FOR PEDO AND MEDICAL STUDENT

1. New Guidelines for
Prophylaxis against
Infective Endocarditis
in children undergoing
interventional procedures
Prof Dr HUSSEIN ABDELDAYEM
PEOFESSOR OF PEDIATRICS AND PEDIATRIC NEUROLOGY
FACULTY OF MEDICINE, ALEX UNIVERSITY, EGYPT
2018

2. Infective Endocarditis:
Definitions
 • A microbial infection of a cardiac valve or the endocardium caused by
bacteria, fungi, or chlamydia
 Categorized as acute or subacute based on the rapidity of the clinical
course

3. Subtypes
1-Acute Bacterial Endocarditis (ABE)
 􀂄 Fulminant and severe course
 􀂄 Death is Frequent
 􀂄 Organisms: Staphylococcus aureus, Streptococcus pyogenes,
Streptococcus pneumoniae
2- Subacute Bacterial Endocarditis (SBE)
 􀂄 Indolent, slower and less severe course over months
 􀂄 Organisms: Streptococcus viridans

4. Organisms
Common:
 ABE: Staphylococcus aureus
 SBE: Streptococcus spp.: viridans
Less common:
 Enterococcus spp.
 Coagulase-negative staphylococci
 Gram negative bacilli
 Fungi especially candida
 Misc. / Polymicrobial
 Culture negative

5. Streptococcus viridans

6. Splinter Hges Osler’s nodes Janeway lesion
Cutaneous Manifestations
Purpura

7. Subungual splinter Hges

8. Osler’s Nodes:
 Painful
 erythmatous
 nodular lesions

9. Janeway lesions
 Non-tender, small erythematous
or hemorrhagic macules or
nodules in the palms or soles,
 The pathology is due to a type
III hypersensitivity reaction.

10. Hgic lesions
due to
1- thrombocytopenia
2- vasculitis

14. Roth Spots
 •“White-centered"
hemorrhages, originally
described in patients with
bacterial endocarditis.
 Don’t interfere with vision

15. Investigation
 1- Blood culture
For aerobic/anaerobic /fungus
positive for SIE :Viridans streptococci, for acute IE Staphylococcus aureus
involvement
 2-Echocardiogram positive for IE
 3 - other blood test: CRP, CBC
 4- other systems (might be affected)
brain (embolization/mycotic aneurysm) : brain MRI, brain MRA
kidney functions
abdominal U/S
chest CT
 ..

16. Specific
AB : IV for at least 2
weeks
 Prophylaxis
 Treatment of complication
Non specific
general: antipyretic
Hospitalization
Treatment

17. Prophylaxis
Bacteremia resulting from daily
activities is much more likely to
cause IE than bacteremia
associated with a dental
procedure.
 1- 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.

18.  2- Antibiotic prophylaxis is no longer
recommended for any other form of
CHD, except for the conditions ???
Next slide

19.  The antibiotic prophylactic regimens recommended by the AHA are only
for patients with underlying cardiac conditions associated with the
highest risk of adverse outcome
from infective endocarditis.
Antibiotic prophylaxis is indicated for the
following high-risk cardiac conditions:.
Feb 5, 2018

20. Cardiac Conditions for which IE Prophylaxis
Recommended for Dental Procedures (4)
1- Previous Infective Endocarditis
2-Prosthetic Cardiac Valve
3- Certain Congenital Heart
Disease (CHD)
4. Cardiac transplant

21. Cardiac Conditions for which IE Prophylaxis
Recommended for Dental Procedures
3- Congenital Heart Disease (CHD)
- Unrepaired Cyanotic CHD
- Completely Repaired CHD with Prosthetic
Material or Device, during the first 6 months
after the procedure
- Repaired CHD with Residual Defects at the
Site or Adjacent to the Site of a Prosthetic
Patch or Prosthetic Device (which Inhibit
Endothelialization)
4- Cardiac Transplant Recipients who Develop
Valvulopathy (valve disease)

22. Infectious Bacterial Endocarditis
Prophylaxis No Longer Recommended
for the Following Conditions
 Acyanotic HD
 􀂄 Ventricular Septal Defect
 􀂄 Ostium Primum Atrial Septal Defect
 􀂄 Pulmonary Stenosis
 􀂄 Aortic Stenosis/Insufficiency
 􀂄 Mitral Valve Prolapse with Valve Regurgitation
 􀂄 Patent Ductus Arteriosus
 􀂄 Coarctation of Aorta
 􀂄 Rheumatic Heart Disease
 􀂄 Hypertrophic Cardiomyopathy
Wilson W, Taubert KA, Gerwitz M, et al. Circulation. 2007;115.

23. NOT Recommended:
 􀂄 “Probably Innocent Murmur” never evaluated
by cardiologist but getting SBE prophylaxis “just in case.”
Recommended for
1- invasive dental procedures
2-invasive respiratory
procedures
3- invasive skin procedures
Endocarditis Prophylaxis

24. Dental Procedures for Which
Endocarditis Prophylaxis Is
Reasonable for Patients
 All dental procedures that involve
1- manipulation of gingival tissue or
2- the periapical region of teeth or
3-perforation of the oral mucosa**

25. Dental Procedures for which Endocarditis
Prophylaxis IS NOT Recommended in Patients
with the Highest Risk Cardiac Conditions
 􀂄 Routine anesthetic injections through non-infected tissue
 􀂄 Taking dental radiographs
 􀂄 Placement of removable prosthodontic or orthodontic appliances
 􀂄 Adjustment of orthodontic appliances
 􀂄 Placement of orthodontic brackets
 􀂄 Shedding of deciduous teeth
 􀂄 Bleeding from trauma to the lips or oral mucosa

26.  Genitourinary or GI Tract Procedures Antibiotics are no longer
recommended for endocarditis prophylaxis for patients undergoing
genitourinary or gastrointestinal tract procedures.

27. Other than dental procedures
1- ear piercing
2- skin tattoo
3- incision or biopsy of the respiratory mucosa (eg, tonsillectomy, adenoidectomy).
Antibiotic prophylaxis is not recommended for bronchoscopy unless the procedure
involves incision of the respiratory tract mucosa
4- Patients with high cardiac risk who undergo a surgical procedure that involves
infected skin, skin structure, or musculoskeletal tissue should receive an agent active
against staphylococci and beta-hemolytic streptococci (eg, antistaphylococcal penicillin,
cephalosporin)

28. Amoxacillin Oral 50 MG/KG
(adult 2gm)
Allergic to penicillin:
Clindamycin
Or
azithromycin or clarithromycin
oral 20 mg/kg (adult
600mg)
20mg/lg
(adult 500mg)
Not oral
Ampicillin
(if Sensitive)
Clindomycin
IM/IV 50 MG/KG
(adult 2 gm)
20mg/kg (600mg
adult)
One dose
of AB
30-60 min
Before
procedure