Endocarditis for the Advanced Practice Provider Julie K. Kuzin, MSN, RN, CPNP-PC/AC Pediatrics Infective Endocarditis The beginnings Pediatrics
Page 2 xxx00.#####.ppt 01/17/20 08:07 AM Pediatrics Infective Endocarditis Pediatrics Page 4 xxx00.#####.ppt 01/17/20 08:07 AM
Endocardial injury Thrombus formation Transient bacteremia Layering of Platelets Fibrin Bacteria Pediatrics
Page 5 xxx00.#####.ppt 01/17/20 08:07 AM Vegetation Vegetation Mayoclinic.org Pediatrics Page 6
xxx00.#####.ppt 01/17/20 08:07 AM How do children get IE? Congenital heart disease highest risk cyanotic / palliations Rheumatic heart disease CVL 1:1280 pedi admissions / yr Pediatrics
Page 7 xxx00.#####.ppt 01/17/20 08:07 AM How does IE present? Prolonged low grade fever Weight loss Somatic complaints Rigors
Fatigue Diaphoresis Weakness Heart failure Arthralgia / myalgia New murmur
Pediatrics Page 8 xxx00.#####.ppt 01/17/20 08:07 AM How does IE present? Emboli - Brain - Abdominal viscera - Kidneys, liver, spleen - Extremities
Pediatrics Page 9 xxx00.#####.ppt 01/17/20 08:07 AM How does IE present? Roth spots Janeway lesions Osler nodes RARE in children
Pediatrics Page 10 xxx00.#####.ppt 01/17/20 08:07 AM Splinter hemorrhages Pediatrics Page 11 xxx00.#####.ppt 01/17/20 08:07 AM
Roth Spots Pediatrics Page 12 xxx00.#####.ppt 01/17/20 08:07 AM Osler Nodes Pediatrics Page 13
xxx00.#####.ppt 01/17/20 08:07 AM Janeway lesions Pediatrics Page 14 xxx00.#####.ppt 01/17/20 08:07 AM Diagnosing Infective Endocarditis Modified Duke Criteria
(AHA, 2005) Pediatrics Page 15 xxx00.#####.ppt 01/17/20 08:07 AM Pediatrics Page 16 xxx00.#####.ppt 01/17/20 08:07 AM
Pediatrics Page 17 xxx00.#####.ppt 01/17/20 08:07 AM Pediatrics Page 18 xxx00.#####.ppt 01/17/20 08:07 AM How serious is IE?
AHA, 2005 Pediatrics Page 19 xxx00.#####.ppt 01/17/20 08:07 AM How serious is IE? Pediatrics
Page 20 xxx00.#####.ppt 01/17/20 08:07 AM Pathogens 3 most common organisms Staphylococci aureus Streptococci viridans Enterococci Others CONS GNR
Hemophilus Aggregatibacter Cardiobacterium Eikenalla Kingella (AHA, 2005) Pediatrics Page 21 xxx00.#####.ppt 01/17/20 08:07 AM
Pathogens Staphylococci aureus Oxacillin and Vancomycin resistance Streptococci viridans Multidrug resistance Enterococcus Vancomycin and aminoglycoside resistance (AHA, 2005) Pediatrics Page 22
xxx00.#####.ppt 01/17/20 08:07 AM How do you treat IE? IE suspected NOT acutely ill Acutely ill Obtain blood cultures & consider starting
antibiotics Pediatrics Start antibiotics, obtain blood cultures prior if possible Page 23 xxx00.#####.ppt 01/17/20 08:07 AM
How do you treat IE? Blood cultures Day 1 3 samples separate venipuncture sites, can be at same time Day 2 and beyond At least 2 sets every 24 48 hours until negative Pediatrics
Page 24 xxx00.#####.ppt 01/17/20 08:07 AM How do you treat IE? ID Consult Tailor treatment to organism High serum concentration to penetrate vegetation IV is preferred over IM in children Fever should resolve within a few days, < 10 (AHA, 2005 & AHA, 2002) Pediatrics
Page 25 xxx00.#####.ppt 01/17/20 08:07 AM How do you treat IE? Choose bactericidal vs. bacteriostatic Anticipate 4-6 week course* Broad spectrum coverage for staph, strept, & HACEK Ceftriaxone & Gentamicin If staph suspected, add beta lactam resistant PCN Consider outpatient therapy Repeat cultures within 8 weeks of completing abx course
