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

2. Page 1 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics Infective Endocarditis The beginnings

3. Pediatrics

4. Page 3 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics Infective Endocarditis

5. Page 4 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics Endocardial injury Thrombus formation Transient bacteremia Layering of Platelets Fibrin Bacteria Vegetation

6. Page 5 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics Vegetation Mayoclinic.org

7. Page 6 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics Congenital heart disease ‐ highest risk cyanotic / palliations Rheumatic heart disease CVL How do children get IE? 1:1280 pedi admissions / yr

8. Page 7 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics Prolonged low grade fever Somatic complaints Fatigue Weakness Arthralgia / myalgia How does IE present? Weight loss Rigors Diaphoresis Heart failure New murmur

9. Page 8 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics Emboli - Brain - Abdominal viscera - Kidneys, liver, spleen - Extremities How does IE present?

10. Page 9 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics Roth spots Janeway lesions Osler nodes How does IE present? RARE in children

11. Page 10 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics Splinter hemorrhages

12. Page 11 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics Roth Spots

13. Page 12 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics Osler Nodes

14. Page 13 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics Janeway lesions

15. Page 14 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics Modified Duke Criteria Diagnosing Infective Endocarditis (AHA, 2005)

16. Page 15 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics

17. Page 16 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics

18. Page 17 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics

19. Page 18 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics How serious is IE? AHA, 2005

20. Page 19 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics How serious is IE?

21. Page 20 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics Pathogens 3 most common organisms Staphylococci aureus Streptococci viridans Enterococci Others CONS GNR Hemophilus Aggregatibacter Cardiobacterium Eikenalla Kingella (AHA, 2005)

22. Page 21 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics Pathogens Staphylococci aureus Oxacillin and Vancomycin resistance Enterococcus Vancomycin and aminoglycoside resistance Streptococci viridans Multidrug resistance (AHA, 2005)

23. Page 22 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics How do you treat IE? IE suspected NOT acutely ill Acutely ill Obtain blood cultures & consider starting antibiotics Start antibiotics, obtain blood cultures prior if possible

24. Page 23 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics 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 How do you treat IE?

25. Page 24 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics 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) How do you treat IE?

26. Page 25 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics 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) How do you treat IE?

27. Page 26 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics Culture negative IE ‐ 20% of cases Causes ‐ Inadequate microbiolical techniques ‐ Fastidious or nonbacterial pathogens ‐ Pretreated cultures (AHA, 2005) How do you treat IE?

28. Page 27 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics Surgical indications ‐ Fistulae ‐ Staph or Fungal vegetations ‐ Risk of embolization ‐ Abscess ‐ Heart failure ‐ Mycotic aneurysm ‐ Goretex & dacron shunts likely to need replacing (AHA, 2005) How do you treat IE?

29. Page 28 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics 2007 guideline revision Frequent exposure is greatest risk Prophylaxis might prevent few cases Risk outweighs benefit Oral health maintenance How do you prevent IE

30. Page 29 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics Prophylaxis is NOT recommended unless …

31. Page 30 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics 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 How do you prevent IE

32. Page 31 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics 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 How do you prevent IE

33. Page 32 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics Respiratory procedures ‐ Not recommended ‐ Reasonable to include abx for Incision or biopsy of the respiratory mucosa tonsillectomy, adenoidectomy, drainage of abscess or empyema How do you prevent IE

34. Page 33 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics How do you prevent IE Unique situations refer to…

35. Page 34 xxx00.#####.ppt 6/13/2016 10:08:19 AM Pediatrics 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 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 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 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 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.