perforation, unstable prosthesis,

27. Complications
 CHF: caused by worsening valvular regurgitation
 Stroke
 Aneurysms
 Metastatic abscesses can develop in spleen,
kidney, and brain
 Vertebral osteomyelitis associated with S. aureus
IE

28. Prevention
 High-risk patients (e.g., artificial heart valves,
unrepaired cyanotic congenital heart disease)
should receive antibiotic prophylaxis during
dental procedures
 Single dose of amoxicillin recommended;
cephalexin and clindamycin are alternatives
for penicillin-allergic patients
 Good oral hygiene is important part of
prevention for high-risk patients

29. THE END