INFECTIVE ENDOCARDITIS-II

DR INAYAT ULLAHPGY-II PEDIATRICS

MANAGEMENT

►Treatment of IE in pediatric patients should be provided through collaboration among I.D.specialists, cardiologists, and cardiac surgeons

► Specific therapy is determined on a case by case basis and involves the use of antimicrobial agents and, when necessary, surgical intervention.

ANTIBIOTIC THERAPHY►To prevent further endocardial damage

and complications, it is imperative that antibiotic therapy be initiated promptly in patients with suspected IE

► Antibiotic regimens for IE are based on the patient’s age, clinical presentation,cardiac status, and organisms most commonly isolated in infections. IV bactericidal antibiotics are necessary for the treatment of IE

Empirical Theraphy► Empirical therapy before the

identifiable agent is recovered may be initiated with vancomycin plus gentamicin in patients without a prosthetic valve and when there is a high risk of S. aureus, enterococcus, or viridans streptococci (the 3 most common organisms).

►A total of 4-6 weeks treatment is usually required.

Treatment ► In nonstaphylococcal disease,

bacteremia usually resolves in 24-48 hr, whereas fever resolves in 5-6 days with appropriate antibiotic therapy. Resolution with staphylococcal disease takes longer.

►If the infection occurs on a valve and induces or increases symptoms and signs of heart failure, appropriate therapy should be instituted, including diuretics, afterload reducing agents, and in some cases, digitalis

Surgery Indication►Surgical intervention for I.E is

indicated for severe aortic, mitral or prosthetic valve involvement with intractable heart failure.

►Mycotic aneurysm, rupture of an aortic sinus, intraseptal abscess causing complete heart block, or dehiscence of an intracardiac patch requires an emergency operation.

Indications for Surgery►Failure to sterilize the blood despite

adequate antibiotic levels in 7-10 days in the absence of extracardiac infection,

►Myocardial abscess,►Recurrent emboli,►Increasing size of vegetations while

receiving therapy. ►Vegetations (aortic, mitral, prosthetic

valve) >10-15 mm are at high risk of embolism

Indications for surgery►Active infection is not a

contraindication for surgery if patient is critically sick

►Removal of vegetations and, valve replacement may be lifesaving, and sustained antibiotic administration will prevent reinfection.

►Replacement of infected prosthetic valves carries a higher risk

Prognosis and complications►Mortality 20-25% despite antibiotics

use,►Serious morbidity 50-60% in

documented I.E due to heart failure secondary to aortic , mitral valves vegetations.

►Myocardial abscesses toxic myocarditis, and fatal arrythmias

►Systemic emboli with CNS menifestations, pulmonary emboli are usually lethal

Prognosis and complications►Mycotic aneurysms, rupture of a sinus

of Valsalva, obstruction of a valve secondary to large vegetations.

►Acquired VSD, Heart block due to involvement(abscess) of conduction system

► Additional complications include meningitis, osteomyelitis, arthritis, renal abscess, purulent pericarditis, and immune complex-mediated glomerulonephritis

Fungal Endocarditis►Difficult to manage, poor prognosis.►Encountered after cardiac surgery in

debilitated, immunocompromised, patients and those on prolong antibiotics.

►Drug of choice Amphotericine-B and Flourocytocine.

►Surgery to excise infected tissue with limited success

►rTPA help to lyse vegetation and avoid surgery in high risk patients

Prevention/ProphylaxisRevised AHA recomedation

2007►A substantial reduction in the number

of patients who require prophylactic treatment and the procedures requiring coverage was recommended (in revised guidelines)

►IE more frequently associated with random bacteremias than dental or GI procedure

►Routine prohylaxis may prevent small cases

►Risk of antibiotics adverse events exceeds the benefit of prophlaxis

Vigorous treatment of sepsis and local infections and careful asepsis during heart surgery and catheterization reduce the incidence of infective endocarditis