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A patient

A patient. 15 yo presents to ED with two days of fever Diffuse myalgis, arthralgias, headache Rx doxy- did not fill No better, return to ED- given levofloxacin Rx, home Once more to ED. Some history?. Born in Korea Surgery for Tetralogy of Fallot in Korea as infant Second surgery in US

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A patient

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  1. A patient 15 yo presents to ED with two days of fever Diffuse myalgis, arthralgias, headache Rx doxy- did not fill No better, return to ED- given levofloxacin Rx, home Once more to ED

  2. Some history? Born in Korea Surgery for Tetralogy of Fallot in Korea as infant Second surgery in US Lost to cardiology follow-up

  3. PE Febrile, rigors Grade 3/6 harsh systolic murmur Redness and swelling and decreased ROM right 2nd MCP joint Multiple skin lesions, some petechial, some papular/pustular

  4. Lab Hgb 13.3, WBC 5300, platelets 26K Multiple blood cultures positive for MSSA Vegetation on tricuspid valve

  5. CT chest TNTC nodular infiltrates

  6. Infective Endocarditis Dave Rupar, MD Pediatric Infectious Diseases 6 Nov 2012

  7. Topics for today • What is infective endocarditis? • How do I diagnose IE? • When should I consider IE? • Population • Presentation • What is the treatment for IE? • Organisms • Treatment recommendations? • How can we prevent IE?

  8. Infective Endocarditis • Rare but serious infection of cardiac endothelium • Usually but not necessarily valvular • Disruption of endothelium • Turbulent flow • Foreign body • Surgery • Fibrin and platelet deposition = vegetation • Bacteremia, settles into welcoming environment • Very high bacterial count • Intravascular source of infection

  9. IE and not SBE • Acute vs subacute • Not always bacterial

  10. Diagnosis: Modified Duke Criteria

  11. Typical organisms from 2 cultures Staphylococcus aureus Viridans streptococci S. bovis HACEK (AACEK?) Enterococci Major Criteria: Blood cultures

  12. Typical organisms from 2 cultures or Organisms consistent with IE At least 2 +BC >12 hours apart All of 3 or ¾ separate cultures at least one hour apart Major Criteria: Blood cultures

  13. Typical organisms from 2 cultures or Organisms consistent with IE At least 2 +BC >12 hours apart All of 3 or ¾ separate cultures at least one hour apart Major Criteria: Blood cultures Note the importance of persistently positive blood cultures!

  14. Major criteria: endocardial involvement • Mass on valves or supporting structures • Abscess • Dehiscence of prosthetic valve • New regurgitant murmur Very large TV vegetation

  15. Limitations of Echocardiography • Less useful for non-valvular IE • Less useful for post-operative IE • Consider pre-test probability before ordering • TTE acceptable for younger, smaller children (<60 kg) • TEE may help in older, larger patients

  16. Minor criteria • Predisposing heart condition or IV drug abuse • Fever • Vascular phenomenon: Septic pulmonary infarcts, mycotic aneurysms, ICH, conjunctival hemorrhage, Janeway lesions • Immunologic phenomenon: glomerulonephritis, Osler’s nodes, Roth spots, RF • Positive blood culture not meeting major criteria or serologic evidence of organism consistent with IE

  17. Diagnosis

  18. Janeway’s lesion (painless, hemorrhagic, palmar) Osler’s node (painful papule on pad) Splinter hemorrhage Maestre A et al. CID 2001; 32:63

  19. Who gets IE? • >80% have underlying heart disease • Pediatrics = Congenital Heart Disease, unrepaired, recently repaired, palliated • Acute rheumatic fever- has declined to almost nothing • Post-operative- early or late • Indwelling catheters (neonates) • Random • IVDU

  20. Fever* Malaise Anorexia Dyspnea Abdominal pain Chest pain Arthralgia IE: Symptoms…

  21. Fever* Malaise Anorexia Dyspnea Abdominal pain Chest pain Arthralgia Fever* Splenomegaly Petechiae New or changing murmur Embolic phenomenon Osler’s, Roth’s, Janeway’s, conjunctival hemorrhages, splinters IE: …and Signs

  22. How to use this in a patient? • Signs and symptoms are very non-specific • Fever is only truly consistent finding • So consider IE in: • Children with heart disease with fever • Children with persistent bacteremia • Children with bacteremia with suspicious organisms (esp S. aureus) • Children with fever and a new murmur • “Consider IE” means….?

