Endocarditis Leigh Bragg, MD,* Ana Alvarez, MD* Author Disclosure Drs Bragg and Alvarez have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/ investigative use of a commercial product/ device. Educational Gaps 1. Because of its associated mortality rate (20%-25%), clinicians must recognize that infective endocarditis can affect children without a history of cardiac abnormality. (1) 2. Pediatricians should be aware of the recently revised American Heart Association recommendations for antimicrobial prophylaxis of infective endocarditis in children. (2) Objectives After completing this article, readers should be able to: 1. List the risk factors for infective endocarditis (IE). 2. Recognize the signs, symptoms, and Duke criteria that aid in the diagnosis of IE. 3. Determine the appropriate laboratory tests and imaging necessary to aid in diagnosing IE. 4. Discuss the medical and surgical management used in the treatment of IE. 5. Identify the population and procedures in which prophylactic antibiotics are used to prevent IE. Case 1 A previously healthy 3-year-old boy presents with 5 days of fever, chills, malaise, and vomit- ing. On examination, his temperature is 102.4°F (39.1°C). He is lethargic and has pete- chiae on the buccal mucosa and extremities. He is admitted to the hospital for evaluation and treatment of sepsis of unknown origin. Three blood cultures that were performed on separate occasions reveal gram-positive cocci on Gram stain. Echocardiography (ECHO) is performed because of concern for endocarditis. Case 2 A 14-year-old girl with congenital heart disease (CHD) underwent an aortic valve replace- ment with a bioprosthetic valve 3 years previously. She presents today at the emergency department with shortness of breath and peripheral edema. On examination, she is afebrile but has a new harsh diastolic murmur and hepatomegaly. ECHO reveals a 1.5-cm vegetation on the aortic valve. She is admitted to the intensive care unit and given broad-spectrum antibiotics. After 24 hours, she continues to clinically deteriorate and is taken to the op- erating room for valve replacement. Three blood cultures performed before the initiation of antibiotic therapy yield Streptococcus mitis. Epidemiology Pediatric patients are rarely diagnosed as having infective en- docarditis (IE); however, IE is a significant cause of morbid- ity and mortality in children. Most often IE is a complication of CHD, but it can occur in children who do not have a car- diac abnormality. The epidemiology of endocarditis has changed throughout the years as the prevalence of rheu- matic heart disease has decreased and the survival of patients with CHD and the use of indwelling central venous cathe- ters (CVCs) have increased. Because of these changes, the actual incidence of IE is hard to determine. Abbreviations AACEK: Aggregatibacter parainfluenzae, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella species AHA: American Heart Association CHD: congenital heart disease CVC: central venous catheter IE: infective endocarditis ECHO: echocardiography *Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Florida College of Medicine Jacksonville, Jacksonville, FL. Article infectious diseases 162 Pediatrics in Review Vol.35 No.4 April 2014 by Desiree 'Desi' Rivera-Nieves on March 22, 2015 http://pedsinreview.aappublications.org/ Downloaded from
Transcript
EndocarditisLeigh Bragg, MD,*
Ana Alvarez, MD*
Author Disclosure
Drs Bragg and Alvarez
have disclosed no
financial relationships
relevant to this article.
This commentary does
not contain
a discussion of an
unapproved/
investigative use of
a commercial product/
device.
Educational Gaps
1. Because of its associated mortality rate (20%-25%), clinicians must recognize that
infective endocarditis can affect children without a history of cardiac abnormality. (1)
2. Pediatricians should be aware of the recently revised American Heart Association
recommendations for antimicrobial prophylaxis of infective endocarditis in children. (2)
Objectives After completing this article, readers should be able to:
1. List the risk factors for infective endocarditis (IE).
2. Recognize the signs, symptoms, and Duke criteria that aid in the diagnosis of IE.
3. Determine the appropriate laboratory tests and imaging necessary to aid in diagnosing IE.
4. Discuss the medical and surgical management used in the treatment of IE.
5. Identify the population and procedures in which prophylactic antibiotics are used to
prevent IE.
Case 1A previously healthy 3-year-old boy presents with 5 days of fever, chills, malaise, and vomit-ing. On examination, his temperature is 102.4°F (39.1°C). He is lethargic and has pete-chiae on the buccal mucosa and extremities. He is admitted to the hospital for evaluationand treatment of sepsis of unknown origin. Three blood cultures that were performed onseparate occasions reveal gram-positive cocci on Gram stain. Echocardiography (ECHO) isperformed because of concern for endocarditis.
Case 2A 14-year-old girl with congenital heart disease (CHD) underwent an aortic valve replace-ment with a bioprosthetic valve 3 years previously. She presents today at the emergencydepartment with shortness of breath and peripheral edema. On examination, she is afebrilebut has a new harsh diastolic murmur and hepatomegaly. ECHO reveals a 1.5-cm vegetationon the aortic valve. She is admitted to the intensive care unit and given broad-spectrumantibiotics. After 24 hours, she continues to clinically deteriorate and is taken to the op-erating room for valve replacement. Three blood cultures performed before the initiationof antibiotic therapy yield Streptococcus mitis.
