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
Acyanotic Heart Disease
VSD
Aortic stenosis
PDA
Coarctation of the aorta
Pulmonary stenosis
VSD with other defects
Atrioventricular septal defect
Mitral valve abnormality
Atrial septal defect
Mitral valve prolapse
Cyanotic Heart Disease
Tetralogy of Fallot
Transposition of Great Vessels
Tricuspid Atresia
Rheumatic Heart Disease
No Heart Disease
No.
%
194
89
25
25
21
18
16
16
11
8
21.8
10.0
2.8
2.8
2.4
2.0
1.8
1.8
1.2
0.9
143
35
9
86
75
16.0
3.9
1.0
9.7
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
• 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 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 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 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
•
•
•
•
•
•
Predisposition
– Predisposing heart condition or IV
drug abuser
Fever
– > 38.0º C
Vascular phenomena
– arterial emboli, septic pulmonary
infarct, mycotic aneurysm,
intracranial hemorrhage,
conjunctival hemorrhage,
Janeway’s lesion
Immunologic phenomena
– glomerulonephritis, Osler’s
nodes, Roth’s spots, rheumatoid
factors
Microbiologic evidence
– positive blood culture but does
not meet major criteria as noted
Echocardiographic 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 nativevalve 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