1. INFECTIVE ENDOCARDITIS
DR MANSOUR ALQURASHI

2. Learning Objectives
• Etiology • Symptoms and Signs • Laboratory and Echo Findings • Criteria for Diagnosis • Management and Prognosis • Prophylaxis

3. INTRODUCTION
- Infective endocarditis is a rare but fatal infection. -It involves cardiac endothelium of patients usually having pre-existing congenital or acquired cardiac lesion. -The affected population is increasingly a post surgical one, whereas rheumatic fever and unoperated congenital heart disease are declining as causes.

4. EPIDEMIOLOGY
The following factors may account for these changes: -Children with complex CHD are often palliated with prosthetic aortopulmonary shunts; with increased risk for endocarditis. - Children with simpler lesions are repaired earlier, reducing their risk. - The incidence of rheumatic fever is decreasing. - The increased use of central venous catheters in immunocompromised patients has created a new population at risk.

5. PATHOGENESIS
- Endothelium is altered by blood turbulence. -Fibrin & platelets are deposited at the damaged site forming vegetative lesions. -Transient bacteremia seeds vegetative lesions. -Bacterial growth is protected from WBC. -Bacteria can damage the valve and seed blood stream with bacteria.

7. This is infective endocarditis
This is infective endocarditis. The aortic valve demonstrates a large, irregular, reddish tan vegetation.

8. Infective endocarditis can lead to serious destruction, as shown here in the aortic valve. Irregular reddish tan vegetations overlie valve cusps that are being destroyed. 

10. HIGH RISK CARDIAC CONDITIONS
- Prosthetic heart valves. - Previous history of endocarditis (even in absence of other cardiac disease ). - Complex congenital cyanotic heart disease. - Surgically constructed systemic pulmonary shunts or conduits.

11. MODERATE RISK CARDIAC CONDITIONS
-Most other congenital cardiac malformations (other than above and below) . -Acquired valvar dysfunction (e.g. rheumatic heart disease) . -Hypertrophic cardiomyopathy. -Mitral valve prolapse with valvar regurgitation and/or thickened leaflets.

13. NEGLIGIBLE RISK CARDIAC CONDITIONS
-Isolated secundum atrial septal defect. -Mitral valve prolapse without valvar regurgitation. -Surgical repair of ASD, VSD, or PDA (without residua beyond 6 months) . -Previous rheumatic fever without valvar dysfunction. -Previous Kawasaki disease without valvar dysfunction. -Innocent heart murmurs. -Cardiac pacemakers and defibrillators. -Previous coronary artery bypass graft surgery.

15. BACTEREMIA PRODUCING PROCEDURES
Procedure and Site Incidence % (Range) Spontaneous bacteremia < 1 (0-3) Tooth extraction 60 (18-85) Periodontal surgery 88 (60-90) Brushing teeth or chewing 40 (7-50) Tonsillectomy 35 (33-38) Catheter insertion or removal 13 (0-26) Cystoscopy 17 Circumcision 0 Cardiac catheterization 2 (0-5)

16. MICROBIOLOGY
Common endocarditis pathogens are: -Alpha hemolytic streptococci. - Staphylococcus aureus . - Staphylococcus epidermidis.
Virulent organisms, such as Staphylococcus aureus, produce an "acute" bacterial endocarditis, while some organisms such as Streptococcus viridans group produce a "subacute" bacterial endocarditis

17. HACEK organisms H: Homophiles species A:Actinobacillus C: Cardiobacterium E: Eikenella K: Kingella HACEK organisms are common in neonates and immunocompromised children.

18. - Entertococci. - Brucella. - Anaerobes. - Fungi. - Rickettsiae
- Entertococci. - Brucella. - Anaerobes. - Fungi. - Rickettsiae. - Chlamydia. - Viruses.

19. CLINICAL FINDINGS
Classic Syndrome: Fever, Anemia, Heart Murmur, Embolic phenomena (FAME). -Fever: 90% of patients. -Heart murmur: 85% have murmur at some stage. -90% of patients with a new regurgitant murmur develop CHF.

20. - Cutaneous: Petichiae are the commonest finding (20-40%)
- Cutaneous: Petichiae are the commonest finding (20-40%). Osler nodules (10-25%). Splinter hemorrhages (15%). Janeway lesions (<10%). - Ophthalmologic: Conjunctival petichiae: common. Roth spot: (<5%).

21. Erythematous,blanching macules non-tender (hemorrhagic lesion).
Janeway lesion:
Erythematous,blanching macules  
non-tender (hemorrhagic lesion).
Often found on extremities.Microabscess.

22. Osler nodes: painful, raised, red lesions commonly found on the hands and feet. Caused by deposition of immune complexes.

23. retinal hemorrhages that have white/pale centers
Roth spots:
retinal hemorrhages that have white/pale centers

24. Conjunctival Hemorrhages

25. Conjunctival Petechiae

26. Splinter hemorrhages are small linear hemorrhages under the fingernails.

27. The image on the left shows an Osler node (tender and erythematous nodule) on the thumb. The image on the right shows Janeway lesions (nontender and erythematous macules on the palm).

28. Splenomegaly: 25 – 6 0 %. Musculoskeletal: - Back pain: the presenting complaint in 5-10% of cases. - Arthritis: can be both immunologic and septic.

