INFECTIVE ENDOCARDITIS

AHMED AFIFI
MBBCh, MSc, PhD, MD, IBCLC, MRCPCH
Lecturer of Pediatric and Neonatology
Helwan University
• A 10-year-old girl presented to the hospital with fever. The patient was initially

admitted to the hospital 2 days prior with 3 days of fevers (up to 40°C), emesis and

fatigue that were thought to be related to a viral illness. She was discharged home

24 hours later after her condition slowly improved. A blood culture, which was

obtained during that hospitalization, resulted positive at 48-hours for gram-positive

cocci, so family was called, and the patient was re-admitted. The patient is a known

case of rheumatic heart disease. She was born full-term with no complications and

her growth and development were age-appropriate.

• On admission she had a temperature of 38.5°C, a pulse of 96
beats/minute, a blood pressure of 98/65 mmHg, a respiratory rate of
20 breaths/ minute, and an oxygen saturation 98% in room air. Her
physical examination was significant for an alert and oriented child
who was mildly dehydrated. She had a regular heart rate and rhythm,
with a new murmur that was not heard before on her. Her lungs were
clear to auscultation bilaterally, and her abdomen was soft, non-
distended, with mild tender splenomegaly.
• What is your provisional diagnosis?
• What are the investigations needed to confirm diagnosis?
Definition

• Infective endocarditis (IE) is an infection on the endothelial

surface of the heart, including the heart valves.

• The management of infections on the endothelial surfaces of

blood vessels (endovascular infections) is very similar.

N.B: Non-Infective endocardites: RF, SLE

Epidemiology

Rheumatic heart disease used to be a major risk factor for IE but has become much less
common.

Patients at highest risk for IE include:

▪ prosthetic cardiac valves
▪ cyanotic congenital heart disease either with or without repair.

The risk in these patients is increased after dental and oral procedures, instrumentation, or
surgical procedures of the respiratory, genitourinary, or gastrointestinal tracts. Use of
central vascular catheters is a significant risk factor for native valve endocarditis.
❑Many microorganisms have been reported to cause endocarditis, although
there are only a few common causes in children. Streptococcus viridans is
the principal cause in children with congenital heart diseases without
previous surgery.

❑Staphylococcus aureus and coagulase-negative staphylococci (CONS) are

important causes of endocarditis, especially following cardiac surgery and in
the presence of prosthetic cardiac and endovascular materials.
❑Candida species can cause fungal endocarditis, especially in
premature infants with central venous catheters and/or on
parenteral nutrition.
Causative organism:

BACTERIA FUNGI CULTURE NEGATIVE

❑ Streptococcus Viridans ❑ Candida species ❑ Fastidious organisms
❑ Staphylococcus aureus (premature infants with ❑ Bartonella species
❑ Others: CVCs and/or on ❑ Tropheryma whipplei
✓ Enterococcus parenteral nutrition, ❑ Coxiella burnetii (Q fever)
✓ Coagulase-negative staphylococci after cardiac surgery, in
✓ Streptococci: groups A, B, Streptococcus pneumoniae immunocompromised
✓ Gram-negative enteric bacilli patients, patients on
✓ HACEK organisms (i.e., Haemophilus aphrophilus, prolonged antibiotic
Aggregatibacter species, Cardiobacterium hominis, therapy)
Eikenella corrodens, and Kingella kingae)
✓ Chlamydophila
✓ Coxiella burnetii (Q fever)
• Fibrin and platelets gather at the site, forming a thrombus. In
the setting of transient bacteremia, this lesion can become
infected and can result in a septic vegetation, which usually
occurs on a valve leaflet and is composed of microorganisms
trapped in a fibrin mesh that extends into the bloodstream.
Predisposing factors:
• Cardiac lesions:
High-risk category Moderate-risk category Negligible-risk category

❑ Complex cyanotic HD e.g.,
TOF,TGA
❑ Repaired CHD with residual
defects
❑ Prosthetic valves
❑ Previous IE
❑ Most other CHD e.g., VSD,
PDA, ASD premium, CoA
❑ RHD
❑ MVP with MR
❑ Secondum ASD
❑ Repaired VSD & PDA
❑ Pacemakers & ICD
❑ MVP without MR
❑ Coronary artery bypass

• Others: ID, CVC, IV drug abusers

Route:
• Adenotonsillectomy
• Polluted (Non-sterile) instrumentation for GIT or GU surgery
• Cardiac surgery, CVC
• Dental procedures
Presentation:

• General manifestation:
❑Fever, anorexia, weight loss
❑Fatigue, myalgia, arthralgia
❑Eye: conjunctival petechiae, retinal (roth spots), sudden blindness
(embolization)
❑Hands:
• Pale clubbing (toxic clubbing)
• Osler`s nodules in pulps of fingers
• Splinter Hge under nails
• Janeway lesions (blue-red macules over palms & soles)
Osler`s nodes
Janeway lesions
Splinter Hemorrhages
Roth spots
❑Cardiac manifestations:
• Features of the underlying cardiac disease
• Change of the character of an already present murmur
• Appearance of new murmur (sea-gull murmur due to rupture of cusps)
• Heart failure (due to valve damage, myocarditis, fever)
❑Extracardiac manifestations:
• Spleen: splenomegaly in 70%
• Renal: post-infectious Glomerulonephritis (hematuria)
• CNS: embolic hemiplegia, ICH (due to rupture mycotic aneurysm)
• Joints: arthritis
• The key to diagnosis is confirming continuous bacteremia or
fungemia by culturing the blood. Multiple blood cultures should
be obtained before initiating antibiotic therapy.