EpidemiologyPediatric patients are rarely diagnosed as having infective en-docarditis (IE); however, IE is a significant cause of morbid-ity and mortality in children. Most often IE is a complicationof CHD, but it can occur in children who do not have a car-diac abnormality. The epidemiology of endocarditis haschanged throughout the years as the prevalence of rheu-matic heart disease has decreased and the survival of patientswith CHD and the use of indwelling central venous cathe-ters (CVCs) have increased. Because of these changes, theactual incidence of IE is hard to determine.
Abbreviations
AACEK: Aggregatibacter parainfluenzae, Aggregatibacteractinomycetemcomitans, Cardiobacteriumhominis, Eikenella corrodens, and Kingella species
AHA: American Heart AssociationCHD: congenital heart diseaseCVC: central venous catheterIE: infective endocarditisECHO: echocardiography
*Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Florida College of Medicine Jacksonville,
Jacksonville, FL.
Article infectious diseases
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Traditionally, data from several pediatric studies indi-cate that most pediatric patients with IE had CHD; how-ever, one study found that 56% of pediatric IE patientsdid not have preexisting heart conditions. (3) The in-crease of IE in children without cardiac abnormalitiesin this study was thought to be secondary to the use ofindwelling CVCs and the diverse population studied,which included children from numerous centers acrossthe United States. Even though patient characteristicswith IE have evolved, the pathogens associated with IEin pediatric patients have not changed.
EtiologyThe most common organisms responsible for IE in pedi-atric patients with or without CHD are viridans strepto-cocci and Staphylococcus aureus. Viridans streptococci area large heterogeneous group of gram-positive cocci thatare part of the oral microflora, and they are commonlyassociated with transient bacteremia occurring with den-tal procedures and even with daily oral hygiene. There aremore than 15 different species in the group (eg, Strepto-coccus sanguis, S mitis, Streptococcus oralis, and Streptococ-cus anginosis), and they have been associated withinfection of abnormal valves (CHD or previous acuterheumatic fever) and with late postoperative endocarditis,which occurs more than 6 months after cardiac valve sur-gery. S aureus can cause IE in structurally normal andabnormal hearts. Although gram-positive bacteria arethe most common pathogens implicated in IE, gram-negative bacteria, better known as AACEK (Aggregatibacterparainfluenzae, Aggregatibacter actinomycetemcomitans,Cardiobacterium hominis, Eikenella corrodens, and King-ella species) organisms, can cause IE in children. Fungi, mostcommonly Candida and Aspergillus, can also be respon-sible for IE, especially in hospitalized patients who haveprosthetic valves or indwelling CVCs. Culture-negative IEhas been described and occurs in approximately 5% to 10%of children, less than that seen in adults. (4)
PathogenesisTransient bacteremia is thought to originate from a dis-ruption in host mucosal surfaces (oropharynx, gastroin-testinal tract, and genitourinary tract) heavily colonizedwith microflora. Dental procedures and daily activities,such as chewing foods and brushing teeth, have been im-plicated as sources of transient bacteremia.
When bacteremia is present, IE can result from the com-plex interaction among microorganisms, platelets, and fi-brin at the site of damaged cardiac endothelium. Theendothelium can be damaged from turbulent blood flow
secondary to CHD or from indwelling CVCs. Once the en-dothelium is damaged, platelets and fibrin are deposited onits surface, forming a nonbacterial thrombotic endocarditis.The thrombus is then colonized by microorganisms invad-ing the bloodstream, creating an infected vegetation.
Bacterial pathogens (streptococci and staphylococcispp) have unique surface components that facilitate at-tachment to the surface of damaged endothelium. Onceattached to the vegetation, the bacteria are further cov-ered with fibrin and platelets, thus evading host defensemechanisms and allowing rapid multiplication. Foreignvalves, pacemaker wires, and CVCs can also develop bio-films on the surface where pathogens can adhere andreplicate.
Clinical ManifestationsThe clinical presentation of pediatric IE can be classified aseither a subacute or acute process. Subacute presentationtypically manifests as nonspecific symptoms for severalweeks, whereas acute IE generally presents as a rapidly pro-gressive serious illness. Patients can have mixed features,and the most common signs and symptoms are listed inTable 1. Children rarely have the classic signs of IE thatdevelop late in disease, such as Roth spots (small retinalhemorrhages), Janeway lesions (small, painless, hemor-rhagic lesions on the palms and soles), Osler nodes (small,tender, intradermal nodules on the fingers and toes), andsplinter hemorrhages (linear streaks beneath the nail beds).Pediatricians should be familiar with the manifestations ofIE in children so that a prompt diagnosis can be attained.
Table 1. Common Manifestations ofPediatric Infective Endocarditisa
SignsSplenomegaly 50–75Embolic phenomenon 25–50Murmur (new or changing) 21–50Petechiae 21–50
aAdapted from Levasseur S, Saiman L. Endocarditis and otherintravascular infections. In: Principles and Practice of PediatricInfectious Diseases, 4th ed, Long SS, Pickering LK, Prober CG, eds.,256-265. Copyright Saunders Elsevier (2012).
