• “…..increases the physician's interest in the development of an infectious process". William Bart Osler, 1893

• One century age- 100% fatal- diagnosis only post-mortem

• Diagnosis- 1994- David Durack et al- Duke university gave a criteria

• Now- real time imaging and diagnosis with effective treatment

Infective endocarditis- Bacterial endocarditis in children

Basics

Objectives

• Basic pathogenesis

• Clinical features

• Diagnosis

• Treatment

• Summary

What is endocarditis?

• Infection and inflammation of the inner layer of the heart- endocardium

• Valvular surfaces commonly involved

Pathogenesis

Damaged cardiac endothelium (usually

over the valves)-produced by turbulent jet

flow- thrombotic foci

Nidus

Bacteremia Vegetation

High risk groups

• Intravenous drug abusers- right heart valves

• Immunocompromised

• Heart diseases:

– High velocity jet- VSD, AS, bicuspid aortic valve, MVP

– Uncorrected Cyanotic congenital heart disease

• Prosthetic heart valves, post cardiac surgery

• Indwelling venous catheters

Microbiology

• Gram positive organisms- most common- bind to fibronectin easily

• Gram positive:

– Streptococcus viridans

– Staphylococcus aureus, Staphylococcus epidermidis

– Enterococci

• Gram negative:

– HACEK group- Haemophilus sp, Actinobacillus sp, Cardiobacterium sp, Eikenella sp, and Kingella kingae

Clinical features

IE C/F

Bacteremia

Fever, Malaise

Local valve destruction

Acute cardiac failure

New or changing murmurs

Immune complex

formation

Glomerulonephritis

Osler nodes

Roth spots

Septic embolization

Hands- Janeway lesions, Splinter hemorrhages

Osteomyelitis, Septic arthritis

Pneumonia

Brain abscess

Infarcts

Others

• Splenomegaly

• Clubbing

Diagnosis• Consider IE- child with heart disease with an

unexplained fever

• Blood culture- vital

– Good volume- 1- 3 mL in infants; 5- 7 mL in older children

– Not necessary to time with fever- bacteremia in IE continuous

– 3 aerobic cultures over the first day before administering antibiotics

Modified Duke’s criteria

Modified Duke’s criteria

• Combination of clinical, microbiologic, and echocardiographic criteria

A, B- Splinter hemorrhages

C- Osler nodes-tender

erythematous nodules located in pulp of fingers

and toes

D- Janeway lesions- flat

painless bluish red spots on

palms and soles

Treatment• Empirical treatment- Crystalline penicillin G plus

Gentamicin

• Alternate- Ceftriaxone plus Gentamicin

• Prosthetic valve/ Staphylococcal endocarditis-Vancomycin plus Gentamicin

• Duration of therapy- 4- 6 weeks

• Modify regimen based on response and sensitivity pattern

Prevention• High risk heart conditions:

– Prosthetic cardiac valve – History of infective endocarditis – Congenital heart disease (CHD): (1) unrepaired cyanotic

CHD, including palliative shunts, (2) completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention- first 6 months after the procedure, (3) repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device

– Cardiac transplantation recipients

Except for the conditions listed, antibiotic prophylaxis is no longer recommended for any other form of CHD

High risk procedures

• Dental: single dose of oral amoxicillin

No if:

Placement of orthodontic brackets

Shedding of milk teeth

Bleeding from trauma to the lips or oral mucosa

Yes if :

Manipulation of gums/ periapicalregion of teeth/ perforation of

the mucosa

Others

• RS- yes for invasive respiratory tract procedures that involve incision or biopsy of the respiratory mucosa (eg, tonsillectomy, adenoidectomy, abscess drainage)- not recommended for bronchoscopy- single dose of oral amoxicillin

• Surgical procedure that involves infected skin, skin structure, or musculoskeletal tissue- yes-Antibiotic active against staphylococci and beta-hemolytic streptococci (eg, cloxacillin or cephalosporin)

• Genitourinary/ GIT procedures- No

Take home messages

• Etiologic agents of IE

• Pathogenesis

• When to suspect IE- any child with heart disease and unexplained fever

• Clinical features

• Modified Duke’s criteria

• Treatment and prevention