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Infective Endocarditis inChildren: an overview

Thomas R. Burklow, MD

LTC, MC

Chief, Pediatric Cardiology,

Walter Reed Army Medical Center

All around nice guy

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Objectives

Describe the incidence of IE in variouspediatric heart conditions.

Review the Duke criteria of infective

endocarditis Review the indications for prophylaxis and

current recommendations for antimicrobial

therapy. Review the efficacy and controversies in

IE prophylaxis.

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Background

Relatively rare in children

Pre-antibiotic era: mortality was nearly100%

Mortality approaches 15-25%

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Epidemiology

Increasing incidence beginning in the 80s

Increasing number of surgical patients Increasing number of complex congenital

heart disease

Increased use of prosthetic materials

NICUs and PICUs

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Pathogenesis, Part 1

Damaged endothelium

undamaged endothelium not conducive tobacterial colonization

endothelium can be damaged by high-velocityflows

trauma to endothelium can induce

thrombogenesis, leading to nonbacterialthrombotic endocarditis (NBTE). NBTE ismore receptive to colonization

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Pathogenesis, Part 2

Microorganism No. %

Streptococcus viridans 289 31.3

Staphylococcus aureus 225 24.4

Negative cultures 152 16.4

Other streptoccal species (e.g. enterococci) 55 5.9

HACEK and diphtheroids 50 5.4

Gram negative bacilli 45 4.8

Strept pneumoniae 18 1.9

Fungi 14 1.5

Others 28 3.0

Berkowitz, FE: Infective endocarditis. IN Nichols EG, Cameron DE, Greeley WJ, et al (eds):Critical Heart Disease in Infants and Children. St. Louis, Mosby-Year Book, 1995.

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Microbiology

S. Viridans Most common causative organism

Gram negative bacilli

Neonates and immunocompromised patients Prosthetic valves

Within first year of surgery: Coag-negative staph

After first year: similar to native valve endocarditis

HACEK organisms Hemophilus, Actinobacillus, Cardiobacterium,

Eikenella, Kingella

Frequently affect damaged valves and can cause

emboli

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Diagnosis

Traditionally based upon positive blood

cultures in the presence of a new orchanging heart murmur, or persistent

fever in the presence of heart disease.

Shortcomings include culture-negativeendocarditis, lack of typical

echocardiographic findings, etc.

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Duke Criteria

Based on pathological and clinical criteria.

Utilizes microbiological data, evidence ofendocardial involvement, and other phenomenon

associated with infective endocarditis to estimate theprobability of infective endocarditis in a givenpatient.

Has been shown to be valid and reproducible in

children

Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of infective endocarditis: utilizationof specific echocardiographic findings. AM J Med 96:200, 1994

Stockheim JA, Chadwick EG, Kessler S, et al. Are the Duke Criteria superior to the Beth Israel

criteria for the diagnosis of infective endocarditis in children? Clin Infect Dis 27:1451, 1998

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Duke criteria

Definitive Pathological criteria Microorganisms, or

Pathologic lesions

Clinical criteria

2 major criteria, or

1 major and 3 minor criteria, or

5 minor

Possible

Findings consistent with infective endocarditis that fall short of definitive but are

not rejected

Rejected Firm alternative diagnosis, or

Resolution of manifestations of endocarditis with antibiotic therapy of 4 days orless, or

No pathological evidence of endocarditis at surgery or autopsy with antibiotictherapy of 4 days or less

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Duke criteria: Major criteria

Positive blood culture

Typical microorganism consistent with IE, from two separate bloodcultures

S. viridans, S. bovis, HACEK

community-acquired S. aureus or enterocci (no primary focus)

Persistently positive cultures

at least two positive cultures, drawn 12 hours apart

all of three, or a majority of four or more cultures (with first and lastsample drawn at least one hour apart

Evidence of endocardial involvement Positive echocardiogram

oscillating intracardiac mass on valve or supporting structures, or

myocardial abscess, or

new partial dehiscence of prosthetic valve

New valvar regurgitation

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The echocardiogram in IE

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Duke criteria: Minor criteria Predisposition

