1. Infective endocarditis is an infection of the inner lining of the heart caused by bacteria or fungi. It can be acute or subacute and affect normal or damaged heart valves. 2. It is diagnosed based on blood cultures and echocardiogram findings according to the modified Duke criteria. Treatment involves prolonged intravenous antibiotics and may require surgery for complications. 3. Prevention focuses on antibiotic prophylaxis for high-risk patients before certain medical procedures to prevent bacteremia that could lead to infective endocarditis.

1. INFECTIVE
ENDOCARDITIS
Dr.Anup John Thomas
Assistant Professor
Department of Pediatrics,MGMC&RI

2. History
• 1885 – well defined by William Osler
• 1944 – penicillin discovered
• 1960 – surgery in IE
• 1973 – ECHO for identifying vegetation
• 1981 – Von Reyn criteria
• 1994 – Dukes criteria

3. Definition
• Infectious Endocarditis (IE): an infection of the heart’s
endocardial surface

4. Background
• Relatively rare in children
• Pre-antibiotic era: mortality was nearly 100%
• Mortality approaches 15-25%

5. Classification
• Acute
• Affects normal heart
valves
• Rapidly destructive
• Metastatic foci
• Commonly Staph.
• If not treated, usually
fatal within 6 weeks
• Subacute
• Often affects damaged
heart valves
• Indolent nature
• If not treated, usually
fatal by one year

6. Pathophysiology
1. Turbulent blood flow disrupts the
endocardium making it “sticky”
2. Bacteremia delivers the organisms to
the endocardial surface
3. Adherence of the organisms to the
endocardial surface
4. Eventual invasion of the valvular
leaflets

7. Epidemiology
• Incidence difficult to ascertain and varies according to
location
• Much more common in males than in females
• Increasing incidence beginning in the ‘80s
• Increasing number of surgical patients
• Increasing number of complex congenital heart disease
• Increased use of prosthetic materials
• NICUs and PICUs

8. Difficult to eradicate: why?
• Less awareness of risks & preventive measures
• Delay in diagnosis
• Special risk groups

9. Risk Factors
• The vast majority (75-90%) of cases after the neonatal
period are associated with an underlying congenital
abnormality
• Aortic valve
• VSD
• Tetralogy of Fallot
• Risk of post-op infection in children with IE is 50%
• Artificial heart valves and pacemakers
• Acquired heart defects
• Calcific aortic stenosis
• Mitral valve prolapse with regurgitation
• Intravascular catheters
• Intravenous drug abuse

10. Microbiology
• S. Viridans
• Most common causative organism
• Gram negative bacilli
• Neonates and immunocompromised patients
• Prosthetic valves
• Within first year of surgery: Coag-negative staph
• Staph.epidermidis
• After first year: similar to native valve endocarditis
• HACEK organisms
• Hemophilus, Actinobacillus, Cardiobacterium, Eikenella,
Kingella
• Frequently affect damaged valves and can cause emboli
• Candida
• 6 -10 % culture negative.

11. Symptoms
• Acute
• High grade fever and
chills
• Breathlessness
• Arthralgia/ myalgia
• Abdominal pain
• Pleuritic chest pain
• Back pain
• Subacute
• Low grade fever
• Anorexia
• Weight loss
• Fatigue
• Arthralgia/ myalgia
• Abdominal pain
The onset of symptoms is usually ~2 weeks or less
from the initiating bacteremia

12. Signs
• Fever
• Heart murmur
• Nonspecific signs – petechiae, subungual or “splinter”
hemorrhages, clubbing, splenomegaly, neurologic
changes
• More specific signs - Osler’s Nodes, Janeway lesions,
and Roth Spots

13. Petechiae
Subconjunctival Hemorrhage
1.Nonspecific
2.Often located on extremities
or mucous membranes

14. Splinter Hemorrhages
1. Nonspecific
2. Nonblanching
3. Linear reddish-brown lesions found under the nail bed
4. Usually do NOT extend the entire length of the nail

15. Osler’s Nodes
1. More specific
2. Painful and erythematous nodules
3. More common in subacute IE

16. Janeway Lesions
1. More specific
2. Erythematous, blanching macules
3. Nonpainful

17. Roth’s Spots

18. Diagnosis
• Traditionally based upon “positive blood cultures in the
presence of a new or changing heart murmur”, or
persistent fever in the presence of heart disease.
• Shortcomings include culture-negative endocarditis, lack
of typical echocardiographic findings, etc.

