* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Document
Cardiovascular disease wikipedia , lookup
Cardiac contractility modulation wikipedia , lookup
Management of acute coronary syndrome wikipedia , lookup
Aortic stenosis wikipedia , lookup
Hypertrophic cardiomyopathy wikipedia , lookup
Coronary artery disease wikipedia , lookup
Antihypertensive drug wikipedia , lookup
Myocardial infarction wikipedia , lookup
Artificial heart valve wikipedia , lookup
Jatene procedure wikipedia , lookup
Congenital heart defect wikipedia , lookup
Lutembacher's syndrome wikipedia , lookup
Quantium Medical Cardiac Output wikipedia , lookup
Mitral insufficiency wikipedia , lookup
Rheumatic fever wikipedia , lookup
Infective endocarditis wikipedia , lookup
Dextro-Transposition of the great arteries wikipedia , lookup
Dr. Talaat Ali Sabeeh Al-Jarrah Pediatric Cardiologist Infective Endocarditis(IE): PREVALENCE: IE accounts for 0.5 to 1 of every 1000 hospital admissions, excluding postoperative endocarditis. The frequency of IE among children seems to have increased in recent years. This is due in part to survivors of surgical repair of complex congenital heart disease and survivors of neonatal intensive care units, who are at an increased risk for IE. PATHOGENESIS: 1)Two factors are important in the pathogenesis of IE: a damaged area of endothelium and bacteremia, even transient. 2)The presence of structural abnormalities of the heart or great arteries, with a significant pressure gradient or turbulence, produces endothelial damage that induces thrombus formation with deposition of sterile clumps of platelet and fibrin (nonbacterial thrombotic endocarditis), which provides a nidus for bacteria to adhere leading to vegetation. 3)Almost all patients who develop IE have a history of congenital or acquired heart disease. Drug addicts may develop IE in the absence of known cardiac anomalies Causes: 1)All congenital heart defects, with the exception of secundum ASD, predispose to IE. More frequently encountered defects are TOF, VSD,AV disease,TGA, and systemic-to-pulmonary artery (PA) shunt(PDA,A-P Window,BT shunt). Rheumatic valvular disease, particularly MR.prosthetic heart valve or prosthetic material in the heart are at particularly high risk for developing IE. Patients with mitral valve disease (MVP with MR) and those with hypertrophic obstructive cardiomyopathy are also vulnerable to IE. 2)Any localized infection (e.g., abscess, osteomyelitis, pyelonephritis) can seed organisms into the circulation MICROBIOLOGY: In the past, Streptococcus viridians, enterococci, and Staphylococcus aureus were responsible for over 90% of the cases,but this decreased to 50% to 60%, with a concomitant increase in cases caused by fungi and HACEK organisms (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, and Kingella). HACEK organisms are particularly common in neonates and immunocompromised children, accounting for 17% to 30% of cases. 4). Fungal endocarditis (which has a poor prognosis) may occur in sick neonates, in patients who are receiving long-term antibiotic or steroid therapy, or after open-heart surgery CLINICAL MANIFESTATIONS History: 1)History of an underlying heart defect. 2)A history of a recent dental procedure or tonsillectomy is occasionally present, but a history of toothache (from dental or gingival disease) is more frequent than a history of a procedure. 3)IE is rare in infancy; at this age, it usually follows openheart surgery.4)The onset is usually insidious with prolonged low-grade fever and somatic complaints, including fatigue, weakness, loss of appetite, pallor, arthralgia, myalgias, weight loss, and diaphoresis Physical Examination: 1)Heart murmur is universal (100%). The appearance of a new heart murmur and an increase in the intensity of an existing murmur are important 2)Fever is common (80% to 90%). The temperature fluctuates between (38.3°C and 39.4°C). 3)Splenomegaly is common (70%). 4)Skin manifestations (50%) (either secondary to microembolization or as an immunologic phenomenon) may be present in the following forms:(Petechiae on the skin, mucous membranes, or conjunctivae are the most frequent skin lesions,Osler's nodes (tender, pea-sized red nodes at the ends of the fingers or toes) are rare in children,Janeway's lesions (small, painless, hemorrhagic areas on the palms or soles) are rare, and Splinter hemorrhages (linear hemorrhagic streaks beneath the nails) are also rare. 5)Embolic or immunologic phenomena in other organs are present in 50% of cases,Hematuria and renal failure may occur,Roth's spots (oval, retinal hemorrhages with pale centers located near the optic disc) occur in less than 5% of patients. Also 1-Carious teeth or periodontal or gingival disease is frequently present. 