Predisposing heart condition or IVdrug abuser

Fever

> 38.0 C

Vascular phenomena

arterial emboli, septic pulmonary

infarct, mycotic aneurysm,intracranial hemorrhage,conjunctival hemorrhage,Janeways lesion

Immunologic phenomena

glomerulonephritis, Oslersnodes, Roths spots, rheumatoid

factors Microbiologic evidence

positive blood culture but doesnot meet major criteria as noted

Echocardiographic evidence

consistent with IE but does not

meet major criteria as noted

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Sequelae

Neurologic manifestations, 20%

Cerebral emboli, mycotic aneurysms,cerebritis, brain abscess, hemorrhage, etc.

Peripheral embolization

Ischemia, infarction, mycotic aneurysms, etc

Pulmonary infarction

Renal insufficiency

Congestive heart failure

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Prevention of IE

No randomized controlled human trials whichdefinitively establishes the efficacy of antibioticprophylaxis.

Most cases of endocarditis are NOT attributable toan invasive procedure

Current recommendations are based upon literatureanalysis of procedure-related endocarditis,

prophylaxis studies in experimental animal models,and retrospective analysis of human endocarditis

Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis:Recommendations by the American Heart Association. JAMA 277;1794: 1997

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IE prophylaxis: Does it work? Strom BL. When data conflict with practice: rethinking the use of

prophylactic antibiotics before dental treatment. LDI Issue Brief2001Mar;6(6):1-4

Lockhart PB, Brennan MT, Fox PC, Norton HJ, Jernigan DB, StrausbaughLJ. Decision-making on the use of antimicrobial prophylaxis for dentalprocedures: a survey of infectious disease consultants and review. ClinInfect Dis. 2002 Jun 15;34(12):1621-6.

Seymour RA, Lowry R, Whitworth JM, Martin MV. Infective endocarditis,dentistry and antibiotic prophylaxis; time for a rethink? Br Dent J2000 Dec9;189(11):610-6

Strom BL, Abrutyn E, Berlin JA, Kinman JL, Feldman RS, Stolley PD,Levison ME, Korzeniowski OM, Kaye D. Dental and cardiac risk factors forinfective endocarditis. A population-based, case-control study. Ann Intern

Med1998 Nov 15;129(10):761-9 Van der Meer JT, Van Wijk W, Thompson J, Vandenbroucke JP,

Valkenburg HA, Michel MF. Efficacy of antibiotic prophylaxis for preventionof native-valve endocarditis. Lancet1992 Jan 18;339(8786):135-9

Epstein JB. Infective endocarditis and dentistry: outcome-based research. JCan Dent Assoc1999 Feb;65(2):95-6

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Endocarditis prophylaxisrecommended

High-risk Prosthestic cardiac valves

Previous bacterial endocarditis

Complex cyanotic heart disease

Surgically constructed systemic-pulmonary shunts or conduits

Moderate-risk Most other congenital heart disease

Acquired valvar dysfunction

Hypertrophic cardiomyopathy

Mitral valve prolapse WITH regurgitation and/or thickenedleaflets

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Endocarditis prophylaxis NOTrecommended

Isolated secundum ASD

Surgically repaired VSD, ASD, or PDA after 6months (no residua)

s/p CABG

MVP without MR

Previous Kawasaki disease w/o valvar

dysfunction Previous rheumatic fever w/o valvar dysfunction

Pacemakers and AICDs

Flow murmurs

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Dental procedures and IEprophylaxis: Recommended

Dental extractions

Periodontal procedures

Dental implants and reimplantation of avulsed teeth

Endodontic proceures Subgingival placement of antibiotic fibers and strips

Initial placement of orthodontic bands (not brackets)

intraligamentary local anesthetic injections Prophylactic cleaning

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Dental procedures and IEprophylaxis: Not recommended

Restorative dentistry

Non-intraligamentary local anesthetic injections

Taking oral impressions

Fluoride treatments Oral radiographs

Orthodontic appliance adjustment

Shedding primary teeth

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Other procedures and IEprophylaxis: Recommended

