infective is presentation

8/8/2019 Infective is Presentation

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Infective Endocarditis

Dr. Mohammad AlGhamdi

King AbdulAziz Cardiac center


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Topics to be covered

Definition

Predisposing factors Clinical features

Diagnosis

Complications Treatment

Prophylaxis


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Aortic valve vegetations


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Mitral valve vegetation


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Aortic valve vegetation


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Aortic root abscess


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Mitral valve destruction


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Predisposing factors Presence of circulating bacteria (bacterimia)

Presence of vulnerable cardiac pathology


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Prosthetic valves


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Clinical presentation symptoms Signs


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Peripheral signs of IE

Janeway Lesions


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Oslers Nodes

Splinter Hemorrhage


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Subconjunctival Hemorrhages

Subconjunctival hemorrhage

Roth spots


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Diagnosis


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Diagnostic (Duke) Criteria Definitive infective endocarditis

pathologic criteria

microorganisms or pathologic lesions: demonstrated

by culture or histology in a vegetation, or in a

vegetation that has embolized, or in an intracardiac

abscess

clinical criteria two major criteria, or one major and three minor

criteria, or five minor criteria


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Diagnostic (Duke) Criteria Possible infective endocarditis

findings consistent of IE that fall short of

definite, but not rejected Rejected

firm alternate Dx for manifestation of IE

resolution of manifestations of IE, withantibiotic therapy fore 4 days

no pathologic evidence of IE at surgery orautopsy, after antibiotic therapy fore 4 days


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Dukes Major Criteria1. positive blood culture for IE

typical microorganism (strep viridans, strep bovis,

HACEK group, staph aureus or enterococci in theabsence of a primary locus) for endocarditis from two

separate blood cultures

persistently positive blood culture from:

blood cultures drawn more than 12 hr apart, or

all of 3 or a majority of 4 or more separate blood cultures,

with first and last drqwn at least 1 hr apart


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Dukes Major Criteria1. Evidence of endocardial involvement

positive echocardiogram for endocarditis

oscillating intracardiac mass on valve orsupporting structure, or in the path of regurgitant

jets, or on implanted material, in the absence of analternate anatomic explanation

abscess

new partial dehiscence of prosthetic valve

new valvular regurgitation (increase orchange in pre-existing murmur not sufficient)


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Dukes Minor Criteria1. predisposition (predisposing heart condition or

iv drug use)

2. fever of 100.40F or higher

3. vascular phenomena (major arterial emboli,

septic pulmonary infarcts, mycotic aneurysm,

intracranial hemorrhage, conjunctive

hemorrhages, Janeway lesions)


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Dukes Minor Criteria1. immunologic phenomena (glomerulonephritis,

Oslers nodes, Roth spots, rheumatoid factor)

2. microbiologic evidence (positive blood culturenot meeting major criteria or serologic evidence

of active infection with organism consistent with

IE)

3. echocardiogram (consistent with IE but not

meeting major criteria)


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Complications


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Embolic events


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Mycotic cerebral aneurysm


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Perivalvular abcess


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Perivalvular abcess


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Early treatment reduces embolic

events


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Medical treatment


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Treatment


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Treatment


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T

reatment


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Treatment of Right-sided

infective endocarditis Methicillin-susceptible S aureus (MSSA) in

IV drug users

2-wk therapy with a penicillinase-resistantpenicillin and an aminoglycoside

2-wk monotherapy with IV cloxacillin

short-term therapy is inappropriate if

complicated by ostomyelitis, meningitis,myocardial abscess, or concomitant left-sidedinvolvement


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Treatment of Right-sided

infective endocarditis Highly penicillin-susceptible Streptococcus

viridans or bovis

Once-daily ceftriaxone for 4 wks cure rate > 98%

easily administered as outpatient, avoidhospitalization, offers significant cost savings

Once-daily ceftriaxone 2 g for 2wks followedby oral amoxicillin qid for 2 wks

Once-daily ceftriazone and netilmicin for 2 wks


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Surgical intervention


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Indications for Surgery Hemodynamic compromise/ Heart failure

Persistent sepsis

Peripheral embolization

Extravalvular extension of infxn


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NVE


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PVE


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Predictors of operative mortality


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Bacterial Endocarditis prophylaxis


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Rational To prevent circulating bacteria from

invading vulnerable cardiac structures.


