Infective Endocarditis

Question 1

Why don’t we just give prophylaxis to everyone and every procedure?

Answer 1

• prophylaxis prevents an exceedingly small number of cases of IE, if any, for procedures
• the risk of antibiotic associated adverse events exceeds the benefits except in high risk situations

Question 2

What is the most important intervention for kids who are at risk of IE?

Answer 2

Brushing teeth - reduces the risk of bacteremia from daily activities

Question 3

What is the risk of mortality with strep viridans IE with prosthetic valve? With a native valve?

Answer 3

20%

5%

Question 4

Who gets prophylaxis?

6

Answer 4

1. Prosthetic valves or prosthetic material used in valve repair
2. Previous IE
3. Congenital heart disease:
   - unrepaired cyanotic lesion
   - fully repaired with prosthetic material - ONLY for the first 6 months
   - repaired CHD with residual defect at the site or adjacent to prosthetic patch or device
4. Cardiac transplant patient who develop cardiac valvulopathy

Question 5

What is the most common condition that predisposes to IE?

Does it qualify for prophylaxis and why?

Answer 5

Mitral valve prolapse

No. Because the incidence of IE is exceedingly low and because IE with MVP is not associated with grave outcome

Question 6

What do you do about kids with rheumatic heart disease?

Answer 6

This was not addressed in the CPS statement. In someone centres, these kids are still getting prophylaxis. The AHA do not currently recommend prophylaxis for these kids.

Question 7

Which dental procedures warrant prophylaxis?

Answer 7

Those involving manipulation of the gingival tissue, the periapical region of the teeth or the perforation of the oral mucosa.

NB these DO NOT require prophylaxis:

• routine anaesthetic for noninfected tooth
• dental X-rays
• placement of removable prosthodontic or orthodontic appliance
• placement of orthodontic brackets
• shedding of deciduous teeth
• bleeding from trauma to the lips or oral mucosa

Question 8

What should the prophylaxis entail?

Answer 8

Give before the procedure (if forgotten to give before the procedure, can give up to 2 hours after)

Antibiotic choice
1st amoxicillin
2nd celhalexin
3rd Clinidamycin
4th Macrolide
If unable to take PO - IV ampicillin, ceftriaxone, cefazolin. 

You may change this for the specific site of procedure
Example: skin you need staph aureus and GAS coverage. And think about MRSA.

Question 9

Do patients having a bronchoscopy need prophylaxis?

Answer 9

Only if incision or biopsy of respiratory mucosa.

Question 10

Do kids need prophylaxis with GI and GU procedures?

Answer 10

Prophylaxis is no longer recommended for these, as a standard thing. For kids who are very high risk and have an established infection already in GI/GU tract, you can consider it. The prophylaxis should be active against enterococcus - ampicillin or vancomycin

You can also consider eradication of infection or colonization prior to the procedure.

Question 11

What is more likely to cause infective endocarditis: dental procedures or daily activities?

Answer 11

IE is much more likely to results from frequent exposure to randome bacteremias associated with daily activities than from bacteremia caused by dental, GI or GU procedures