infective endocarditis- dental applications

1. “The practice of medicine is an art, not a trade;
a calling, not a business; a calling in which your heart
will be exercised equally with your head. Often the
best part of your work will have nothing to do with
potions and powders, but with the exercise of an
influence of the strong upon the weak, of the
righteous upon the wicked, of the wise upon the
foolish.”
- SIR WILLIAM OSLER
1

2.  Osler created the first residency program for speciality training of
physicians,
 He liked to say, "He who studies medicine without books sails an uncharted
sea, but he who studies medicine without patients does not go to sea at all.“
Hence
 He was the first to bring medical students out of the lecture hall for bedside
clinical training.
 First formal journal club
 Principles and practice of medicine – key book for medical students
 He has frequently been described as the "Father of Modern Medicine".
 His best-known saying was "Listen to your patient, he is telling you the
diagnosis," which emphasises the importance of taking a good case history.
2

3. INFECTIVE ENDOCARDITIS 3
Sohail
PGT 1st year
S.V.S.I.D.S

4. Contents
 Introduction
 Etiology
 Microbiology
 Pathophysiology
 Classification
 Clinical features
 Laboratory findings
 Diagnosis
 Dentistry and endocarditis
4

5. Endocarditis- History
 In pre-Abx era, largely fatal disease
 First described by a French physician- Jean Francois Fernel,
in his book Medicina in 1554.
 Almost 300 years later, in 1885, Sir William Osler gave a
comprehensive account of endocarditis in three Gulstonian
lectures.
 1940’s – PCN revived hope for a cure of IE, however
morbidity and mortality only partially altered
5
Chamoun. Am J Med Sci. Oct 2000; 320 (4)

6. Endocarditis – surgical Rx
 1961 – Kay et al first to report surgical cure with medically
resistant IE
 1965 Wallace et al – first report of successful valve
replacement in active endocarditis
 1994 - Duke’s Criteria proposed by Dr. Durack from Duke
University.
6

7.  Infective endocarditis is defined as an infection of the endocardial
surface of the heart, which may include one or more heart valves, the
mural endocardium, or a septal defect. It is caused by a wide variety of
bacteria and fungi
 The intracardiac effects of this infection include severe valvular
insufficiency, which may lead to congestive heart failure and myocardial
abscesses.
7Definition:

8. What causes endocarditis…???
- predisposing factors
 Dental procedures
 Dental disease (caries, abscess)
 Extracardiac infection (lung, urinary tract, skin, bone,
abscess)
 Instrumentation (urinary tract, GI tract, IV infusions)
 Cardiac surgery
 Injection drug use (IVDA)
8

9. Pathophysiology
 I.E – bacteremia.
 Prosthetic heart valves – foci for platelet adhesion and
thrombus formation.
 Early infection of prosthetic valves – intraoperative
contamination.
 Late infection – due to microbes and entry portals.
9

10. A peculiar disease…!!!
Infective Endocarditis (IE) is a Peculiar Disease for at least Three
Reasons
 First- Despite major advances in both diagnostic and therapeutic
procedures, this disease still carries a poor prognosis and a high
mortality. Neither the incidence nor the mortality of the disease have
decreased in the past 30 years.
 Secondly - IE is not a uniform disease, but presents in a variety of
different forms
 Third - Guidelines are often based on expert opinion because of the
low incidence of the disease, the absence of randomized trials, and
the limited number of meta analyses.
10

11. ln the Indian scenario;
 Still it is common in younger age groups.
 A study by Garg N et al. in Indian patients during the last
decade indicates that 76% of the patients with IE were
younger than 40 years (median age 27.6 ± 12 years).
 At least 17,000 episodes of IE must be occurring per year in
India
11

12. UNDERLYING HEART DISEASES
 Rheumatic valvular diseases 30%
 Congenital heart diseases 10-20%.
 Mitral valve prolapse 10-33%.
 Degenerative heart diseases- calcific AS, syphilitic AR,
Marfan’s syndrome, AV fistula.
 No underlying heart disease in 20-40%.
12