29. LABORATORY & IMAGING FINDINGS
Blood cultures:
-Positive in 99% if prior to starting antibiotics.
-Multiple blood cultures, long incubation, and check for HACEK organisms.
CBC:
-Anemia in 50-80%.
-Leukocytosis is usually present.
-Thrombocytopenia is unusual.
ESR: Almost always elevated but nonspecific.
CRP: Commonly elevated but nonspecific.

30. Urinalysis: Microscopic hematuria and proteinuria are the commonest findings. (immune complex injury). Pyuria (metastatic infection). Cellular casts (immune complex mediated glomerulonephritis), or gross hematuria (infarction) may be seen. - Rheumatoid Factor: Positive in 50%. Resolves after appropriate treatment.

31. Radiology
CXR: -Peripheral nodular densities (metastatic lesions). -Pleural effusions in 75% of cases. -Cavitations or atelectasis. Echocardiogram: -Vegetations. -Myocardial abscess. -Valve competence. -Risk for embolism. TTE: less sensitive for vegetations (40-70%) but noninvasive. TEE:90-95% sensitive for a vegetation.

33. DIAGNOSIS
Duke criteria : Major criteria. Minor criteria. For definite diagnosis we must have: 2 major criteria, or 1 major + 3 minor criteria, or 5 minor criteria.

34. Duke Major Criteria
- Positive blood culture for a typical pathogen or multiple positive cultures. -Evidence of endocardial involvement: a- New evidence of valve regurgitation (i.e. new coming murmur). b- Positive echocardiogram: vegetation or intra-cardiac abscess.

35. Duke Minor Criteria
-Fever. -Presence of predisposing heart disease. -Positive blood culture but not for a typical pathogen. -Echo finding but not meeting major criterion. -Immune phenomena: Osler node, Roth spot, or glomerulonephritis. - Vascular phenomena: Janeway lesion, arterial emboli, or intracranial hemorrhage.

36. Additional Minor Criteria
-Newly diagnosed splenomegaly. -Newly diagnosed clubbing. -Splinter hemorrhages. -Petechiae. -High ESR and/ or high C-reactive protein. -Microscopic hematuria. - Central or Peripheral venous lines.

37. PROGNOSIS AND COMPLICATIONS
Mortality remains at 20-25%. Complications occur in % of cases. The commonest complications are: -Cardiac failure due to valve vegetations, myocardial abscesses, toxic myocarditis, acquired VSD, or heart block. -Systemic emboli: often with central nervous system or renal manifestations. -Pulmonary emboli. -Ruptured mycotic aneurysms. -Complications of medical or surgical treatment.

38. TREATMENT
For Complete eradication of the causing organism we need Prolonged, Parenteral, and Bactericidal antibiotic regimen guided by antibiotic sensitivity studies. Empiric treatment should be started as soon as diagnosis is suspected. Recommended combination of penicillinase resistant penicillin (or vancomycin) and gentamicin can be initiated.

39. SURGICAL INDICATIONS IN ENDOCARDITIS
-Hemodynamically unstable: a. New or worsening heart failure. b. Valvular dysfunction. -Uncontrolled infection: a. Remaining positive blood cultures. b. Fungal endocarditis. c. Perivalvular or myocardial abscess. -Embolic manifestations

40. Prevention of Infective Endocarditis
IE prophylaxis used to be indicated (before updates) in: 1. Moderate and high risk cardiac conditions. 2. Prior to dental , upper respiratory tract procedures , GI , and GU procedures.

41. Prevention of Infective Endocarditis
Updated Guidelines From the American Heart Association (2007) IE prophylaxis is indicated in: 1. High risk cardiac conditions. 2. Prior to dental , upper respiratory tract procedures.

42. Recommended Endocarditis Prophylaxis During Oral-Dental or Respiratory Tract Procedures*
Route
Drug and Dosage in Adults (and Children)
Drug and Dosage in Adults (and Children) Allergic to Penicillin
Oral (given 1 h before procedure)
Amoxicillin 2 g (50 mg/kg) po
Clindamycin 600 mg (20 mg/kg) po or
Cephalexin or cefadroxil 2 g (50 mg/kg) po
Azithromycin or clarithromycin500 mg (15 mg/kg) po
Parenteral (given 30 min before procedure)
Ampicillin 2 g (50 mg/kg) IM or IV
Clindamycin 600 mg (20 mg/kg) IV
Cefazolin 1 g (25 mg/kg) IM or IV
*For patients without active infection.
Adapted from Wilson W, Taubert KS, Gewitz M, et al: Prevention of infective endocarditis. Circulation 116(15):1736–1754, 2007.

43. Procedures Requiring Antimicrobial Endocarditis Prophylaxis in High-Risk Patients
Oral-dental*
Dental extraction
Dental implant placement or reimplantation of avulsed teeth
Periodontal procedures, including surgery, scaling, root planing, and probing
Prophylactic cleaning of teeth or implants when bleeding is anticipated
Root canal instrumentation or surgery beyond the apex
Respiratory tract
Bronchoscopy if mucosa is to be incised
Procedures done during an established infection
Tonsillectomy, adenoidectomy, or both