Infective Endocarditis in Children

Infective endocarditis is often a complication of congenital or rheumatic heart disease in children.

1. Infective Endocarditis Major (Dr) Jahangir Alam DCH, FCPS Classified Child Specialist Bangladesh Army

2. Definition Infective endocarditis is a form of endocarditis , or inflammation, of the inner tissue of the heart (such as its valves) caused by infectious agents. The agents are usually bacterial, but other organisms can also be responsible.

3. Epidemiology Infective endocarditis is often a complication of congenital or rheumatic heart disease. It is rare in infancy. Prevalence of Infective endocarditis (IE) accounts for 0.5 to 1 of every 1000 hospital admissions, excluding postoperative endocarditis The frequency of IE among children seems to have increased in recent years due to Survivors of surgical repair of complex congenital heart disease Survivors of neonatal intensive care units, who are at an increased risk for IE.

4. Etiology

5. COMMON: NATIVE VALVE OR OTHER CARDIAC LESIONS Viridans group streptococci Staphylococcus aureus Group D streptococcus Note: In the past, these organisms were responsible for over 90% of the cases. This frequency has decreased to 50% to 60%, with a concomitant increase in cases caused by fungi and HACEK organisms ( Haemophilus , Actinobacillus , Cardiobacterium , Eikenella , and Kingella ).

6. UNCOMMON: NATIVE VALVE OR OTHER CARDIAC LESIONS Streptococcus pneumoniae Haemophilus influenzae Coagulase -negative staphylococci Coxiella burnetii (Q fever)* Brucella * Chlamydia HACEK group ( Haemophilus , Actinobacillus , Cardiobacterium , Eikenella , and Kingella ). Streptobacillus moniliformis * Pasteurella multocida * Campylobacter fetus Culture negative (6%)

7. PROSTHETIC VALVE Staphylococcus epidermidis Staphylococcus aureus Viridans group streptococcus Pseudomonas aeruginosa Serratia marcescens Diphtheroids Legionella species HACEK group Fungi

8. Association of causative organism in various situation Organism responsible Risk factor viridans group streptococcal after dental procedures; Group D enterococci After bowel or genitourinary surgery Pseudomonas aeruginosa or Serratia In I/V drug users fungal organisms after open heart surgery Coagulase - ve staphylococci (S. aureus ) indwelling central venous catheter.

9. Pathogenesis

10. Pathogenesis in congenital heart lesion Congenital heart lesion Turbulence of blood flow through stenotic orifice Traumatize vascular endothelium Deposition of platelet & fibrin over lesion Formation of non bacterial thrombotic embolus(NBTE) Transient bacterimia colonize NBTE Rapid proliferation of bacteria Infective endocarditis

11. Pathogenesis in implanted prosthesis Biofilm on the surface of implanted mechanical device Acts as an adhesive substrate for infection Bacterial colonization over biofilm Rapid proliferation of bacteria Infective endocarditis

12. Manifestation of Infective Endocarditis

13. History Prior congenital or rheumatic heart disease Preceding dental, urinary tract, or intestinal procedure Intravenous drug use Central venous catheter Prosthetic heart valve

14. Symptoms Fever : prolong fever without other manifestation may be the early symptoms of IE Chills Night sweat Weight loss Chest and abdominal pain fatigue Arthralgia , myalgia Dyspnea Malaise, weakness CNS manifestations ( stroke, seizures, headache )

15. Sign Elevated temperature Tachycardia Clubbing Skin menifestation Petechiae Osler’s nodes Janeway lesions Splinter hemorrhages CVS: Arrhythmias New or changing murmur Heart failure Splenomegaly Osler's nodes Splinter hemorrhages

16. Sign contd … Embolic or immunologic phenomena Roth spots Seizures and hemiparesis Pulmonary haemorrhage Haematuria & renal failure Metastatic infection arthritis, meningitis, mycotic arterial aneurysm, pericarditis , abscesses, septic pulmonary emboli Roth spots Janeway lesions

17. Investigation

18. Laboratory studies Blood cultures : positive in > 90% of patients in the absence of previous antimicrobial therapy 50% to 60% positive in pretreatment with antibiotics Complete blood count: Anemia present in 80% of patient leukocytosis Raised ESR Raised CRP Urine Microscopic haematuria is found in 30% of patients

19. Other specimens that may be cultured : scrapings from cutaneous lesions, urine, synovial fluid, Abscesses cerebrospinal fluid CXR : Evidence of heart failure ECG : Evidence of underlying heart disease or conduction defect due to abscess.

20. Echocardiography Certain echo findings are included as major criteria in the modified Duke criteria Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitation jets, or on implanted material    Abscesses    New partial dehiscence of prosthetic valve    New valvular regurgitation

21. Diagnosis

22. The Duke criteria help in the diagnosis of endocarditis Major criteria: Positive blood cultures 2 separate cultures for a usual pathogen, 2 or more for less-typical pathogens Evidence of endocarditis on ECHO intracardiac mass on a valve Partial dehiscence of prosthetic valves New valvular regurgitation worsening or changing of pre-existing murmur

23. Minor criteria fever, embolic-vascular signs, Immune complex phenomena ( glomerulonephritis , arthritis, rheumatoid factor, Osler nodes, Roth spots), a single, positive blood culture or serologic evidence of infection, echocardiographic signs not meeting the major criteria. Newly diagnosed clubbing, splenomegaly , splinter hemorrhages, and petechiae ; High erythrocyte sedimentation rate; High C-reactive protein level; Presence of central nonfeeding lines,peripheral lines, microscopic hematuria .

