Endocarditis


Article Author:
Olga Brea Pena


Article Editor:
Magda Mendez


Editors In Chief:
Venkat Minnaganti
John Brusch
Janak Koirala


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
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John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
5/5/2019 10:01:37 PM

Introduction

Infective endocarditis is a substantial cause of morbidity and mortality in children and adolescents despite new advantages in management and prophylaxis. Infective endocarditis can include acute and subacute bacterial endocarditis, as well as nonbacterial endocarditis caused by viruses, fungi, and other microbiologic agents. Since the infecting organism has changed over time, diagnosis sometimes can be difficult during early stages of the disease and is often delayed until a serious infection is already in place.[1][2][3]

Etiology

The leading cause of endocarditis in pediatric population remains Staphylococcus aureus, followed by Viridans-type streptococci (alpha-hemolytic streptococci). Other organisms are involved but less frequently. Usually, staphylococcal endocarditis is more common in patient with an unremarkable history of heart disease. A recent dental procedure should prompt suspicions of viridans group streptococcal infection. Pseudomonas aeruginosa or Serratia marcescens are seen commonly in intravenous drug users. Fungal organisms can be an issue during open heart surgery. In the presence of an indwelling central venous catheter, a coagulase-negative staphylococcus is frequently found as the causative agent.[4][5][6][7]

Epidemiology

It is common to find infective endocarditis as a complication of congenital heart disease or rheumatic heart disease. However, is important to mention that infective endocarditis can present in children without any abnormal valves or cardiac malformations.

In developed countries, congenital heart disease is the most important predisposing factor. In approximately 30% of patients with infective endocarditis, a predisposing factor is acknowledged and identified.

If a history of dental procedure is recognized, the time range from the procedure may range from 1 to 6 months prior to the onset of symptoms. The existence of endocarditis after routine heart surgery is low; however, in the setting of prosthetic material use, this can be a predisposing factor.

History and Physical

An early manifestation of the disease is mild. Prolonged duration of fever that persists for several months without other manifestations may be the only symptom. On the other hand, the onset can be acute and severe with high, intermittent fever. Associated symptoms are often nonspecific and include fatigue, myalgia, arthralgia, headache, chills, nausea, and vomiting.

The presence of a new heart murmur or sounds of changing heart murmur is associated with heart failure. Splenomegaly and petechial are frequently seen. Neurologic manifestations of meningismus, increased intracranial pressure, altered sensorium, focal neurologic signs, embolic strokes, cerebral abscesses, mycotic aneurysm, and hemorrhage are associated with the staphylococcal disease. Besides neurologic manifestation, staphylococcal disease can present complications like myocardial abscesses and may injure the cardiac conducting system producing heart block, or an abscess may rupture into the pericardium and cause purulent pericarditis.

The classic skin manifestation of Osler nodes, Janeway lesions, and splinter hemorrhages usually develop late in the course of the disease. The appearance of this lesions signifies the vasculitis caused by circulating antigen-antibody complexes.

Recognition of infective endocarditis is based on a high suspicion of infection in a child with an underlying risk factor.

Evaluation

Blood specimens should be attained as early as possible, even if the child has mild illness with no significant physical findings. Three to 5 separate blood cultures should be collected after cautious preparation of the phlebotomy site. Contamination represents an issue when results come back positive for skin bacteria. Since bacteremia remains constant, the timing for collection is irrelevant. In approximately 90% of cases of endocarditis, the causative agent is identified from the first 2 blood cultures.[8][9][10]

Is well known that antimicrobial pretreatment can reduce the yield of blood culture to 50% to 60%. Hence, the microbiology laboratory needs to be informed that the patient recently used an antimicrobial pretreatment, so other methods can be used to identify the etiologic cause.[11][12][13]

When a patient has a contributing factor, the index of suspicion should be high. Echocardiography can be use to increase the probability of diagnosing endocarditis. Echocardiography can be useful in predicting embolic complications if lesions are found to be greater than 1 cm or fungal lesions are noted. Important to mention, the absence of vegetation des does not exclude endocarditis.

The Duke criteria aid in the diagnosis of endocarditis. The major criteria consist of positive blood cultures and evidence of endocarditis on echocardiography. The minor criteria include predisposition factors, fever, embolic-vascular signs, complex immune phenomena (glomerulonephritis, arthritis, rheumatoid factor, Osler nodes, Roth spots), single positive blood culture or serologic confirmation of infection, and echocardiographic signs not meeting the major criteria. Diagnosis of infective endocarditis is defined as 2 major criteria, 1 major and 3 minor, or 5 minor criteria.