Respiratory

T&A

Surgical procedures involving respiratory mucosa

Rigid bronchoscopy

Gastrointestinal

Sclerotherapy

Esophageal stricture dilation

ERCP with biliary obstruction Surgery involving biliary tract or intestinal mucosa

Genitourinary tract

Prostatic surgery, cystoscopy

Urethral dilation

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Other procedures and IEprophylaxis: Not Recommended Respiratory

Endotracheal intubation

PE tubes

Flexible bronchoscopy

Gastrointestinal

Transesophageal echocardiography

Endoscopy (with or without biopsy)

Circumcision Genitourinary tract

Vaginal hysterectomy, and vaginal or Caesarean deliveries

In uninfected tissues: urethral catheterization, uterine

D&C, therapeutic abortions, sterilization procedures,insertion or removal of IUDs

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How aboutTattoos and Body piercing?

Ear piercing 43% of respondents had ear piercing

Only 6% took antibiotics

23% reported infections but no IE reported

Tattoos 5% of respondents had tattoos

No antibiotics or infections reported

Physicians Majority of physicians did not approve of piercing or tattoos

60% felt that IE prophylaxis use was appropriate

Cetta F, Graham LC, Lichtenberg RC, Warnes CA. Piercing and tattooing

in patients with congenital heart disease. J Adolesc Health 1999;24:160

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References Bayer AS, Bolger AF, Taubert KA, Wilson W, Steckelberg J, Karchmer AW, et al. Diagnosis and Management of

Infective Endocarditis and Its Complications. Circulation. 1998;98:2936-2948. Berkowitz, FE: Infective endocarditis. IN Nichols EG, Cameron DE, Greeley WJ, et al (eds):Critical Heart Disease in Infants and Children. St. Louis, Mosby-Year Book, 1995.

Cetta F, Graham LC, Lichtenberg RC, Warnes CA. Piercing and tattooing in patients with congenital heartdisease. J Adolesc Health 1999;24:160

Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: Recommendations by the AmericanHeart Association. JAMA 277;1794: 1997

Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of infective endocarditis: utilization of specificechocardiographic findings. AM J Med 96:200, 1994

Epstein JB. Infective endocarditis and dentistry: outcome-based research. J Can Dent Assoc1999 Feb;65(2):95-6 Lockhart PB, Brennan MT, Fox PC, Norton HJ, Jernigan DB, Strausbaugh LJ. Decision-making on the use of

antimicrobial prophylaxis for dental procedures: a survey of infectious disease consultants and review. Clin InfectDis. 2002 Jun 15;34(12):1621-6.

Seymour RA, Lowry R, Whitworth JM, Martin MV. Infective endocarditis, dentistry and antibiotic prophylaxis; timefor a rethink? Br Dent J2000 Dec 9;189(11):610-6

Stockheim JA, Chadwick EG, Kessler S, et al. Are the Duke Criteria superior to the Beth Israel criteria for thediagnosis of infective endocarditis in children? Clin Infect Dis 27:1451, 1998

Strom BL, Abrutyn E, Berlin JA, Kinman JL, Feldman RS, Stolley PD, Levison ME, Korzeniowski OM, Kaye D.

Dental and cardiac risk factors for infective endocarditis. A population-based, case-control study. Ann Intern Med1998 Nov 15;129(10):761-9

Strom BL. When data conflict with practice: rethinking the use of prophylactic antibiotics before dental treatment.LDI Issue Brief2001 Mar;6(6):1-4

Taubert KA and Dajani AS. Infective Endocarditis IN Garson A, Bricker JT, Fisher DJ, and Neish SR, eds. TheScience and Practice of Pediatric Cardiology. Williams and Wilkins. Baltimore. 1998. Pp. 768-779.

Van der Meer JT, Van Wijk W, Thompson J, Vandenbroucke JP, Valkenburg HA, Michel MF. Efficacy of antibioticprophylaxis for prevention of native-valve endocarditis. Lancet1992 Jan 18;339(8786):135-9