13. Organisms Causing Major Clinical
Forms of Endocarditis:
 Staphylococcus aureus infection is the most common cause of IE,
including PVE, acute IE, and IVDA IE.
 Approximately 35-60.5% of staphylococcal bacteremias are
complicated by IE.
 More than half the cases are not associated with underlying
valvular disease.
 The mortality rate of S aureus IE is 40-50%.
13

14.  Streptococcus viridans
 This organism accounts for approximately 50-60% of
cases of subacute disease.
 Most clinical signs and symptoms are mediated
immunologically.
 Streptococcus intermedius group
 These infections may be acute or subacute.
 S intermedius infection accounts for 15% of streptococcal
IE cases.
 S intermedius is unique among the streptococci; it can
actively invade tissue and can cause abscesses.
14

15. • Haemophilus aphrophilus,
• Actinobacillus actinomycetemcomitans,
• Cardiobacterium hominis,
• Eikenella corrodens,
• Kingella kingae
 These organisms usually cause subacute disease.
 They account for approximately 5% of IE cases.
 They are the most common gram-negative organisms isolated
from patients with IE.
 Complications may include massive arterial emboli and congestive
heart failure.
 Cure requires ampicillin, gentamicin, and surgery.
15HACEK organisms

16. Fungi
 These usually cause subacute disease.
 The most common organism of both fungal NVE and fungal
PVE is Candida albicans.
 Fungal IVDA IE is usually caused by Candida parapsilosis
or Candida tropicalis.
 Aspergillus species are observed in fungal PVE and NIE.
16

17. Acute I.E – microbemia
Staph.aureus, Strep.pneumonia, N.gonorrheae,
strep.pyogenes, E.faecalis.
17Remember …

18. Subacute I.E – underlying Valvular Disease.
viridans streptococci, enterococci,
nonenterococcal group D streptococci,
microaerophilic streptococci, and Haemophilus
species.
18
And…

19. Difference between ..
 Acute
 Affects normal heart
valves
 Rapidly destructive
 Metastatic foci
 Commonly Staph.
 If not treated, usually
fatal within 6 weeks
 Subacute
 Often affects damaged
heart valves
 Indolent nature
 If not treated, usually
fatal by one year
19

20. Bacteremia can result from various
invasive procedures
 Endoscopy
 Rate of 0-20%
 streptococci, diphtheroids
 Colonoscopy
 Rate of 0-20%
 Escherichia coli, Bacteroides species
 Barium enema
 Rate of 0-20%
 Enterococci, aerobic and anaerobic gram-negative rods
 Dental extractions
 Rate of 40-100%
 S viridans
 Transurethral resection of the prostate
 Rate of 20-40%
 Coliforms, enterococci, S aureus
20

21. Clinical features..
21

22. Clinical and Laboratory Features of
Infective Endocarditis
 Fever 80-90 %
 Chills and sweats 40-75 %
 Anorexia, weight loss, malaise 25-50 %
 Myalgias, arthralgias 15-30 %
 Back pain 7-15 %
 Heart murmur 80-85 %
 New/worsened regurgitant murmur 10-40 %
22

23. Clinical and Laboratory Features of
Infective Endocarditis
 Arterial emboli 20-50 %
 Splenomegaly 15-50 %
 Clubbing 10-20 %
 Neurologic manifestations 20-40 %
 Peripheral manifestations (Osler's nodes, subungual
hemorrhages, Janeway lesions, Roth's spots) 2-15 %
 Petechiae 10-40 %
23

24. Clinical and Laboratory Features of
Infective Endocarditis
Laboratory manifestations:
 Anemia 70-90 %
 Leukocytosis 20-30 %
 Microscopic hematuria 30-50 %
 Elevated erythrocyte sedimentation rate>90 %
24

25. Clinical and Laboratory Features of
Infective Endocarditis
 Rheumatoid factor 50 %
 Circulating immune complexes 65-100 %
 Decreased serum complement 5-40 %
25

26. (A) Splinter hemorrhages are normally seen
under the fingernails
(B)conjunctival petechiae.
(C) Osler's nodes - tender, subcutaneous nodules,
often in the pulp of the digits or the thenar
eminence.
(D)Janeway's lesions are nontender,
erythematous, hemorrhagic, or pustular lesions,
often on the palms or soles.
26
Peripheral Manifestations of
Infective Endocarditis.