(AHA, 2005) Pediatrics Page 26 xxx00.#####.ppt 01/17/20 08:07 AM How do you treat IE? Culture negative IE 20% of cases Causes
Inadequate microbiolical techniques Fastidious or nonbacterial pathogens Pretreated cultures (AHA, 2005) Pediatrics Page 27 xxx00.#####.ppt 01/17/20 08:07 AM
How do you treat IE? Surgical indications Fistulae Staph or Fungal vegetations Risk of embolization Abscess Heart failure Mycotic aneurysm Goretex & dacron shunts likely to need replacing (AHA, 2005) Pediatrics
Page 28 xxx00.#####.ppt 01/17/20 08:07 AM How do you prevent IE 2007 guideline revision Frequent exposure is greatest risk Prophylaxis might prevent few cases Risk outweighs benefit Oral health maintenance Pediatrics
Page 29 xxx00.#####.ppt 01/17/20 08:07 AM Prophylaxis is NOT recommended unless Pediatrics Page 30 xxx00.#####.ppt 01/17/20 08:07 AM How do you prevent IE
Give before procedure or within 2 hours Dental procedures Recommended for all dental procedures manipulating the gingival tissue or periapical region of teeth or perforation of oral mucosa NOT recommended for Shedding of baby teeth Oral trauma Removal / placement or adjustment of orthodontic appliances
Routine anesthetic injections Pediatrics Page 31 xxx00.#####.ppt 01/17/20 08:07 AM How do you prevent IE Skin - Recommended for procedures on infected skin or muscle GI/GU procedures
Not recommended Reasonable to include abx to treat enterococci in a high risk patient Being treated for a GI/GU infection Urinary tract manipulation during infection (cystoscopy Pediatrics Page 32 xxx00.#####.ppt 01/17/20 08:07 AM How do you prevent IE
Respiratory procedures Not recommended Reasonable to include abx for Incision or biopsy of the respiratory mucosa tonsillectomy, adenoidectomy, drainage of abscess or empyema Pediatrics Page 33 xxx00.#####.ppt 01/17/20 08:07 AM How do you prevent IE
Unique situations refer to Pediatrics Page 34 xxx00.#####.ppt 01/17/20 08:07 AM American Heart Association, Council on Cardiovascular Disease in the Young and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. (2007). Prevention of infective endocarditis guidelines from the american heart association. http://circ.ahajournals.org/content/116/15/1736.full.pdf
American Heart Association, Council on Cardiovascular Disease in the Young and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. (2005). Infective endocarditis diagnosis, antimicrobial therapy, and management of complications. http://circ.ahajournals.org/content/111/23/e394.full American Heart Association Committee on rheumatic fever, endocarditis, and kawasaki disease of the American Heart Association Council on Cardiovascular disease in the young. (2002). Unique Features of infective endocarditis in childhood. Circulation. http://circ.ahajournals.org/content/105/17/2115.full#T1 Durack, D., Lukes, A., & Bright, D. (1994). New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke endocarditis service. American Journal of Medicine. 96(3): 200-9
Hoyer, A., & Silberbach, M. (2005). Infective endocarditis. Pediatrics in Review. 26,394. Levy, D. (1985). Centerary of William Oslers 1885 Gulstonian lectures and their place in the history of bacterial endocarditis. Journal of the Royal Society of Medicine. 78 (12); 10391046. Pediatrics Page 35 xxx00.#####.ppt 01/17/20 08:07 AM
