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Infective Endocarditis
Epidemiology:
Greatest morbidity occurs among those with recent cardiac prostheses, status-post
heart transplant, or prior endocarditis
Pathogenesis
Step 2: Pathogen seeds blood; generally occurs via trauma to a mucosal surface from
such daily activities as teeth brushing or chewing, or invasive activities like dental,
GI, or GU procedures
Sequelae
Valvular damage: Pathogen destroys valves - cause regurgitation and possibly even
heart failure
Emboli: Septic emboli travel to lung, brain, kidney, or extremities and cause local
infection and ischemia/infarction
Immune-mediated: Circulating
glomerulonephritis or vasculitis
immune
complexes
can
possibly
mediate
Clinical Presentation:
Overview:
o Non-specific signs fever, myalgia, arthralgia, headache, malaise, anorexia,
weight loss are common
o Classic signs Roth spots (retinal hemorrhages with a pale center), Janeway
lesions (nontender macules on fingers and soles), Osler nodes (painful
lesions on hands and feet), and splinter hemorrhage are rare in children
Duke Criteria
Major Criteria
Positive blood culture*
Positive echocardiogram (vegetation, paravalvular abscess, or valve dehiscence after
surgery). While transesophageal echo recommended in adults, transthoracic echo is fine in
children.
New valvular regurgitation (by auscultation, not echocardiogram)
Minor Criteria
Predisposing heart condition (including prior IE)
Injection drug use
Fever (temperature >100.4 F [38 C])
Major arterial emboli
Septic pulmonary infarcts
Mycotic aneurysm
Intracranial hemorrhage
Conjunctival hemorrhage
Janeway lesions (painless hemorrhagic lesions on palms and soles)
Glomerulonephritis
Osler nodes (painful lesions at fingertips)
Roth spots (retinal hemorrhages)
Positive rheumatoid factor
Note: Splinter hemorrhagees and erythrocyte sedimention rate are not criteria. Also, there are
no minor echo criteria, ie, valvular regurgitation alone is not a criterion.
*A positive blood culture is a major criterion when 1) there is growth on two occasions of a
microorganism typical for IE (eg, viridans group Streptococcus, Staphylococcus aureus, or
enterococcus), OR 2) there are persistently postiive blood cultures (two positive cultures
from samples 12 h apart or three positive cultures drawn 1 h apart) of a microorganism
consistent with IE, such as S epidermidis, OR 3) Coxiella burnetii (Q fever) grows from a
single blood culture, or there is serologic evidence of C burnetii (IgG titer _1:800).
From Li JS, Sexton DJ, Mick N, et al. Proposed modifications to the Duke Criteria for the
diagnosis of infective endocarditis. Clin Infect Dis.
2000;30:633638. Used with permission from the University of Chicago Press.
Treatment
If blood cultures have not come back and need to begin treatment, generally begin
empiric coverage against staph and strep with penicillin or ampicillin plus gent for 4-6
weeks; IV treatment most effective
Surgery indicated in those with persistent blood cultures after two weeks of
appropriate treatment, fungal vegetations, abscess formation, worsening heart failure,
or systemic emboli
Prophylaxis
In 2007, the American Heart Association (AHA) revised its criteria for bacterial prophylaxis
against endocarditis. Current guidelines state that only those individuals with the following
conditions require one dose antibiotic prophylaxis prior to undergoing dental procedures:
1. Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
2. Previous infectious endocarditis
3. Of those with congenital heart disease (CHD), those with
1. Unrepaired cyanotic CHD, including palliative shunts and conduits
2. Completely repaired congenital heart defect with prosthetic material or device
for the first 6 months after the procedure
3. Repaired CHD with residual defects at the site or adjacent to the site of a
prosthetic patch or prosthetic device
4. Cardiac transplantation recipients who develop cardiac valvulopathy
The rationale for the revised criteria is that the majority of endocarditis in non-IV drug users
is caused by transient bacteremia resulting from daily activities, such as chewing food,
flossing, and brushing teeth, rather than semi-annual, invasive dental procedures. However,
by the reasoning of the AHA, in the aforementioned groups, the risk of serious adverse
outcome from endocarditis is so great as to warrant prophylaxis.