  23. “Consider IE” means….? • Obtain multiple blood cultures of adequate volume • Wait to start empiric therapy • 3 blood cultures 12 hours apart (0, 12, 24) • If you cannot safely wait to start therapy, obtain 3 or 4 blood cultures over 1-2 hours

  24. Differential Diagnosis • Fever from any source in high-risk patient • Undifferentiated bacteremia (in high-risk patient, typical organisms in any patient) • Contaminant • Line-associated infection, septic thrombophlebitis, etc. (intravascular sources)

  25. Organisms

  26. Causes of IE in children * Aggregatibacter, Cardiobacterium, Eikenella, Kingella

  27. Causes of endocarditis, other • CoNS HC-associated, prosthetic material • S. pneumoniae Associated pneumonia, meningitis • Β-streptococci • Gram-neg enterics • Fungus Esp Candida; HC-associated • Culture negative 5-10%; pretreatment

  28. CMC/LCH experience 43 patient convenience sample • 18 S. aureus (6 NICN) • 6 CoNS (1 NICN) • 6 Enterococcus sp. (1 NICN) • 3 S. pneumoniae • 2 viridans streptococci • 2 Candida (1 NICN) • 4 others (Ch, Nm, GBS, Enterobacter) • 2 culture-negative

  29. Treatment principles • Prolonged course • Bactericidal therapy (may require combo) • Repeat blood cultures q 24-48 hrs • Time starts with negative blood cultures • Watch for complications

  30. Drug therapy of IE Circulation 2005;111:e394-e422

  31. Drug therapy of IE Circulation 2005;111:e394-e422

  32. Drug therapy of IE Circulation 2005;111:e394-e422

  33. Drug therapy of IE For further info, consult the guidelines: Circulation 2005;111:e394-e422 Ask for help

  34. Complication • Emboli • Right-sided: lungs • Left-sided: brain (~5% pediatric patients), kidneys, other* • Perivalvular extension of infection* • Persistent fever, + bc* • Heart failure* • 5-10% mortality *Consider surgical intervention

  35. Prevention Rationale for prevention: • An ounce of prevention… • Certain cardiac conditions predispose to IE • Bacteremia with oral flora occurs commonly with dental and other procedures • Prophylaxis works in experimental animals • Prophylaxis might work in people, but does it?

  36. Prevention: 2007 guidelines Rationale for revision • Most IE results from random bacteremia associated with daily activity • Prophylaxis appears to prevent a very small number of cases, if any • The risk of antibiotics exceeds the benefit, if any • Maintenance of optimal oral health is more likely to be effective than antibiotics Circulation 2007:116:1736-1754

  37. IE Prophylaxis: who gets it? • Prosthetic valves • Previous IE • Congenital heart disease • Unrepaired Cyanotic CHD • Completely repaired CCHDwith prosthetic material < 6 months • Repaired CHD with residual defect • Cardiac transplant with valvulopathy

  38. Dental procedures with manipulation of the gingival tissue or periapical region of teeth or perforation of the oral mucosa NOT: Anesthetic injections dental radiographs placement or adjustment of orthodontic devices Shedding of deciduous teeth Bronchoscopy, GI and GU procedures IE Prophylaxis: who gets it?

  39. IE prophylaxis: What drugs? • Directed against viridans streptococci • Single dose • Amoxicillin/Ampicillin • Cephalosporin • Clindamycin • Clarithromycin • Go to the guidelines: Circulation 2007:116:1736-1754

  40. Summary • Rare but serious infection • Non-specific clinical presentation in an identifiable group of patients • Intravascular focus leads to persistent bacteremia • Staph, strep and a bunch of other things • Use guidelines and criteria

  41. ?

  42. Special thanks Nick Sliz, MD, for assistance with echos

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