Download INFECTIVE ENDOCARDITIS

Infective Endocarditis
Senior Oral Medicine
Chapter 2
August 27, 2009
Susan Settle, D.D.S.
Infective Endocarditis
• A microbial infection of the endothelial
surface of the heart or valves
• Usually is near congenital or acquired cardiac
defects
• Designated by the causative organism
• Also classified as NVE or PVE
Etiology
• Usually Bacterial
– Staphylococcus aureus Endocarditis
– Streptococcus viridans Endocarditis
– Actinobacillus actinomycetemcomitans
Endocarditis
• Sometimes Fungal
– Candida albicans Endocarditis
Etiology
• Streptococci most common cause (35-60%)
– Mostly viridans group
• Staphylococci about 30-40 and gaining
– S. aureus most common cause in IVDU’s
– Incidence increasing in hospital-acquired
infections
Epidemiology
• Incidence <1% Of
General Population
Epidemiology
• Population Groups At Greater Risk:
– Rheumatic Fever History
– Hemodialysis
– Previous History Of Endocarditis
– Patients With Prosthetic Valves
– IV Drug Users (30% Risk Within 2 Years)
Predisposing Conditions
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Mitral valve prolapse
Aortic valve disease
Congenital heart disease
Prosthetic valve
Intravenous drug use
No identifiable cause in 25-47%
Epidemiology
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More Common In Men
Median Age 50 Years
Acute Cases Increasing
Streptococcal Cases 
Slightly; Fungal And Gram
Negative Cases Increasing
Epidemiology
• Incidence Increases With Age, Probably
Due To Increased Cardiac Disease And
Decreased Immunity
• Prosthetic Heart Valve Infections Are
Increasing
Dentistry And Endocarditis
• Streptococcus viridans: Usual Etiologic
Agent
• Usually Is Not Acute (Subacute)
– (That Is Why It Is Referred To As “SBE”)
• Incubation Period Approximately Two
Weeks
Epidemiology
• Mitral Valve Prolapse:
Only 1/4 Of MVP
Patients Have Mitral
Insufficiency
(Regurgitation Or
Murmur) - This Results
In The Very Slight
Increased Risk For
Endocarditis
MVP
• Mitral valve prolapse accounts for 25-30% of
adult cases of native valve endocarditis
• MVP is now the most common underlying
condition among patients who develop
infective endocarditis
Aortic Valve Disease
Accounts for 1230% of IE cases
Epidemiology
• Fenfluramine (Pondimin) And
Dexfenfluramine (Redux) Were Reported To
Cause Cardiac Valvular Damage When Used
For 4 Or More Months
• Premedication No Longer Indicated
Epidemiology
• Vena Cava Filters Or
Umbrella Stents Placed
To Catch Blood Clots
Have Not Demonstrated
Increased Risks
3 Types Of Endocarditis
Lesions
• Cardiac Lesions
• Embolic Lesions: Friable Cardiac
Lesions That Break Away
• General Lesions
Cardiac Lesions
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Usually Valvular
Most Often Mitral Valve
May Cover The Entire Valve
Mass Of Platelets, Fibrin And
Bacteria
• Sterile Vegetations May Occur In
50% Of Lupus Patients
Sites of Endocarditis Involvement
Embolic Lesions
• Osler’s Nodes: Are Small, Painful
Petechiae In Extremities
Janeway Lesions
• Pathognomonic of IE
• Non-tender dermal abscesses
Splinter Hemorrhages
Late-appearing symptom in
endocarditis
These represent damage to
capillaries
May also appear due to nail trauma
General Lesions
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Enlarged Spleen
Arthritis
Clubbing Of Fingers
Cardiac Failure
Conduction Abnormalities
Stroke
Psychiatric Disease
Renal Failure
Mortality
• Overall Rate About 40%
• Death Usually Due To Heart
Failure Resulting From Valve
Dysfunction
• Highest Death Rate Is In Early
Prosthetic Valve Endocarditis
Classic Triad - But May Not Always Be
Present
1. Fever
2. Positive Blood Culture
3. Heart Murmur
• Sometimes Insidious Onset
• “Flu-Like” Symptoms
Lab Findings
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+Culture In 95% Of BE
Strep viridans Most Commonly Causes SBE
Staph aureus Most Commonly Causes ABE
Electrocardiography: Will Determine If
Infection Progresses To Myocardium
Lab Findings
• Echocardiography - As Important As A
Positive Blood Culture Are Results Which
Show Vegetations, Abscesses, Etc.