• In patients who are not critically ill, empiric antibiotic therapy

should be held until at least three sets of blood cultures (from
different venipuncture sites) are obtained.
Investigations

1. Repeated blood culture:

✓ 3-5 times after proper skin decontamination for detection of the organism
2. ECHO:
✓ Diagnosis of the 1ry lesion
✓ Detection of vegetations (absence of vegetations does not exclude IE)
✓ Cardiac evaluation (FS)
3. Others:
✓ CBC,ESR,CRP
✓ Renal (urinalysis, KFT,C3, and C4)
Modified Duke Clinical Criteria for Diagnosis
of IE

Major Criteria
• Positive blood cultures
• Two or more separate cultures positive with typical
organisms for infective endocarditis
• Two or more positive cultures of blood drawn more
than 12 hr apart or 4 positive blood cultures
irrespective of timing of obtaining specimen
• A positive blood culture for Coxiella burnetii or
positive IgG titer >1 : 800
• Evidence of endocardial involvement
• Positive findings on echocardiogram (vegetation on
valve or supporting structure, abscess, new valvular
regurgitation)
Minor Criteria
• Predisposition—predisposing heart condition or injection
drug use
• Fever—temperature >38°C (>100.4°F)
• Vascular phenomena (major arterial emboli, septic
pulmonary infarcts, mycotic aneurysm, intracranial
hemorrhage, conjunctival hemorrhages, Janeway
lesions)
• Immunological phenomena (glomerulonephritis, Osler
nodes, Roth spots, rheumatoid factor)
• Microbiologic evidence (positive blood culture result,
but not meeting major criteria, or serological evidence
of active infection with organism consistent with
infective endocarditis)
• REJECTED
1. Firm alternative diagnosis for manifestations of endocarditis or

2. Resolution of manifestations of endocarditis with antibiotic therapy

for <4 days or

3. No pathological evidence of endocarditis at surgery or autopsy

after antibiotic therapy of >4 days or does not meet criteria for
possible endocarditis
 Major criteria Minor criteria
1. ≥ positive blood culture 1. Predisposing factors
2. Evidence of endocarditis on ECHO: 2. Single positive blood culture
▪ Vegetations 3. Fever
▪ New valvular regurg 4. Embolic manifestations
5. Immune-complex disease (GN, arthritis)

❑Interpretation of Duke criteria

▪ Definitive IE: 2 major OR 1 major + 3 minor OR 5 minor
▪ Possible: 1 major + 1 minor OR 3 minor
 Mortality

Direct damage to cardiac tissue and function

Damage to cardiac valves may cause regurgitation, defects in valve

leaflets, abscess of the valve ring, or myocardial abscess

HF

Complications:
Heart block

Septic emboli can result in pneumonia, osteomyelitis, and abscesses in the

brain, kidneys, and spleen.

Immune-complex disease e.g., GN

Inflammation: meningitis, arthritis

Rupture aortic sinus

Rupture mycotic aneurysm

 Prevention is more important than
treatment.

Indications:
❑Cardiac lesions requiring prophylaxis
Prevention: (according to level of risk)
❑Procedures requiring prophylaxis:
1.Dental procedures e.g., tooth extraction
2.Respiratory procedures e.g.,
adenotonsillectomy
3.Esophageal procedures e.g., sclerotherapy
for esophageal varices, esophageal stricture
dilatation
4.No longer recommended prophylaxis for GIT
& GU procedures
Measures:

Maintenance of good oral hygiene (more important than

antibiotic prophylaxis)

Antibiotic prophylaxis:
• Oral amoxicillin or IV/IM ampicillin ± gentamycin
• Oral erythromycin or IV clindamycin in patients allergic to penicillin
Treatment
I. Medical:
Organism Drugs
Initial empiric treatment 3rd generation cephalosporin + Vancomycin 4-8 weeks

Strept. Penicillin G OR vancomycin for 4-6 weeks + gentamicin for 2

weeks
After results of

Staph. Oxacillin OR vancomycin for 4-6 weeks ± gentamicin

Enterococci Ampicillin OR vancomycin for 4-6 weeks + gentamicin

HACEK Ceftriaxone for 4 weeks

C&S

Fungal Amphotericin B for 6 weeks

 II. Surgical:
❑Removal of vegetations & valve replacement is indicated in:
✓ Intractable HF
✓ Myocardial abscess
✓ Prosthetic valve
✓ Failure of medical treatment (↑ size of vegetations)
✓ Fungal IE
❑Surgical repair: rupture aortic sinus or rupture mycotic aneurysm