Treatment / Management

When a definitive diagnosis is made, antibiotic therapy should begin as early as possible. The choice of antibiotics, a method of administration, and length of treatment should be synchronized with pediatric infectious disease and pediatric cardiology.[14][15]

For empirical therapy, is recommended to start with vancomycin and gentamycin which will cover the most common causes including Staphylococcus aureus, Enterococcus, and Vviridans streptococci. Is required a total of 4 to 6 weeks of treatment to cover the period of vegetation formation, which is usually several weeks. Antibiotic therapy can be adjusted depending on the clinical status of the patient and laboratory findings regarding antibiogram.

If associated complications like heart failure are present, appropriate therapy including diuretics and reducing agents can aid in the treatment. Surgical intervention for infective endocarditis is recommended in cases of the severe aortic valve, mitral valve or prosthetic valve involvement with intractable heart failure.

Fungal endocarditis is challenging to manage. Is usually seen in severely immunosuppressed patients who have had cardiac surgery. For these cases, the recommendation is amphotericin B and 5-fluorocytosine. In some cases, surgery may be attempted to remove the vegetation.

Prognosis

Infective endocarditis remains high. Morbidity occurs in more than half of children with a diagnosis of infective endocarditis. Most common complications are heart failure secondary to vegetation in the aortic or mitral valve, myocardial abscesses, toxic myocarditis, and life-threatening arrhythmias. Serious complications are systemic emboli, especially affecting the central nervous system. Other complications include a mycotic aneurysm, acquired ventricular septal defect, and heart block.

Deterrence and Patient Education

There has been a significant reduction in the incidence of infective endocarditis in patients with a history of procedure, thanks to the recommendation of prophylactic treatment. However, not all procedures need prophylaxis.

In 2007, the AHA modified their infective endocarditis prophylaxis guidelines, and the indications for prophylaxis were reduced for dental procedures, genitourinary, and gastrointestinal tract procedures.[8][16]

Indications for prophylaxis based on 2007 AHA:

  • Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
  • Previous infective endocarditis

Cardiac Heart Disease (CHD) with: 

  • Unrepaired cyanotic CHD (including shunts and conduits)
  • CHD entirely repaired with prosthetic material or device, during the first 6 months after the procedure
  • Repaired CHD with residual defects to the site of a prosthetic patch or prosthetic device
  • Cardiac transplantation recipients who develop cardiac valvulopathy

The particular individual condition of these recommendations makes reasonable direct consultation with pediatric cardiology to determine the ongoing need for prophylaxis.

Enhancing Healthcare Team Outcomes

Endocarditis is a serious life threatening disorder which is best managed by a multidisciplinary team that includes a cardiologist, neurologist, infectious disease expert, cardiac surgeon, internist and ICU nurses. The key is to make a promot diagnosis and start antibiotic treatment. Patients should get echos to determine if the treatment is working and assess the valve function. In some cases, valve replacement may be required.

Even with optimal treatment, endocarditis is associated with high morbidity and mortality. Healthcare workers should be aware of new endocarditis prophylactic guidelines.


  • Image 6363 Not availableImage 6363 Not available
    Contributed by Olga Brea Pena, MD.
Attributed To: Contributed by Olga Brea Pena, MD.

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Endocarditis - Questions

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In a male with mitral valve endocarditis and numerous small vegetations, which of the following complication is least likely?



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Which of the following statements about marantic endocarditis is correct?



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Which of the following is not true of endocarditis?



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A patient presents with complaints of general malaise, a low-grade fever, and chills. He says he has not been feeling well for at least 2 weeks. He denies any past medical history and exam reveals a few hemorrhagic lesions on the sole of his feet and some needle marks on the leg. What is the next step?



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Select the organism that most commonly causes infective endocarditis.



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Which of the following statements is not true with regards to infectious endocarditis?



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A typical Aschoff nodule does not include:



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The most common etiologic agent in infective endocarditis in the antibiotic era is:



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A 33-year old individual presents to the emergency department with complaints of a high fever, malaise and night sweats. He denies any trauma but does indicate that he uses intravenous drugs. He has no allergies. Exam reveals diminished air entry in the right chest and a chest x-ray reveals a consolidation. Which indirect diagnostic test may help discover the pathology in this patient?



