Infective Endocarditis in Children: an overview

Thomas R. Burklow, MD

LTC, MC

Chief, Pediatric Cardiology,

Walter Reed Army Medical Center

All around nice guy

Objectives

• Describe the incidence of IE in various pediatric 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.

Background

• Relatively rare in children

• Pre-antibiotic era: mortality was nearly 100%

• Mortality approaches 15-25%

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

Pathogenesis, Part 1

• Damaged endothelium– undamaged endothelium not conducive to

bacterial colonization– endothelium can be damaged by high-velocity

flows– trauma to endothelium can induce

thrombogenesis, leading to nonbacterial thrombotic endocarditis (NBTE). NBTE is more receptive to colonization

Heart disease and IE

Disease No. %Acyanotic Heart Disease

VSD 194 21.8Aortic stenosis 89 10.0PDA 25 2.8Coarctation of the aorta 25 2.8Pulmonary stenosis 21 2.4VSD with other defects 18 2.0Atrioventricular septal defect 16 1.8Mitral valve abnormality 16 1.8Atrial septal defect 11 1.2Mitral valve prolapse 8 0.9

Cyanotic Heart DiseaseTetralogy of Fallot 143 16.0Transposition of Great Vessels 35 3.9Tricuspid Atresia 9 1.0

Rheumatic Heart Disease 86 9.7No Heart Disease 75 8.4

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.

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.

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

Diagnosis

• Traditionally based upon “positive blood cultures in the presence of a new or changing heart murmur”, or persistent fever in the presence of heart disease.

• Shortcomings include culture-negative endocarditis, lack of typical echocardiographic findings, etc.

Duke Criteria

• Based on pathological and clinical criteria.

• Utilizes microbiological data, evidence of endocardial involvement, and other phenomenon associated with infective endocarditis to estimate the probability of infective endocarditis in a given patient.

• Has been shown to be valid and reproducible in children

Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of infective endocarditis: utilization of 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

Duke criteria• DefinitiveDefinitive

– Pathological criteria• Microorganisms, or• Pathologic lesions

– Clinical criteria• 2 major criteria, or• 1 major and 3 minor criteria, or• 5 minor

• PossiblePossible

– Findings consistent with infective endocarditis that fall short of “definitive” but are not “rejected”

• RejectedRejected– Firm alternative diagnosis, or– Resolution of manifestations of endocarditis with antibiotic therapy of 4 days or less, or– No pathological evidence of endocarditis at surgery or autopsy with antibiotic therapy

of 4 days or less

Duke criteria: Major criteria

• Positive blood culturePositive blood culture– Typical microorganism consistent with IE, from two separate blood

cultures

• 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 last sample drawn at least one hour apart

• Evidence of endocardial involvementEvidence 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

The echocardiogram in IE

Duke criteria: Minor criteria• PredispositionPredisposition

– Predisposing heart condition or IV drug abuser

• FeverFever– > 38.0º C

• Vascular phenomenaVascular phenomena– arterial emboli, septic pulmonary

infarct, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage, Janeway’s lesion

• Immunologic phenomenaImmunologic phenomena– glomerulonephritis, Osler’s nodes,

Roth’s spots, rheumatoid factors • Microbiologic evidenceMicrobiologic evidence

– positive blood culture but does not meet major criteria as noted

• Echocardiographic evidenceEchocardiographic evidence– consistent with IE but does not meet

major criteria as noted

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

Prevention of IE

• No randomized controlled human trials which definitively establishes the efficacy of antibiotic prophylaxis.

• Most cases of endocarditis are NOT attributable to an invasive procedure

• Current recommendations are based upon literature analysis 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

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

antibiotics before dental treatment. LDI Issue Brief 2001 Mar;6(6):1-4• 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 Infect 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 J 2000 Dec 9;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 for infective endocarditis. A population-based, case-control study. Ann Intern Med 1998 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 prevention of native-valve endocarditis. Lancet 1992 Jan 18;339(8786):135-9

• Epstein JB. Infective endocarditis and dentistry: outcome-based research. J Can Dent Assoc 1999 Feb;65(2):95-6

Endocarditis prophylaxis recommended

• 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 thickened

leaflets

Endocarditis prophylaxis NOT recommended

• Isolated secundum ASD• Surgically repaired VSD, ASD, or PDA after 6

months (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

Dental procedures and IE prophylaxis: 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

Dental procedures and IE prophylaxis: Not recommended

• Restorative dentistry• Non-intraligamentary local anesthetic injections• Taking oral impressions• Fluoride treatments• Oral radiographs• Orthodontic appliance adjustment• Shedding primary teeth

Other procedures and IE prophylaxis: 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

Other procedures and IE prophylaxis: 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

How about Tattoos 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

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 heart

disease. J Adolesc Health 1999;24:160• Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: Recommendations by the American

Heart Association. JAMA 277;1794: 1997• Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of infective endocarditis: utilization of specific

echocardiographic findings. AM J Med 96:200, 1994• Epstein JB. Infective endocarditis and dentistry: outcome-based research. J Can Dent Assoc 1999 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 Infect 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 J 2000 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 the diagnosis 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 Med 1998 Nov 15;129(10):761-9

• Strom BL. When data conflict with practice: rethinking the use of prophylactic antibiotics before dental treatment. LDI Issue Brief 2001 Mar;6(6):1-4

• Taubert KA and Dajani AS. Infective Endocarditis IN Garson A, Bricker JT, Fisher DJ, and Neish SR, eds. The Science 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 antibiotic prophylaxis for prevention of native-valve endocarditis. Lancet 1992 Jan 18;339(8786):135-9