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Rheumatic fever prophylaxis

To prevent the initial attack and any subsequent

episode of acute rheumatic fever.


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B

enefits To prevent the potential and serious

complications of endocarditis.

Valve destruction and dysfunction

Abscess and fistula formation

Thrombo-embolic events

Surgical risks

Antibiotic risks

Death


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Clinical indications Heart-related conditions Cyanotic heart disease

Prosthetic valves

Others

Procedure-related bacteremia

Dental procedures

Upper airway procedures

Others


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Facts Bacteremia resulting from daily activities is muchmore likely to cause IE than bacteremia associated

with a dental procedure.

Most cases of IE of oral origin are not caused bydental procedures, but rather due to poor oral health

and hygiene.

Prophylaxis for dental procedures is reasonable only

for patients with underlying cardiac conditions

carrying the highest risk of adverse outcome from IE.


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Frequency of Viridans Streptococcal BacteremiasHall:CID 29:1,1999

Procedure Viridans Strep %

Dental extraction 40-89

Dental scaling 8-80

Intraligamentary injection 97

Rubber dam placement 9-32

Matrix placement 32

Endodontic treatment 42

Periodontal surgery 36-88

Brushing teeth/irrigation 7-50

Mastication 0-51


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Conclusion Routine prophylaxis is likely to prevent only a very

small fraction of IE.

The risk of antibiotic associated adverse eventsexceeds the benefit, if any, from prophylactic

antibiotic therapy

Maintenance of optimal oral health and hygiene may

reduce the incidence of bacteremia from dailyactivities and is more important than prophylactic

antibiotics for a dental procedure to reduce the risk of

IE.


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Highest Risk population

Prosthetic cardiac valve or prosthetic material used forcardiac valve repair.

Congenital heart disease (CHD):

Unrepaired cyanotic CHD, including palliative shunts and conduits During the first 6 months following complete repair of a congenitalheart defect, using prosthetic material or device.

Repaired CHD with residual defects at the site or adjacent to the siteof a prosthetic patch or prosthetic device.

Cardiac transplantation recipients who develop cardiacvalvulopathy

Previous infective endocarditis.


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What dental procedures?

Prophylaxis is recommended for:

Dental procedures that involve: manipulation of gingival tissue

manipulation of periapical region of teeth

perforation of the oral mucosa.

Not recommended for: routine anesthetic injections through noninfected tissue,

taking dental radiographs,

placement of removable prosthodontic or orthodontic appliances,

adjustment of orthodontic appliances,

Placement of orthodontic brackets,

shedding of deciduous teeth,

bleeding from trauma to the lips or oral mucosa.


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Recommended pre-dental

prophylaxis regimens

Situation AgentRegimen-Single dose 30-60

minutes before procedure

Oral Amoxicillin Adults Children

2 gm 50 mg/kg

Unable to take oral

medication

Ampicillin or cephazolin or

cephtriaxone

2 gm IM or IV

1 gm IM or IV

50 mg/kg IM or IV

Allergic to

penicillin or

ampicillinOral

Cephalexin* or

Clindamycin or

Azithromycin orClarithromycin

2 gm

600 mg

500 mg500 mg

50 mg/kg

20 mg/kg

15 mg/kg15 mg/kg

Allergic to penicillins

or ampicillin and

unable to take oralmedication

Cephazolin or cephtriaxone

Clindamycin phosphate

1 gm IM or IV

600 mg IM or IV

50 mg/kg IM or IV

20 mg/kg IM or IV


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Risk for Endocarditis

High risk

prosthetic cardiac valve

prior episodes of endocarditis

complex congenital cardiac defect

surgically constructed systemic-pulmonary

shunts or conduits


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No indication for prophylaxis

Moderate risk

patent ductus arteriosus

VSD, primum ASD coarctation of the aorta

bicuspid aortic valve

hypertrophic cardiomyopathy

acquired valvular dysfunction

MVP with mitral regurgitation


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No indication for prophylaxis

Low risk

isolated secundum atrial septal defect

ASD, VSD, or PDA >6 months past repair

innocent heart murmur by auscultation in the

pediatric population

innocent heart murmur by echocardiographyin adult patients

infective is presentation

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