27. Janeway’s lesions. 27
Hemorrhagic, infarcted
macules and papules on
the volar fingers in a
patient with S. aureus
endocarditis.

28. Septic vasculitis 28
Associated with bacteremia.
Dermal nodule with
hemorrhage and necrosis on
the dorsum of a finger. This
type of lesion occurs with
bacteremia (e.g., S. aureus)
and fungemia (e.g., Candida
tropicalis).

29. Subconjunctival hemorrhage. 29
Submucosal hemorrhage
of the lower eyelid in an
elderly diabetic with
enterococcal endocarditis;

30. Splinter hemorrhages 30
Embolic Subungual hemorrhages in
the midportion of the nail bed

31. Splinchter
haemorrhages are
linear lying parallel to
the long axis of finger
or toe nails.
31

32. 32
Osler's nodes - Violaceous, tender
nodules on the volar fingers
associated with minute infective
emboli or immune complex
deposition.

33. 33
Septic emboli with hemorrhage
and infarction due to acute
Staphylococcus aureus
endocarditis.

34. 34
Vasculitis

35. 35
A middle-aged man with a history of
intravenous drug use who presented with severe
myalgias and a petechial rash..

36. Clubbing - Seen in
patients with chronic
lung disease, cyanotic
heart disease, cirrhosis
and infective
endocarditis.
36

37. 37
Computed tomography of the
abdomen showing large
embolic infarcts in the spleen
and left kidney of a patient with
Bartonella endocarditis.

38. Neurological symptoms
Neurological embolic damage includes
 Cranial nerve palsies,
 Cerebritis
 Mycotic aneurysms caused by weakening of the vessel walls and
produced by embolization to the vasa vasorum.
 Mycotic aneurysms may occur in the abdominal aorta and the
splenic, coronary, and pulmonary arteries.
38

39. 39
Cardiac symptoms
•Myocardial infarction, pericarditis, cardiac
arrhythmia
•Cardiac valvular insufficiency
•Congestive heart failure
•Sinus of Valsalva aneurysm
•Aortic root or myocardial abscesses
•Arterial emboli, infarcts, mycotic aneurysms

40. 40
In the presence of aortic insufficiency,
vegetations characteristically occur on
(A)The ventricular surface of the
aortic valve.
(B)On the chordae tendinae or
papillary muscles.
(C)In mitral regurgitation, the
vegetations characteristically are
located on the atrial surface of the
mitral valve
(D) At sites of jet lesions on the atrial
wall.
Characteristic sites of vegetations within the heart.

41. 41
Vegetations caused by streptococci on mitral valve

42. 42

43. 43

44. 44
Vegetations (arrows) due to viridans streptococcal
endocarditis involving the mitral valve.

45. Aortic Valve Disease 45

46.  Echocardiography Identification of vegetation
is one of the two major criteria for IE.
 Typical Echo Features
• Oscillating intracardiac mass on a valve or
supporting structure or device or in the path of a
regurgitant stream
• Abscess
• New partial dehiscence of the prosthetic valve
• New valvular regurgitation
• Echo is useful in predicting complications based
on the size of the vegetation, mobility, extent and
consistency, either embolization or local destruction
46
Transesophageal echocardiogram showing
aortic valve vegetation (arrow).