2-Clubbing of fingers without cyanosis develops rarely in more chronic cases. 3-Signs of heart failure may be a complication of IE. 4-C/F in a neonate with IE are nonspecific (respiratory distress, tachycardia) Laboratory Studies 1-Positive blood cultures are found in more than 90% of patients in the absence of previous antimicrobial therapy. Antimicrobial pretreatment reduces the yield of positive blood culture to 50% to 60%. 2-A complete blood cell count shows anemia, with hemoglobin levels lower than 12 g/100 mL (present in 80% of patients), and leukocytosis with a shift to the left. 3-ESR is increased unless there is polycythemia. 4-Microscopic hematuria is found in 30% of patients. 5-Certain echo :(Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitation jets, or on implanted material,Abscesses, New partial dehiscence of prosthetic valve,New valvular regurgitation). TEE may be superior to TTE in identifying (vegetations on prosthetic valves, detecting complications of left ventricular (LV) outflow tract endocarditis (either valvular or subvalvular), and in detecting aortic root abscess and involvement of the sinus of Valsalva). Certain echo features suggest a high-risk case or a need for surgery: 1-Large vegetations (greatest risk when the vegetation is >10 mm). 2-Severe valvular regurgitation. 3-Abscess cavities. 4-Pseudoaneurysm. 5-Valvular perforation or dehiscence. 6-Decompensated heart failure. DIAGNOSIS: There are three categories of diagnostic possibilities using the modified Duke criteria: definite, possible, and rejected Definition of terms used in the modified duke criteria . MAJOR CRITERIA A)Blood culture positive for IE: 1)Typical microorganisms consistent with IE from two separate blood cultures; or 2)Microorganisms consistent with IE from persistently positive blood cultures defined as follows: at least two positive cultures of blood samples drawn >12 hours apart; or all of three or a majority of four separate cultures of blood (with first and last samples drawn at least 1 hour apart) 3)Single positive blood culture for Coxiella burnetii or anti-phase 1 IgG titer >1:800 B)Evidence of endocardial involvement 1) Echocardiogram positive for IE; or 2)Abscess; or 3)New partial dehiscence of prosthetic valve; or 4)New valvular regurgitation (worsening or changing or preexisting murmur not sufficient) MINOR CRITERIA 1)Predisposition, predisposing heart condition, or injection drug users. 2)Fever, temperature >38°C. 3)Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway's lesions 4)Immunologic phenomena: glomerulonephritis, Osler's nodes, Roth's spots, and rheumatoid factor . 5)Microbiologic evidence: positive blood culture but does not meet a major criterion as noted above or serologic evidence of active infection with organism consistent with IE MANAGEMENT 1-Blood cultures are indicated for all patients with fever of unexplained origin and a pathologic heart murmur, a history of heart disease, or previous endocarditis. a)Usually, three blood culture samples are drawn by separate venipunctures over 24 hours, unless the patient is very ill. In 90% of cases, the causative agent is recovered from the first two cultures. b)If there is no growth by the second day of incubation, two more maybe obtained. There is no value in obtaining more than five blood cultures over 2 days unless the patient received prior antibiotic therapy. c)It is not necessary to obtain the cultures at any particular phase of the fever cycle. d)An adequate volume of blood must be obtained; 1 to 3 mL in infants and young children and 5 to 7 mL in older children are optimal. e)Aerobic incubation alone suffices because it is rare for IE to be due to anaerobic bacteria. 2-It is highly recommended that consultation with a local infectious disease specialist . 3-Initial empirical therapy is started with the following antibiotics while awaiting the results of blood cultures.a)The usual initial regimen is an antistaphylococcal semisynthetic penicillin (nafcillin, oxacillin, or methicillin) and an aminoglycoside (gentamicin). This combination covers against S. viridans, S. aureus, and gram-negative organisms. 