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How many major and minor criteria are needed for definitive diagnosis in infective endocarditis?



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What is the classic skin manifestation of infective endocarditis?



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What is the most common etiologic agent for cause of infective endocarditis in native valve?



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What is the most common complication from infective endocarditis?



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Endocarditis - References

References

Rogolevich VV,Glushkova TV,Ponasenko AV,Ovcharenko EA, [Infective Endocarditis Causing Native and Prosthetic Heart Valve Dysfunction]. Kardiologiia. 2019 Apr 13;     [PubMed]
Jillella DV,Wisco DR, Infectious causes of stroke. Current opinion in infectious diseases. 2019 Jun;     [PubMed]
Sotero FD,Rosário M,Fonseca AC,Ferro JM, Neurological Complications of Infective Endocarditis. Current neurology and neuroscience reports. 2019 Mar 30;     [PubMed]
Elbatarny M,Bahji A,Bisleri G,Hamilton A, Management of endocarditis among persons who inject drugs: A narrative review of surgical and psychiatric approaches and controversies. General hospital psychiatry. 2019 Mar - Apr;     [PubMed]
Elagha A,Mohsen A, Cardiac MRI clinches diagnosis of Libman-Sacks endocarditis. Lancet (London, England). 2019 Apr 27;     [PubMed]
Bekker T,Govind A,Weber DM, A Case of Polymicrobial, Gram-Negative Pulmonic Valve Endocarditis. Case reports in infectious diseases. 2019;     [PubMed]
McCann M,Gorman M,McKeown B, No Fever, No Murmur, No Problem? A Concealed Case of Infective Endocarditis. The Journal of emergency medicine. 2019 Apr 24;     [PubMed]
Garg P,Ko DT,Bray Jenkyn KM,Li L,Shariff SZ, Infective Endocarditis Hospitalizations and Antibiotic Prophylaxis Rates Before and After the 2007 American Heart Association Guidelines Revision. Circulation. 2019 Apr 26;     [PubMed]
Borger P,Charles EJ,Smith ED,Mehaffey JH,Hawkins RB,Kron IL,Ailawadi G,Teman N, Determining Which Prosthetic to Use During Aortic Valve Replacement in Patients Aged Younger than 70 Years: A Systematic Review of the Literature. The heart surgery forum. 2019 Feb 28;     [PubMed]
Bamford P,Soni R,Bassin L,Kull A, Delayed diagnosis of right-sided valve endocarditis causing recurrent pulmonary abscesses: a case report. Journal of medical case reports. 2019 Apr 19;     [PubMed]
Galar A,Weil AA,Dudzinski DM,Muñoz P,Siedner MJ, Methicillin-Resistant Staphylococcus aureus Prosthetic Valve Endocarditis: Pathophysiology, Epidemiology, Clinical Presentation, Diagnosis, and Management. Clinical microbiology reviews. 2019 Mar 20;     [PubMed]
Martínez PA,Guerrero M,Santos JÉ,Hernández MS,Mercado MC, [Pediatric clinical experience in infectious endocarditis due to Candida spp]. Revista chilena de infectologia : organo oficial de la Sociedad Chilena de Infectologia. 2018;     [PubMed]
Samaroo-Campbell J,Hashmi A,Thawani R,Moskovits M,Zadushlivy D,Kamholz SL, Isolated Pulmonic Valve Endocarditis. The American journal of case reports. 2019 Feb 4;     [PubMed]
Anguita P,Anguita M,Castillo JC,Gámez P,Bonilla V,Herrera M, Are Dentists in Our Environment Correctly Following the Recommended Guidelines for Prophylaxis of Infective Endocarditis? Revista espanola de cardiologia (English ed.). 2019 Jan;     [PubMed]
Keller K,Hobohm L,Munzel T,Ostad MA, Incidence of infective endocarditis before and after the guideline modification regarding a more restrictive use of prophylactic antibiotics therapy in the United States of America and Europe. Minerva cardioangiologica. 2019 Feb 5;     [PubMed]
Ibrahim AM,Siddique MS, Subacute Bacterial Endocarditis (SBE) Prophylaxis 2019 Jan;     [PubMed]

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