47. Prosthetic valve endocarditis 47
Prosthetic valve endocarditis(PVE) is an
endovascular, microbial infection occurring on
parts of a valve prosthesis or on reconstructed
native heart valves

48. Libman-Sacks Endocarditis 48

49. Bracht-Wachter bodies are a finding in infective
endocarditis consisting of yellow-white miliary spots in
the myocardium.
Histologically, these are collections of chronic inflammatory
cells, mainly lymphocytes and histiocytes
49
Histological features

50. INVESTIGATIONS
 Blood culture – 3 Samples, 20 ml, 1/2 hr interval
 2D-Echocardiography.
 ECG
 Measurement of plasma C-reactive protein
 Raised ESR
 Chest radiograph .
50

51. 51

52. 52

53. 53

54. Antibiotic Treatment for Infective
Endocarditis Caused by Common Organisms
 Streptococci Penicillin-susceptible streptococci, S.
bovis
 Penicillin G 2-3 million units IV q4h for 4 weeks
 Penicillin G 2-3 million units IV q4h plus
gentamicin 1 mg/kg IM or IV q8h, both for 2 weeks
 Ceftriaxone 2 g/d IV as single dose for 4 weeks
 Vancomycind 15 mg/kg IV q12h for 4 weeks
54

55. Antibiotic Treatment for Infective
Endocarditis Caused by Common Organisms
 Relatively penicillin-resistant streptococci
- Penicillin G 3 million units IV q4h for 4-6 weeks plus gentamicin 1
mg/kg IV q8h for 2 weeks
 Penicillin-resistant streptococci, pyridoxal-requiring streptococci
(Abiotrophia spp.)
- Penicillin G 3-4 million units IV q4h plus gentamicinc 1 mg/kg IV
q8h, both for 4-6 weeks
55

56. Indications for Cardiac Surgical
Intervention in Patients with Endocarditis
 Perivalvular extension of infection
 Poorly responsive S. aureus endocarditis involving the aortic or
mitral valve
 Large (>10-mm diameter) hypermobile vegetations with increased
risk of embolism
 Poorly responsive or relapsed endocarditis due to highly
antibiotic-resistant enterococci or gram-negative bacilli
56

57.  Moderate to severe congestive heart failure due to valve dysfunction
 Partially dehisced unstable prosthetic valve
 Persistent bacteremia despite optimal antimicrobial therapy
 Lack of effective microbicidal therapy (e.g., fungal or Brucella
endocarditis)
 S. aureus prosthetic valve endocarditis with an intracardiac
complication
 Relapse of prosthetic valve endocarditis after optimal antimicrobial
therapy
57

58. Vegetation
Persistent vegetation after systemic embolization
Anterior mitral leaflet vegetation, particularly with size >10 mm
≥1 Embolic event during first 2 wk of antimicrobial therapy
≥2 Embolic events during or after antimicrobial therapy
Increase in vegetation size after 4 wk of antimicrobial therapy
Valvular dysfunction
Acute aortic or mitral insufficiency with signs of ventricular failure
Heart failure unresponsive to medical therapy
Valve perforation or rupture
Perivalvular extension
Valvular dehiscence, rupture, or fistula
New heart block
Large abscess or extension of abscess despite appropriate antimicrobial therapy
58
Echocardiographic Features Suggesting Potential Need for Surgical Intervention

59. Prevention
 Approximately 15-25% of cases of IE are a consequence of invasive
procedures that produce a significant bacteremia.
 Because only 50% of those who developed valvular infection following a
procedure were identified as being candidates for antibiotic prophylaxis,
only approximately 10% of cases of IE can be prevented by the
administration of preprocedure antibiotics.
 Maintaining good oral hygiene is probably more effective in the overall
prevention of valvular infection because gingivitis is the most common
source of spontaneous bacteremias.
 The American Heart Association periodically compiles recommendations for
IE prophylaxis.
59

60. Coutinho et al, knowledge and practices of dentists in preventing infective
endocarditis in children. Spec care dent; 2009; 29:4; 175-8.
 This study assessed the knowledge and practices of dentists in the
prevention of infective endocarditis (IE).
 Included 21 dentists working at two hospitals who treated children with
cardiac conditions.
 15 said they had treated patients with a previous history of IE and 6 stated
that many guardians seemed to be afraid to mention that their child had a
previous history of IE.
 The main risk of infectivity was the oral cavity according to 16 subjects
(76%). Nine subjects (43%) considered a dental procedure involving any
amount of bleeding as being a risk, and periodontal/endodontic treatments
were mentioned by 5 (24%) as procedures that needed antibiotic
prophylaxis.
 As for prophylactic treatment, only 7 subjects (33%) said they followed the
American Heart Association guidelines.
60