4-The final selection of antibiotics depends on the organism isolated and the results of an antibiotic sensitivity test. Streptococcal IE: intravenous (IV) penicillin , 4 weeks. Staphylococcal IE 1)If methicillin-susceptible staphylococci (MSSA): is one of the semisynthetic β- lactamase-resistant penicillins (nafcillin, oxacillin, and methicillin) for a minimum of 6 weeks (with or without gentamicin for the first 3 to 5 days). 2). Patients with methicillin-resistant(MRSA) native valve IE are treated with vancomycin for 6 weeks (with or without gentamicin for the first 3 to 5 days). Enterococcus-caused native valve endocarditis usually requires a combination of IV penicillin or ampicillin with gentamicin for 4 to 6 weeks. If patients are allergic to penicillin, vancomycin combined with gentamicin for 6 weeks is required. HACEK organisms have begun to become resistant to ampicillin.Ceftriaxone or another third-generation cephalosporin alone or ampicillin plus gentamicin for 4 weeks . Fungal IE :Amphotericin B. For culture-negative endocarditis:treatment is directed against staphylococci, streptococci, and the HACEK organisms using ceftriaxone and gentamicin. Prosthetic valve endocarditis should be treated for 6 weeks based on the organism isolated and the results of the sensitivity test. Operative intervention may be necessary before the antibiotic therapy is completed if the clinical situation warrants (such as progressive CHF, significant malfunction of prosthetic valves, persistently positive blood cultures after 2 weeks of therapy). Bacteriologic relapse after an appropriate course of therapy also calls for operative intervention PROGNOSIS: overall recovery rate is 80% to 85%; it is 90% or better for S. viridans and enterococci and about 50% for Staphylococcus organisms. Fungal endocarditis is associated with a very poor outcome PREVENTION:More important than the diagnosis and treatment of IE is its prevention. Maintenance of good oral hygiene is more important than antibiotic prophylaxis. Indications and non indications of IE prophylaxis based on cardiac lesions PROPHYLAXIS RECOMMENDED High-Risk Category 1-Prosthetic cardiac valve, including bioprosthesis and homograft valves 2- Previous bacterial endocarditis3-Complex cyanotic congenital heart defect (e.g., single ventricle, transposition of the great arteries, tetralogy of Fallot) 4-Surgically constructed systemic-to-pulmonary artery shunt or conduit Moderate-Risk Category 1-Most other congenital heart defects (e.g., patent ductus arteriosus, ventricular septal defect, primum atrial septal defect, coarctation of the aorta, bicuspid aortic valve) 2-Acquired valvular dysfunction (e.g., rheumatic heart disease, collagen vascular disease) 3-Hypertrophic cardiomyopathy4-Mitral valve prolapse with mitral regurgitation and/or thickened mitral valve leaflets PROPHYLAXIS NOT RECOMMENDED (Negligible-Risk Category) 1-Isolated secundum atrial septal defect2-Surgical repair of atrial or ventricular septal defects or patent ductus arteriosus (without residua beyond 6 months).3-Previous coronary artery bypass surgery.4-Mitral valve prolapse without mitral regurgitation.5- Innocent heart murmurs.6-Previous Kawasaki disease without valvular dysfunction7- Previous rheumatic fever without valvular dysfunction 8-Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators. Dental procedures and endocarditis prophylaxis PROPHYLAXIS RECOMMENDED 1-Dental extraction.2-Periodontal procedures including surgery, scaling and root planing, probing, and recall maintenance.3Dental implant placement and reimplantation of avulsed teeth 4-Endodontic (root canal) instrumentation or surgery only beyond the apex .5-Subgingival placement of antibiotic fibers or strips. 6-Initial placement of orthodontic bands but not brackets Intraligamentary local anesthetic injections.7-Prophylactic cleaning of teeth or implants when bleeding is anticipated PROPHYLAXIS NOT RECOMMENDED 1-Restorative dentistry (operative and prosthodontic) with or without retraction cord. 2-Local anesthetic injection (non-intraligamentary).3-Intracanal endodontic treatment; post placement and buildup. 4Placement of rubber dams.5-Postoperative suture removal.6Placement of removable prosthodontic or orthodontic appliances.7- Taking of oral impressions.8-Fluoride treatments.9- Taking of oral radiographs.10.Orthodontic appliance adjustment Shedding of primary teeth