24. Interpretation of Duke criteria: Definite endocarditis : 2 major criteria or 1 major and 3 minor or 5 minor criteria Possible endocarditis : 1 major + 1 minor Or 3 monor criteria

25. Management Antibiotics: Antibiotic therapy should be instituted immediately once a definitive diagnosis is made. Initial empirical therapy should be Flucloxacillin / Methicillin + Gentamicin If methicillin resistant S. aureus is suspected then Vancomycin + Gentamicin The final selection of antibiotics depends on the organism isolated and the results of an antibiotic sensitivity test . A total of 4-6 wk of treatment is usually recommended.

26. Therapy of Native Valve Endocarditis Caused by Highly Penicillin-Susceptible Viridans Group Streptococci and Streptococcus bovis Regimen Dosage & route Duratio (WK) Aqueous crystalline penicillin G sodium 200,000 U/kg per 24 hr IV in 4-6 equally divided doses; 4 Ceftriaxone sodium Aqueous crystalline penicillin G sodium 100 mg/kg per 24 hr IV/IM in 1 dose 200,000 U/kg per 24 hr IV in 4-6 equally divided doses 4 2 Ceftriaxone sodium Gentamicin sulfate 100 mg/kg per 24 hr IV/IM in 1 dose 3 mg/kg per 24 hr IV/IM in 1 dose or 3 equally divided doses 2 2 Vancomycin hydrochloride 40 mg/kg per 24 hr IV in 2-3 equally divided doses 4

27. Therapy for Endocarditis Caused by Staphylococci in the Absence of Prosthetic Materials Regimen Dosage & route Duratio (WK) Nafcillin or oxacillin With Optional addition of gentamicin sulfate‡ 200 mg/kg per 24 hr IV in 4-6 equally divided doses 3 mg/kg per 24 hr IV/IM in 3 equally divided doses 6 3-5 d For penicillin-allergic Cefazolin With Optional addition of gentamicin sulfate 100 mg/kg per 24 hr IV in 3 equally divided doses; 3 mg/kg per 24 hr IV/IM in 3 equally divided doses 6 3-5 d OXACILLIN-RESISTANT STRAINS Vancomycin 40 mg/kg per 24 hr IV in 2 or 3 equally divided doses 6

28. General management Bed rest if CHF occurs Digitalis Restriction of salt intake Diuretic when indicated

29. Surgery Surgery is indicated if- severe aortic, mitral or prosthetic valve involvement with intractable heart failure. Severe heart failure may be associated with acute valve regurgitation, obstruction, or fistula formation. failure to sterilize the blood despite adequate antibiotic levels in 7-10 days Vegetations (aortic, mitral, prosthetic valve) >10-15 mm are at high risk of embolism. Emergency operation required in mycotic aneurysm, rupture of an aortic sinus, intraseptal abscess causing complete heart block, or dehiscence of an intracardiac patch

30. Prophylaxis Prophylaxis required for Dental Procedures in following cases:2007 Statement of the American Heart Association Prosthetic cardiac valve or prosthetic material used for cardiac valve repair Previous infective endocarditis CONGENITAL HEART DISEASE (CHD)* Unrepaired cyanotic CHD, including palliative shunts and conduits Completely repaired CHD with prosthetic material or device, whether placed by surgery or catheter intervention, during the 1st 6 mo after the procedure Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch, or prosthetic device (which inhibit endothelialization ) Cardiac transplantation recipients who develop cardiac valvulopathy

31. Why the routine antibiotic prophylaxis is revised & limited in 2007? Infective endocarditis is much more likely to result from exposure to the more frequent random bacteremias associated with daily activities than from a dental or surgical procedure; Routine prophylaxis may prevent “an exceedingly small” number of cases; and The risk of antibiotic-related adverse events exceeds the benefits of prophylactic therapy. Improving general dental hygiene was felt to be a more important factor in reducing the risk of infective endocarditis resulting from routine daily bacteremias .

32. Children at highest risk of adverse outcome after infective endocarditis include prosthetic cardiac valves or other prosthesis used for cardiac valve repair, unrepaired cyanotic congenital heart completely repaired defects with prosthetic material or device during the 1st 6 mo after repair, repaired CHD with residual valve stenosis or insufficiency occurring after heart transplantation, permanent valve disease from rheumatic fever (mitral stenosis , aortic regurgitation), and previous infective endocarditis

33. Prognosis Despite the use of antibiotic agents, mortality remains high, in the range of 20-25%. Serious morbidity occurs in 50-60% of children with documented infective endocarditis the most common morbidity is heart failure caused by vegetations involving the aortic or mitral valve.

34. Thank you