19. The Essential Blood Test
• Blood Cultures
• Minimum of three blood cultures
• Three separate venipuncture sites
• 0.5-5mL in children
• Positive Result
• Typical organisms present in at least 2 separate samples
• Persistently positive blood culture (atypical organisms)
• Two positive blood cultures obtained at least 12 hours apart
• Three or a more positive blood cultures in which the first and last
samples were collected at least one hour apart

20. Additional Labs
• CBC:normochromic normocytic anemia and/or
leukocytosis
• ESR and CRP elevated
• Complement levels ↓ (C3, C4, CH50)
• RF
• Urinalysis: Microscopic hematuria
• Baseline chemistries and coagulation profile

21. Imaging
• Chest x-ray
• Look for multiple focal infiltrates and calcification of heart valves
• EKG
• Rarely diagnostic
• Look for evidence of ischemia, conduction delay, and arrhythmias
• Echocardiography

22. Indications for Echocardiography
• Transthoracic echocardiography (TTE)
• First line if suspected IE
• Native valves
• Transesophageal echocardiography (TEE)
• Prosthetic valves
• Intracardiac complications
• Inadequate TTE
• Fungal or S. aureus or bacteremia

23. Making the Diagnosis
• Pelletier and Petersdorf criteria (1977)
• Classification scheme of definite, probable, and possible IE
• Reasonably specific but lacked sensitivity
• Von Reyn criteria (1981)
• Added “rejected” as a category
• Added more clinical criteria
• Improved specificity and clinical utility
• Duke criteria (1994)
• Included the role of echocardiography in diagnosis
• Added IVDA as a “predisposing heart condition”

24. Duke Criteria
• Based on pathological and clinical criteria.
• Utilizes microbiological data, evidence of endocardial
involvement, and other phenomenon associated with
infective endocarditis to estimate the probability of
infective endocarditis in a given patient.
• Has been shown to be valid and reproducible in
children

25. Modified Duke Criteria
• Definite IE
• Pathological
• Microorganism (via culture or
histology) in a valvular
vegetation, embolized
vegetation, or intracardiac
abscess
• Histologic evidence of
vegetation or intracardiac
abscess
• Clinical
• 2 major
• 1 major and 3 minor
• 5 minor
• Possible IE
• At least 1 major and 1 minor,
• 3 minor
• Rejected IE
• Firm alternative diagnosis, or
• Resolution of manifestations of
endocarditis with antibiotic
therapy of 4 days or less, or
• No pathological evidence of
endocarditis at surgery or
autopsy with antibiotic therapy
of 4 days or less

26. Duke criteria: Major criteria
• Positive blood culture
• Typical microorganism consistent with IE, from two separate blood
cultures
• S. viridans, S. bovis, HACEK
• community-acquired S. aureus or enterococci (no primary focus)
• Persistently positive cultures
• at least two positive cultures, drawn 12 hours apart
• all of three, or a majority of four or more cultures (with first and last
sample drawn at least one hour apart
• Evidence of endocardial involvement
• Positive echocardiogram
• oscillating intracardiac mass on valve or supporting structures, or
• myocardial abscess, or
• new partial dehiscence of prosthetic valve
• New valvular regurgitation

27. The echocardiogram in IE

28. Duke criteria: Minor criteria
• Predisposition
• Predisposing heart condition or IV
drug abuser
• Fever
• > 38.0º C
• Vascular phenomena
• arterial emboli, septic pulmonary
infarct, mycotic aneurysm,
intracranial hemorrhage,
conjunctival hemorrhage, Janeway’s
lesion
• Immunologic phenomena
• glomerulonephritis, Osler’s nodes,
Roth’s spots, rheumatoid factors
• Microbiologic evidence
• positive blood culture but does not
meet major criteria as noted
• Echocardiographic evidence
• consistent with IE but does not meet
major criteria as noted

