Endocarditis for the Advanced Practice Provider Julie K

Endocarditis for the Advanced Practice Provider Julie K. Kuzin, MSN, RN, CPNP-PC/AC Pediatrics

Infective Endocarditis The beginnings Pediatrics Page 1 xxx 00. #####. ppt 10/26/2020 7: 47: 10 AM

Pediatrics

Infective Endocarditis Pediatrics Page 3 xxx 00. #####. ppt 10/26/2020 7: 47: 14 AM

Endocardial injury Thrombus formation Transient bacteremia Layering of Platelets Fibrin Bacteria Pediatrics Page 4 xxx 00. #####. ppt 10/26/2020 7: 47: 16 AM Vegetation

Vegetation Mayoclinic. org Pediatrics Page 5 xxx 00. #####. ppt 10/26/2020 7: 47: 16 AM

How do children get IE? • Congenital heart disease ‐ highest risk cyanotic / palliations • Rheumatic heart disease • CVL 1: 1280 pedi admissions / yr Pediatrics Page 6 xxx 00. #####. ppt 10/26/2020 7: 47: 17 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 7 xxx 00. #####. ppt 10/26/2020 7: 47: 18 AM

How does IE present? Emboli - Brain - Abdominal viscera - Kidneys, liver, spleen - Extremities Pediatrics Page 8 xxx 00. #####. ppt 10/26/2020 7: 47: 18 AM

How does IE present? Roth spots Janeway lesions Osler nodes RARE in children Pediatrics Page 9 xxx 00. #####. ppt 10/26/2020 7: 47: 18 AM

Splinter hemorrhages Pediatrics Page 10 xxx 00. #####. ppt 10/26/2020 7: 47: 18 AM

Roth Spots Pediatrics Page 11 xxx 00. #####. ppt 10/26/2020 7: 47: 19 AM

Osler Nodes Pediatrics Page 12 xxx 00. #####. ppt 10/26/2020 7: 47: 20 AM

Janeway lesions Pediatrics Page 13 xxx 00. #####. ppt 10/26/2020 7: 47: 22 AM

Diagnosing Infective Endocarditis Modified Duke Criteria (AHA, 2005) Pediatrics Page 14 xxx 00. #####. ppt 10/26/2020 7: 47: 24 AM

Pediatrics Page 15 xxx 00. #####. ppt 10/26/2020 7: 47: 24 AM

Pediatrics Page 16 xxx 00. #####. ppt 10/26/2020 7: 47: 25 AM

Pediatrics Page 17 xxx 00. #####. ppt 10/26/2020 7: 47: 25 AM

How serious is IE? AHA, 2005 Pediatrics Page 18 xxx 00. #####. ppt 10/26/2020 7: 47: 26 AM

How serious is IE? Pediatrics Page 19 xxx 00. #####. ppt 10/26/2020 7: 47: 27 AM

Pathogens 3 most common organisms • Staphylococci aureus • Streptococci viridans • Enterococci Others • CONS • GNR • Hemophilus • Aggregatibacter • Cardiobacterium • Eikenalla • Kingella (AHA, 2005) Pediatrics Page 20 xxx 00. #####. ppt 10/26/2020 7: 47: 27 AM

Pathogens Staphylococci aureus • Oxacillin and Vancomycin resistance Streptococci viridans • Multidrug resistance Enterococcus • Vancomycin and aminoglycoside resistance (AHA, 2005) Pediatrics Page 21 xxx 00. #####. ppt 10/26/2020 7: 47: 28 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 22 xxx 00. #####. ppt 10/26/2020 7: 47: 28 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 23 xxx 00. #####. ppt 10/26/2020 7: 47: 28 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 24 xxx 00. #####. ppt 10/26/2020 7: 47: 28 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 25 xxx 00. #####. ppt 10/26/2020 7: 47: 29 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 26 xxx 00. #####. ppt 10/26/2020 7: 47: 29 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 27 xxx 00. #####. ppt 10/26/2020 7: 47: 30 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 28 xxx 00. #####. ppt 10/26/2020 7: 47: 30 AM

Prophylaxis is NOT recommended unless … Pediatrics Page 29 xxx 00. #####. ppt 10/26/2020 7: 47: 31 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 30 xxx 00. #####. ppt 10/26/2020 7: 47: 31 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 31 xxx 00. #####. ppt 10/26/2020 7: 47: 32 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 32 xxx 00. #####. ppt 10/26/2020 7: 47: 32 AM

How do you prevent IE Unique situations refer to… Pediatrics Page 33 xxx 00. #####. ppt 10/26/2020 7: 47: 32 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/e 394. 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#T 1 • 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 Osler’s 1885 Gulstonian lectures and their place in the history of bacterial endocarditis. Journal of the Royal Society of Medicine. 78 (12); 1039 -1046. Pediatrics Page 34 xxx 00. #####. ppt 10/26/2020 7: 47: 33 AM