61. Oncag et al, Bacteremia incidence in pediatric patients under general
anesthesia. Congenit heart dis, 2006;1:5;224-8.
 The aim of this study was to assess the incidence of bacteremia from various
procedures in children undergoing dental treatment under general anesthesia.
 Three blood samples for cultures were obtained from each patient; the first sample (10
ml basal) at the onset of the process and the second sample (10 ml) within 30 seconds
following the nasotracheal intubation. The third blood sample (10 ml) was taken 30
seconds after the extraction of a deciduous tooth or a permanent tooth or slow drilling.
Following incubation in an automated blood culture system, bacteria were identified
by using conventional biochemical methods.
 All blood cultures were negative before intubation (baseline) in every patient.
However, the percentage of positive samples in deciduous tooth extraction and
permanent tooth extraction groups were 18/26 (69.2%) and 18/25 (72%), respectively.
61

62. Brian et al, Antibiotics for Prevention of Endocarditis
during Dentistry: Time To Scale Back? Ann Intern
Med. 1998;129(10):761-769
 Objective: To quantitate the risk for endocarditis from dental treatment and
cardiac abnormalities.
 Patients: Persons with community-acquired infective endocarditis not
associated with intravenous drug use were compared with community
residents,
 Results: Of 273 case-patients, 104 (38%) knew of previous cardiac lesions
compared with 17 controls (6%) . Case-patients more often had a history of
mitral valve prolapse, congenital heart disease, cardiac valvular surgery,
rheumatic and heart murmur without other known cardiac abnormalities.
 Among case-patients with known cardiac lesions-the target of prophylaxis-
dental therapy was significantly (P = 0.03) less common than among controls.
 Few participants received prophylactic antibiotics.
62

63. 63In 2002 - American Heart Association (AHA) published “Unique
Features of Infective Endocarditis in Childhood,”
In 2005 - AHA reports have focused on new recommendations
for treatment of IE in adults.
In 2007 - Major changes regarding prevention of IE
2010 - To reduce the risk of bacteremia from dental procedure:
maintaining good oral health and hygiene is more important
than Antibiotic prophylaxis

64. Reasons for 2002- 2005 –
2007 - 2010 Revision
 IE more likely due to frequent exposure to random
bacteremias from daily activities than from bacteremia
during dental/GI/GU procedure
 Prophylaxis may prevent only small number of cases of
IE, even if 100% effective
 Risk of antibiotic-assoc. adverse events exceeds the
benefit, if any, from prophylaxis
 To reduce the risk of bacteremia from dental
procedure: maintaining good oral health and hygiene
is more important than Antibiotic prophylaxis
64

65. Dental Procedures
 “If it bleeds, give prophylaxis” - vance fowler , duke
university. 2008
 There should be a shift in emphasis away from a focus
on a dental procedure and antibiotic prophylaxis toward a
greater emphasis on improved access to dental care and
oral health in patients with underlying cardiac conditions
associated with the highest risk of adverse outcome from
IE and those conditions that predispose to the acquisition
of IE
65

66. Prophylaxis always required Prophylaxis required in
some circumstances
Prophylaxis not required
Extraction
Periodontal procedures
including surgery,
subgingival scaling and
root planing
Replanting avulsed teeth
Surgical procedures (eg
apicoectomy)
Full periodontal probing for
patients with periodontitis
Intraligamentary and
intraosseous local anaesthetic
injection
Supragingival calculus
removal/cleaning
Rubber dam placement with
clamps (where there is a risk
of damaging gingiva)
Restorative matrix band/strip
placement
Endodontics beyond the
apical foramen
Placement of orthodontic
bands
Placement of interdental
wedges
Subgingival placement of
retraction cords, antibiotic
fibres or antibiotic strips
Oral examination
Infiltration and block local
anaesthetic injection
Restorative dentistry
Supragingival rubber dam
clamping and placement of
rubber dam
Intracanal endodontic
procedures
removal of sutures
Impressions and construction
of dentures
Orthodontic bracket
placement and adjustment of
fixed appliances
Application of gels
Intraoral radiographs
Supragingival plaque removal
66
Dental procedures and their requirement for endocarditis prophylaxis in patients with a
cardiac condition