29. Treatment
• Parenteral antibiotics
• High serum concentrations to penetrate vegetation
• Prolonged treatment to kill dormant bacteria clustered in vegetation
• Surgery
• Intracardiac complications
• Surveillance blood cultures

30. Treatment
• Parenteral antibiotics
• strep Viridans : 4wks
• penicillin 20Lakh u/kg/d
• ceftriaxone 100mg/kg/d
• vancomycin 30/mg/kg/d
• prosthetic valve; 6wks
• Staph aureus:
• cloxacillin+ gentamicin [6wks]
• vancomycin [clox resistant ]
• prosthetic valve: add rifampicin & GM > 6wks

31. Treatment
• Parenteral antibiotics
• Enterococcus: ampicillin + GM /streptomycin
• vancomycin / linezolid
• HACEK: ceftriaxone / ampicillin+GM / ciprofloxacin
• Candida : amphotericin+ 5 flurocytosine
• Recombinant tissue plasminogen activation

32. Surgical Treatment of Intra-Cardiac
Complications
• NYHA Class III/IV CHF due to valve
dysfunction
• Unstable prosthetic valve
• Uncontrolled infection

33. Sequelae
• Neurologic manifestations, 20%
• Cerebral emboli, mycotic aneurysms, cerebritis, brain abscess,
hemorrhage, etc.
• Peripheral embolization
• Ischemia, infarction, mycotic aneurysms, etc.
• Pulmonary infarction
• Renal insufficiency
• Congestive heart failure

34. Embolic Complications
• Occur in up to 40% of patients with IE
• Predictors of embolization
• Size of vegetation
• Left-sided vegetation
• Fungal pathogens, S. aureus, and Strep. Bovis
• Incidence decreases significantly after initiation of
effective antibiotics

35. Embolic Complications
• Stroke
• Myocardial Infarction
• Fragments of valvular vegetation or vegetation-induced stenosis of
coronary ostia
• Ischemic limbs
• Hypoxia from pulmonary emboli
• Abdominal pain (splenic or renal infarction)

36. Poor Prognostic Factors
• Female
• S. aureus
• Vegetation size
• Aortic valve
• Prosthetic valve
• Older age
• Low serum albumin
• Heart failure
• Paravalvular abscess
• Embolic events

37. Prevention
• Prophylactic regimen targeted against likely organism
• Strep. viridans – oral, respiratory, esophageal
• Enterococcus – genitourinary, gastrointestinal
• S. aureus – infected skin, mucosal surfaces

38. Endocarditis prophylaxis recommended
• High-risk
• Prosthetic cardiac valves
• Previous bacterial endocarditis
• Complex cyanotic heart disease
• Surgically constructed systemic-pulmonary shunts or conduits
• Moderate-risk
• Most other congenital heart disease
• Acquired valvar dysfunction
• Hypertrophic cardiomyopathy
• Mitral valve prolapse WITH regurgitation and/or thickened leaflets

39. Dental procedures and IE prophylaxis:
Recommended
• Dental extractions
• Periodontal procedures
• Dental implants and reimplantation of avulsed teeth
• Endodontic procedures
• Subgingival placement of antibiotic fibers and strips
• Initial placement of orthodontic bands (not brackets)
• intraligamentary local anesthetic injections
• Prophylactic cleaning

40. Other procedures and IE prophylaxis:
Recommended
• Respiratory
• T&A
• Surgical procedures involving respiratory mucosa
• Rigid bronchoscopy
• Gastrointestinal
• Sclerotherapy
• Esophageal stricture dilation
• ERCP with biliary obstruction
• Surgery involving biliary tract or intestinal mucosa
• Genitourinary tract
• Prostatic surgery, cystoscopy
• Urethral dilation

41. Prophylaxis
• Dental & oral & URT procedures;
oral amox 50mg/kg 1hr before
IM/IV ampicillin 50mg/kg 30mt before
oral cephalexin / azithromycin
IV cefazolin

42. GIT / GUT surgery
• Moderate risk:
Oral amox / IV ampicillin
• High risk:
IV ampicillin+ GM 30mt before & oral amox 6h
later
Vancomycin + GM 30 mt before