Major Diagnostic Criteria
• Positive Blood Culture
• Echocardiogram Findings
Of Endocardial Involvement
• New Valvular Regurgitation
Minor Diagnostic Criteria
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Predisposing Heart Conditions
IV Drug Use
Vascular Emboli
Osler Nodes
Aneurysm
Roth Spots Of The Eye
Splinter Hemorrhages
Treatment
• Treat It Early!
• Culture
• Use Bactericidal Agents
–PCN G; Cefatriaxone; PCN G +
Gentamicin; Nafcillin; Vancomycin
Treatment
• Use Adequate Dosage
• Parenteral Route
• Sufficient Duration: 4-6 Weeks Or
Longer
Dental Management
• Prevention In Susceptible Patients: An
Academic Issue
• Very Few Cases Related In Time To
Dental/Medical Procedures
– Incidence Has Been Estimated To Be 100-200
Patients Susceptible To BE In A Dental Practice
With 2,000 Patients
Antibiotic Prophylaxis
• Regimen Designed For Alphahemolytic Strep (S. viridans)
• No Clinical Trials Available To Show
This Works! (Actually Prevents BE In
Humans)
• 25-50% Hospital Antibiotic Usage Is
For Prophylaxis
Antibiotic Prophylaxis
• Complications: Resistant
Bacteria, Toxicity, Allergies,
Suprainfections, Costs
• Will Not Prevent All Cases
Antibiotic Prophylaxis
• Allergy Morbidity Is Higher Than
Endocarditis (Allergy To Premed)
– 400-800 PCN Deaths Per Year
• Effective For Patients With Prosthetic
Valves And Previous Endocarditis
History
American Heart Association
Guidelines
• Not Intended To Be A Standard Of Care
• Not A Substitute For Clinical Judgment
• Must Be Considered If You Receive A Medical
Opinion That Conflicts With The Guidelines (You
Are Responsible For The Outcome Of Your Patient’s
Dental Treatment)
American Heart Association
Guidelines
• First Recommendations Were In
1955
• Can Still Develop Endocarditis Even
When Using Guidelines
Prophylaxis Myths
• Most Cases Of BE Of Oral Origin Are
Caused By Dental Procedures
• AHA Regimens Give Almost Total
Protection Against Endocarditis
After Dental Procedures
Prophylaxis Myths
• If A Patient Is Taking Antibiotics For An
Infection Before The Dental Procedure,
You Do Not Need To Change The
Patient To Another Antibiotic Before
The Dental Procedure
Prophylaxis Myths
• The Risk Of Endocarditis Is
Greater Than The Risk Of Toxic
Effects Of The Antibiotic
2007 AHA Recommendations
Prophylaxis Indicated For The Following Groups
Of Patients:
• Those with a previous history of endocarditis
• Those with prosthetic cardiac valves
• Post-heart transplant patients with
valvulopathy
• Those with certain congenital types of heart
disease
Congenital Heart Disease
Indications for Prophylaxis
• Unrepaired cyanotic CHD, including those patients
with palliative shunts & conduits
• Completely repaired CHD with prosthetic material or
device placed by surgery or catheter during the first
6 months after the procedure
• Repaired CHD with residual defects at the site or
adjacent to the site of a prosthetic patch or
prosthetic device, which inhibits endothelialization
Dental Procedures For Which
Prophylaxis Is Recommended
• All procedures involving manipulation of gingival
tissue or the periapical region of teeth or perforation
of oral mucosa
• Excluded procedures:
– Routine anesthetic injections through noninfected tissue
– Radiographs
– Placement of removable prosthodontic or orthodontic
appliances
– Adjustment of orthodontic appliances
– Shedding of primary teeth and bleeding from trauma to
lips or oral mucosa
Nonvalvular Cardiovascular Devices
• Such as coronary artery stents, hemodialysis grafts
• Routine antibiotic prophylaxis for dental procedures
is not recommended
• However, prophylaxis is recommended if an abscess
is going to be incised & drained,
• Or, if there is leakage present after the device is
placed
Not In This Presentation!
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Know Antibiotics in AHA Regimen
Know Dosages of These Antibiotics
Know The Regimen
Remember To Wait 9-14 Days Between
Premed Appointments To Avoid Antibiotic
Resistance Development
• If Patient Is On A “Regimen” Antibiotic Switch
To Another Drug In The Regimen