Clinical Aspects of Endocarditis

Question 1

Endocarditis Risk Factors and Predisposing Factors

Answer 1

• Rheumatic heart disease (still very common in developing countries)
• Illicit IV drug use
• Poor dentition or dental infection
• Advanced age
• Comorbid conditions of diabetes, hemodialysis, HIV and immunocompromised state
• Degenerative valve disease
• Prosthetic heart valves
• Intracardiac devices
• Prior IE

Question 2

Acute Left Sided IE

Answer 2

• Sepsis, fever (90%), chills (40%), tachycardia
• +/- CHF: dyspnea, frothy sputum, chest pain
• Murmur of aortic or mitral regurgitation (85%)
• Neurologic symptoms (20-30%) secondary to aseptic meningoencephalitis and embolization of vegetation
• Mental status changes, hemiplegia, aphasia, ataxia, severe headache

Question 3

Subacute Left Sided IE

Answer 3

• Recurrent intermittent fever
• Malaise, anorexia, weight loss
• Murmur of aortic or mitral regurgitation

Question 4

Right Sided IE

Answer 4

• Usually acute
• 60% assoc. w/ IVDU
• Fever, cough, chest pain, hemoptysis, dyspnea
• Pulmonary effusions, pulmonary infiltrates of variable size and shape, pulmonary infarcts, possible cavitation from emboli

Question 5

IE Clinical Manifestations

Answer 5

• Splinter hemorrhages- usually on nail beds; nonspecific findings
• Petechiae/Hemorrhage- usually on extremities, mucous membranes
• Clubbing
• Janeway lesions, osler nodes, roth spots
• Septic pulmonary emboli
• Major arterial emboli
• Mycotic aneurysm

Question 6

HACEK Organism

Answer 6

• Organism commonly causing IE
• Haemophilus species
• Aggregatibacter aphrophilus
• A. actinomycetemcomitans
• Cardiobacterium species
• Eikenella species
• Kingella species

Question 7

Diagnostic Criteria of IE

Answer 7

DUKE CRITERIA

Blood cultures

• At least 2 separate blood cultures deemed infective
• persistently pos. BCs (2 BC sets drawn >12hrs apart or 3 BCs or the majority of >4 BC sets w/ the first and last separated by >1hr)
• Single pos. culture for Coxiella brunetii or anti-phase 1 antibody titer > 1:800

Imaging showing endocardial involvement

• New valve regurgitation
• Echo showing oscillating intracardiac mass on the valve or supporting structure, in the path of regurgitant jets
• Echo showing abscess
• Echo showing new partial dehiscence

Minor Critera

• Predisposing cardiac condtion or IVDU
• Fever (>38 C or 100.4 F)
• Pos. BCs, but not meeting major criteria; serologic evidence of active infection w/ plausible microorganisms
• Vascular phenomena: arterial emboli, mycotic aneurysms, petechiae, and or Janeway lesions
• Immunologic phenomena: glomerulonephritis, Osler nodes, Roth spots, and or rheumatoid factor

Question 8

Positive IE Diagnosis Using Duke Criteria

Answer 8

Definite

• Pathology or bacteriology of vegetations, or
• 2 major criteria, or
• 1 major and 3 minor, or
• 5 minor

Possible

• 1 majore and 1 minor
• 3 minor

Rejected

• Firm alternative diagnosis
• Resolution of IE syndrome after <4 days of antibiotics
• No pathologic evidence at surgery or autopsy after <4 days of antibiotics
• Does not meet criteria mentioned above

Question 9

Primary Reasons for Revision of IE Prophylaxis Guidelines

Answer 9

1. IE is much more likely to result from frequent exposure to random bacteremia assoc. w/ daily activities than from bacteremia caused by dental, GI or GU tract procedures
   - Cumulative exposure of 5370 min of bacteremia/mos from eating and brushing compared to 6-30min assoc w/ a single tooth extraction
   - Tooth brushing 2x/day has a 154,000 x greater risk of exposure than a single tooth extraction
   - Cumulative exposure for daily activites may be as high as 5.6 million times greater than a single tooth extraction
2. Prophylaxis may prevent an exceedingly small number of cases of IE in individuals who undergo a dental, GI tract or GU procedure
3. The risk of antibiotic assoc. adverse events exceed the benefit, if any, from prophylactic antibiotic therapy
4. Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE

Question 10

Cardiac Conditions Assoc. with the Highest Risk of Adverse Outcomes from IE for which Prophylaxis with Dental Procedures is Recommended

Answer 10

• Prosthetic cardiac valves
• Previous IE
• Congenital Heart Disease

*unrepaired cyanotic CHD including palliative shunts and conduits

*completely repaired CHD w/ prosthetic material or device during the first 6 mo after the procedure

*repaired CHD w/ residual defects at the site or adjacent to the site of pathology or prosthetic device

• Cardiac transplantation recipients who develop cardiac valvulopathy

All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa