1y old boy

Sudden fever
Tachycardia
S3 gallop
Soft s1 s2
Diagnosis?

10 yr old
Mild fever
Tachycardia
Muffled heart sounds
Cardiomegaly
Pulsus paradoxus
Diagnosis?
12yr old
Fever 2 wks
CCF
Systolic murmur
Splenomegaly
Known c/o RHD
Diagnosis?
Few disease present greater difficulties in the way of
diagnosis than malignant endocarditis, difficulties in
many cases are practically insurmountable. It is so
disparagement to the most skilled physicians who
have put on cases upon record to say that, in fully one
half the diagnosis was made post mortem.

WILLIAM OSLER 1885

1885 well defined by William Osler
1944 pencillin discovered
1960 surgery in IE
1973 ECHO for identifying vegetation
1981 Von Reyn criteria
1994 Dukes criteria


Infective endocarditis
Infection & inflammation of endocardial lining
Bacterial Endocarditis : Acute /Subacute
Nonbacterial endocarditis : virus,fungi.

Significant morbidity & mortality.
1-3cases / 1000 admissions.

Difficult to eradicate: why?
Less awareness of risks & preventive measures
Delay in diagnosis
Special risk groups

Who is at risk?
CHD, RHD, IV drug abusers
Post cardiac surgery
Valve replacement
Chronic IV catheters
Immunosuppressed
Healthy heart?
newborn?
Organisms
STREP. VIRIDANS
STAPH.AUREUS
Group D streptococcus (enterococcus)
Pseudomonos
Coxiella burnetti
CONS
HACEK
Candida
Staph.epidermidis prosthetic valve
6 -10 % culture - ve
Lesions at risk
CHD with high speed shunt or stenosis
VSD, TOF, PDA,
Aortic stenosis
Older child
Bicuspid AV, MVPS
Valve replacement


Features
Uncommon <2yrs
General : fever- chills-rigors, arthralgia,myalgia
wt loss, anorexia
CVS features: CCF,new murmur, embolism,
stroke,infarct,regurgitant lesions,
immunological: vasculitis,petechiae,osler
node,janeway lesion,splenomegaly, roth spot,
splinter hemorrhage, clubbing



Metastatic infections:
cereberal abcess, myocardial abcess,
pyopericardium,
arthritis,meningitis,pericarditis,
pulmonary emboli,
mycotic aneurysms.
heart block,
Fungal endocarditis
Candida
IV drug abuser
Intensive antibiotics
Steroids
Catheters
Prosthetic valve
Lab diagnosis
BLOOD CULTURE +ve
ECHO,
HB,ESR,CRP, TC,platelet
Immune complex, complement,
gammaglobulin, cryoglobulin,
Hematuria, RFT,
CXR
Echo
Vegetations >2mm
Ruptured chordae,
AV,MV more involved
Diagnosis
Blood culture
3-5 separate cultures
careful skin antisepsis
Culture from skin lesions
Dukes criteria
Major
> 2 separate +ve blood c/s
Echo e/o endocarditis
Minor
Fever, splenomegaly, clubbing,
Embolic/vasculitis signs, single +ve blood c/s
ESR,CRP,


Criteria
2major
1 major+3 minor
5 minor

Management
Immediate antibiotic therapy
High serum bactericidal levels
5-20 times of MIC
4-8 wks of treatment
CCF management
Surgery
AV/MV involvement, mycotic aneurysm,
rupture of aortic sinus

Treatment
strep Viridans : 4wks, penicillin 2lu/kg/d
ceftrioxone 100mg/kg/d
vancomycin 30/mg/kg/d
prosthetic valve; 6wks
Staph aureus: cloxacillin+ gentamicin [6wks]
vancomycin [clox resistant ]
prosthetic valve: add rifampacin &
GM > 6wks

Enterococcus: ampicillin + GM /streptomycin
vancomycin / linezolid
HACEK: ceftrioxone / ampicillin+GM /
ciprofloxacin
Candida : amphotericin+ 5 flurocytosine
Recombinant tissue plasminogen activation
Complications
Heart failure, Toxic myocarditis
Systemic emboli
Mycotic Aneurysms
Rupture Of A Sinus Of Valsalva,
Obstruction Of Aortic Valve Secondary To Large
Vegetations
Acquired VSD, Heart Block
Meningitis, Osteomyelitis, Arthritis, Renal
abscess, immune complexmediated
glomerulonephritis.

Prophylaxis
Dental & oral & URT procedures;
oral amox 50mg/kg 1hr before
IM/IV ampicillin 50mg/kg 30mt before
oral cephelexin / azithromycin
IV cephazolin

GIT / GUT surgery
Moderate risk:
Oral amox / IV ampicillin
High risk:
IV ampicillin+ GM 30mt before & oral amox 6h
later
Vancomycin + GM 30 mt before
Prognosis
S viridans 90%
S fecalis 85 - 90%
Staphylococcus aureus 60 - 75%
Death due to resistant CHF, aneurysmal
rupture, embolization, surgical complications

Prevention
Prevention of IE is more important than
treatment
Good oral hygiene is important than antibiotic
prophylaxis