67. Rationale
 IE prophylaxis regimen has been evolving for the
past 50 years.
 Basis for recommendations and quality of evidence
limited to expert opinion.
 Several assumptions have led to development of abx
prophylaxis in humans, and these assumptions have
been recently questioned
67
Wilson, et al. Circulation. 2007; 115

68. Evidence
(1) Frequency, nature, magnitude, and duration of bacteremia
associated with dental procedures
(2) Impact of dental disease, oral hygiene, and type of dental procedure
on bacteremia
(3) Impact of antibiotic prophylaxis on bacteremia from a dental
procedure
(4) The exposure over time of frequently occurring bacteremia from
routine daily activities compared with bacteremia from various dental
procedures.
68
Wilson, et al. Circulation. 2007; 115

69. Evidence
 Dental procedures
 Transient bacteremia is common with manipulation of the teeth
and periodontal tissues.
 Wide variation in reported frequencies of bacteremia in patients
resulting from dental procedures:
 Tooth extraction (10% to 100%),
 Periodontal surgery (36% to 88%),
 Teeth cleaning (up to 40%)
 Endodontic procedures (up to 20%)
69
Wilson, et al. Circulation. 2007; 115

70. Antibiotic prophylaxis – AHA 2015 guidelines
 amoxycillin (child: 50 mg/kg up to 2 g) orally, 1 hour before the procedure
or
 amoxy/ampicillin (child: 50 mg/kg up to 2 g) IV, within the 60 minutes (ideally 15 to 30 minutes)
before the procedure
or
 amoxy/ampicillin (child: 50 mg/kg up to 2 g) IM, 30 minutes before the procedure.
For patients hypersensitive to penicillins (excluding immediate hypersensitivity)
 cephalexin (child: 50 mg/kg up to 2 g) orally, 1 hour before the procedure
or
 cephazolin (child: 30 mg/kg up to 2 g) IV, within the 60 minutes (ideally 15 to 30 minutes) before the
procedure
or
 clindamycin (child: 20 mg/kg up to 600 mg) IV over at least 20 minutes, within the 60 minutes
(ideally 15 to 30 minutes) before the procedure
70

71. Take away points…
 Infective endocarditis -infection of the endocardial surface of
the heart.
 Pre disposing factors – Dental procedures, Extra cardiac
infections, IVDA.
 Development of I.E – prosthetic heart valves, underlying
cardiac diseases.
 17,000 incidents of I.E per year in India.
 Staphylococcus aureus infection - most common cause of IE.
 Classified as Acute I.E and Subacute I.E
 Fever, Chills and sweats, Anorexia.
 Heart murmur , worsened regurgitant murmur, emboli.
71

72.  Blood cultures, 2D-Echocardiography, ECG, TTE, TOE.
 Duke’s criteria for diagnosing infective endocarditis.
 Initial therapy - vancomycin or ampicillin/sulbactam (Unasyn) plus an
aminoglycoside
 Remember the guidelines to proceed for surgerical procedures in I.E
 Dental procedures which may induce bleeding and any other minor
surgical procedures require anti-biotic prophylaxis.
72

73. References
 BURKET’S Text book of oral medicine – 11th edition
 NELSON’S – Textbook of pediatrics.
 SCULLY AND CAWSON , Medical problems in dentistry – 5th edition
 ROBINS AND COTRAN – Pathological basics of disease – 8th
edition.
 PRESCOTT’S Microbiology – Whilley and Sherwood 8th edition.
 SCULLY – Oral and maxillofacial medicine. – 3rd edition.
 LANGE – Basics of clinical pharmacology – 11th edition.
73