Infective endocarditis

Infective Endocarditis in children

1. Dr.Azad A Haleem AL.Brefkani University Of Duhok Faculty of Medical Science School Of Medicine Pediatrics Department [email protected] 2015 Infective Endocarditis in children

2. Definition of Infective Endocarditis Infective endocarditis , a serious infection of the endocardium of the heart, particularly the heart valves, It generally occurs in patients with altered and abnormal heart architecture, in combination with exposure to bacteria.

3. Etiology Infective endocarditis includes acute and subacute bacterial endocarditis , as well as nonbacterial endocarditis caused by viruses, fungi, and other microbiologic agents.

4. Etiology Viridans -type streptococci (α-hemolytic streptococci) and Staphylococcus aureus remain the leading causative agents for endocarditis in pediatric patients. Other organisms cause endocarditis less frequently and, in ≈6% of cases, blood cultures are negative for any organisms. Staphylococcal endocarditis is more common in patients with no underlying heart disease; viridans group streptococcal infection is more common after dental procedures; group D enterococci are seen more often after lower bowel or genitourinary manipulation;

5. Distinction between Acute and Subacute Bacterial Endocarditis Feature Acute Subacute Underlying Heart Disease Heart may be normal RHD,CHD, etc. Presentation Toxic presentation Progressive valve destruction & metastatic infection developing in days to weeks Mild toxicity Presentation over weeks to months Organism S. aureus, Pneumococcus S. pyogenes, Enterococcus viridans Streptococci, Entercoccus

6. Pathophysiology Turbulent blood flow due to a hole or stenotic orifice, especially if there is a high pressure gradient across the defect, are most susceptible to endocarditis . This turbulent flow traumatizes the vascular endothelium, creating a substrate for deposition of fibrin and platelets, leading to the formation of a nonbacterial thrombotic embolus (NBTE) that is thought to be the initiating lesion for infective endocarditis . Bacteraemia – delivers organisms to the damaged (sticky) endocardial surface resulting in adherence & colonisation Eventual invasion of valve leaflets results in infected vegetation (sheath of fibrin & platelets, ideal conditions for further bacterial multiplications)

7. Epidemiology Infective endocarditis is often a complication of congenital or rheumatic heart disease but can also occur in children without any abnormal valves or cardiac malformations.

8. Children at highest risk of adverse outcome after infective endocarditis include those with: congenital heart disease. Repaired congenital heart disease. congenital or acquired valvular heart disease. Immunocompromised patients with central venous line.

9. Bacterial Endocarditis Predisposing Factors Dental manipulation & Dental disease (caries, abscess) Extra cardiac infection (lung, urinary tract,skin , bone, abscess) 4. Instrumentation (urinary tract, GI tract, IV infusions) 5. Cardiac surgery 6. Injection drug use 7. None apparent

10. Clinical Features Fever (Prolonged fever without other manifestations that persists for as long as several months may be the only symptom). The symptoms are often nonspecific and consist of low-grade fever with afternoon elevations, fatigue, myalgia , arthralgia , headache, and, at times, chills, nausea, and vomiting. Heart murmur ( New or changing heart murmurs are common) Nonspecific signs : Petechial and cutaneous manifestations, Conjunctival and mucosal petechiae , splinter hemorrhages. petechiae,splinter hemorrhages, clubbing. Splenomegaly More specific signs - Osler’s Nodes, Janeway lesions, and Roth Spots. Splenomegaly Embolism: CNS, spleen, lung, retinal vessels, coronary artery, large vessels. CHF General. Weight loss, anorexia.

11. Osler nodes (tender, pea-sized intradermal nodules in the pads of the fingers and toes), Janeway lesions (painless small erythematous or hemorrhagic lesions on the palms and soles), and splinter hemorrhages (linear lesions beneath the nails). These lesions may represent vasculitis produced by circulating antigen-antibody complexes.

12. Janeway Lesions More specific Erythematous, blanching macules Nonpainful Located on palms and soles

13. Splinter Hemorrhages Nonspecific Nonblanching Linear reddish-brown lesions found under the nail bed Usually do NOT extend the entire length of the nail

14. Subconjuctival Hemorrhages 30-03-2015 Dr.T.V.Rao MD 14

15. Roth’s Spots

16. Osler’s Nodes More specific Painful and erythematous nodules Located on pulp of fingers and toes More common in subacute IE

17. Blood Cultures Blood Cultures Minimum of three blood cultures ( start within 1 h prior to commencement of empirical therapy) Three separate venipuncture sites ideally Obtain correct volume of blood for culture bottles

18. Additional Tests CBC ESR and CRP Complement levels (C3, C4, CH50) RF Urinalysis Baseline chemistries

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

20. Diagnosis The Duke criteria help in the diagnosis of endocarditis . Major criteria include (1) positive blood cultures; 2 separate cultures for a usual pathogen, 2 or more for less typical pathogens), and (2) evidence of endocarditis on echocardiography ( intracardiac mass on a valve or other site, regurgitant flow near a prosthesis, abscess, partial dehiscence of prosthetic valves, or new valve regurgitant flow).

21. Minor criteria include predisposing heart conditions, prior cardiac surgery, indwelling catheter. Fever > 38c embolic-vascular signs: Major arterial emboli. Septic pulmonary infarct. Mycotic aneurysm. Intracranial hemorrhage. Conjunectival hemorrhage. Janeway lesion. immune complex phenomena: Glomerulonephritis arthritis, rheumatoid factor Osler nodes Roth spots. positive blood culture not meeting the major criteria. echocardiographic signs not meeting the major criteria.

22. Two major criteria, one major and three minor, or five minor criteria suggest definite endocarditis . A modification of the Duke criteria may increase sensitivity while maintaining specificity.

23. Prognosis and Complications Despite the use of antibiotic agents, mortality is at 20-25%. Serious morbidity occurs in 50-60% of children with documented infective endocarditis ;

24. Complications Local cardiac complications: The most common is heart failure, Myocardial abscesses, toxic myocarditis , life-threatening arrhythmias and heart block. Embolic like Stroke & Ischemic limbs Metastatic spread of infection like Meningitis Formation of immune complexes – glomerulonephritis and arthritis.

25. Treatment Antibiotic therapy should be instituted immediately once a definitive diagnosis is made. Empirical therapy before the identifiable agent is recovered may be initiated with vancomycin plus gentamicin in patients without a prosthetic valve and when there is a high risk of S. aureus enterococcus or viridans streptococci (the 3 most common organisms). A total of 4-6 wk of treatment is usually recommended. Depending on the clinical and laboratory responses, antibiotic therapy may require modification and, in some instances, more prolonged treatment is required.

26. If symptoms and signs of heart failure , appropriate therapy should be instituted, including diuretics, afterload reducing agents, and in some cases, digitalis. Surgical intervention for infective endocarditis is indicated for severe aortic or mitral valve involvement with intractable heart failure. Other surgical indications include failure to sterilize the blood despite adequate antibiotic levels, myocardial abscess.

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

28. Prevention – the underlying lesion High risk lesions Prosthetic valves Prior IE Cyanotic congenital heart disease PDA AR, AS, MR,MS with MR VSD Coarctation Surgical systemic-pulmonary shunts

29. Antibiotics Guidelines IE prophylaxis Standard general prophylaxis: Oral Amoxicillin 50 mg/kg or IV/IM Ampicillin 50 mg/kg . Penicillin Allergy : Erythromycin 20 mg/kg Note : give oral therapy one hour before procedur ; IV therapy 30 min before procedure