Infective endocarditis

Dr. Mohamed Rafa

Msc Pediatrics

Subacute bacterial endocarditis (SBE) affects 0.5:1000 to 1:1000 hospital patients, excluding those with
postoperative endocarditis.

Pathology and Pathogenesis

Structural abnormalities of the heart or great arteries with a significant pressure gradient or
turbulence, with resulting endothelial damage and platelet-fibrin thrombus formation. Bacteremia,
even if transient, with adherence of the organisms and eventual invasion of the underlying tissue.
Almost all patients who develop IE have a history of congenital or acquired heart disease. Drug addicts
may develop endocarditis in the absence of known cardiac anomalies.
Bacteremia resulting from dental procedures can cause IE. Bacteremia also occurs with activities
such as chewing or brushing the teeth. Chewing with diseased teeth or gums may be the most frequent
cause of bacteremia. Therefore, good dental hygiene is very important in the prevention of IE.

Microbiology
1. In the past, Streptococcus viridans, enterococci, and Staphylococcus aureus were responsible for
over 90% of cases of IE. In recent years, this frequency has decreased to 50% to 60%, with a
concomitant increase in cases caused by fungus and HACEK organisms (Haemophilus, Actinobacillus,
Cardiobacterium, Eikenella, and Kingella).
2. Alpha-hemolytic streptococci (S. viridans) are the most common cause of IE following dental
procedures or in those patients with carious teeth or periodontal disease.
3. Enterococci are the organisms most often found after genitourinary or gastrointestinal surgery or
instrumentation.

CLINICAL PICTURE
1. Most patients are known to have an underlying heart disease. The onset is usually insidious with
prolonged low-grade fever and various somatic complaints.
2. Heart murmur is almost always present and splenomegaly is common (70%).
3. Skin manifestations (50%) may be present in the following forms:
a. Petechiae on the skin, mucous membranes, or conjunctivae are frequent.
b. Osler nodes (tender, pea-sized red nodes at the ends of the fingers or toes) are rare in children.
c. Janeway lesions (small, painless, hemorrhagic areas on the palms or soles) are rare.
d. Splinter hemorrhages (linear hemorrhagic streaks beneath the nails) also are rare.

4. Embolic or immunologic phenomena in other organs are present in 50% of cases.

a. Pulmonary emboli or hematuria and renal failure may occur.
b. Seizures and hemiparesis (20%) may occur.
c. Roth spots (oval, retinal hemorrhages with pale centers located near the optic disc) occur in <5% of
patients.

LABORATORY STUDIES
a. Positive blood cultures are obtained in more than 90% of patients in the absence of previous
antimicrobial therapy.
b. Anemia and leukocytosis with a shift to the left are common.
c. The sedimentation rate is increased unless there is polycythemia.
d. Microscopic hematuria is found in 30% of patients.

DIAGNOSIS

Definition of Terms Used in the Modified Duke Criteria for the Diagnosis of Infective
Endocarditis
Major Criteria
A. Blood culture positive for IE
1. Typical microorganisms consistent with IE from two separate blood cultures: Viridans streptococci,
Streptococcus bovis, HACEK group, Staphylococcus aureus; or community-acquired enterococci in the
absence of a primary focus or
2. Microorganisms consistent with IE from persistently positive blood cultures defined as follows: at
least two positive cultures of blood samples drawn >12 h apart or all of three or a majority of four or
more separate cultures of blood (with first and last sample drawn at least 1 h apart)
3. Single positive blood culture for Coxiella burnetii or anti–phase 1 IgG antibody titer >1:800
B. Evidence of endocardial involvement
Echocardiogram positive for IE (TEE is recommended for patients with prosthetic valves, rated at
least“possible IE” by clinical criteria, or complicated IE [paravalvular abscess]; TTE as first test in other
patients) defined as follows:
1. Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on
implanted material in the absence of an alternative anatomic explanation or
2. Abscess or
3. New partial dehiscence of prosthetic valve or
4. New valvular regurgitation (worsening or changing or preexisting murmur not sufficient)
Minor Criteria
1. Predisposition, predisposing heart condition, or IDU
2. Fever, temperature >38°C
3. Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm,
intracranial hemorrhage, conjunctival hemorrhages, and Janeway’s lesions
4. Immunologic phenomena: glomerulonephritis, Osler’s nodes, Roth’s spots, and rheumatoid factor
5. Microbiologic evidence: positive blood culture but does not meet a major criterion as noted above∗
or serologic evidence of active infection with organism consistent with IE

MANAGEMENT

Initial empirical therapy is started with the following antibiotics while awaiting the results of blood
cultures. Consultation from a local infectious disease specialist is strongly recommended.
a. The usual initial regimen is an antistaphylococcal semisynthetic penicillin (nafcillin, oxacillin, or
methicillin) and an aminoglycoside (gentamicin). This combination covers against S. viridans, S. aureus,
and gram-negative organisms.
b. If a methicillin-resistant S. aureus is suspected, vancomycin should be substituted for the
semisynthetic penicillin.
c. Vancomycin can be used in place of penicillin or a semisynthetic penicillin in penicillin-allergic
patients

Prevention