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DiagnosisIE is a complex syndrome that requires the presence ofmultiple findings to establish the diagnosis. Identification
of IE is frequently based on a highindex of suspicion because the clini-cal presentation is often nonspecific.The Duke criteria serve as a clinicalguide to aid in the diagnosis of IEand have been validated and modi-fied to increase sensitivity. As indi-cated in Table 2, the Duke criteriaconsist of pathologic, clinical, labo-ratory, and ECHO criteria used toestablish the likelihood of IE. Col-laboration among pediatricians, car-diologists, and infectious diseasespecialists is critical in the diagnosisand treatment of IE because of thediverse clinical presentation, need forprolonged therapy, and potentiallyfatal outcomes.
Laboratory TestsBlood cultures are themost importantlaboratory test for the diagnosis of IEbecause identification of a pathogen iscritical in the selection of appropriateantimicrobial therapy. Because IE canbe caused by organisms found on theskin, it is important to obtain 3 ormore cultures on separate occasionsto reduce the likelihood of contami-nation. It is imperative to obtain ade-quate volumes of blood in aerobicand anaerobic culture bottles to de-tect pathogens in patients who havea low level of bacteremia. For smallchildren, 3 to 5 mL per bottle is rec-ommended; for larger children, 10mLper bottle. (4)
Other nonspecific laboratory find-ings can be present, including in-creased erythrocyte sedimentationrate, anemia, positive rheumatoid fac-tor, hematuria, and low complement.Elevated b-natriuretic peptide andtroponin I levels can indicate cardiacinjury.
ImagingECHO is the primary imaging modality used in the diag-nosis and treatment of IE. ECHO should be performed
Table 2. Modified Duke Criteria for the Diagnosisof IEa
Definite IE
Pathologic Criteria1. Microorganisms demonstrated by culture or histologic testing in a vegetation,
embolized vegetation, or intracardiac abscess; or2. Pathologic lesions (vegetation or intracardiac abscess) with active endocarditis
confirmed by histologic testing
Clinical Criteria: 2 major criteria, 1 major and 3 minor criteria, or 5 minor criteriaMajor Criteria1. Positive blood culture result for IEa. Typical microorganism consistent with IE from 2 separate blood cultures:
i. Viridans streptococciii. Streptococcus bovisiii. AAECK groupiv. Staphylococcus aureusv. Community-acquired enterococci (without a primary focus)
b. Microorganism consistent with IE from blood cultures with persistently positiveresults if:
i. At least 2 positive results of blood cultures sampled more than 12 hours apartii. All 3 or a majority of more than 4 blood cultures
c. Single positive blood culture for Coxiella burnetii or IgG antibody titer >1:8002. Evidence of endocardial involvement by echocardiogram result positive for IE,
defined as:a. Oscillating intracardiac mass on valve or supporting structures in the path of
regurgitant jets or on implanted materialb. Abscessc. New partial dehiscence of prosthetic valved. New valvular regurgitation (worsening or changing of preexisting murmur not
sufficient)Minor Criteria1. Predisposing heart condition or intravenous drug abuse2. Fever: temperature 100.4oF (‡38oC)3. Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic
rheumatoid factor5. Microbiologic evidence: positive blood culture result but does not meet major
criteria or serologic evidence of active infection with organism consistent with IE
Possible IE1. 1 Major criterion and 1 minor criterion2. 3 Minor criteria
Rejected1. Firm alternative diagnosis for manifestations of endocarditis2. Resolution of endocarditis manifestations with antibiotic therapy £4 days3. No pathologic evidence of IE at surgery or autopsy with antibiotic therapy for £4 days4. Does not fulfill criteria above
AAECK¼Aggregatibacter parainfluenzae, Aggregatibacter actinomycetemcomitans, Cardiobacteriumhominis, Eikenella corrodens, and Kingella species; IE¼infective endocarditis.aModified from Li JS, Sexton DJ, Mick N, et al. Proposed modifications to the Duke criteria for the diagnosisof infective endocarditis. Clin Infect Dis. 2000;30(4):633-638. By permission of Oxford University Press.
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when there is a high index of suspicion for IE, especiallyin patients with CHD or indwelling CVCs who have per-sistent bacteremia. It allows visualization of the abnormal-ities listed in the Duke criteria: vegetations, abscesses, orprosthetic valve dehiscence (Figure). It also allows moni-toring of abnormalities and cardiac function. In contrast toadults, transthoracic ECHO is highly sensitive in pediatricpatients and is most commonly used. TransesophagealECHO is more invasive but can be used to evaluate pa-tients with complex heart disease or when there is poor vi-sualization with transthoracic ECHO. Although ECHO isa useful diagnostic tool for IE, vegetations are not alwaysvisualized early in the disease, and their absence does notrule out IE. If there is a continued suspicion for IE,ECHO should be performed again in 7 to 10 days.
In patients who have definite IE, ECHO is essential tomonitor heart function and the presence and size of veg-etations during therapy and to determine the risk of em-bolization. Other imagingmodalities have been introducedbut are not yet widely used for diagnosing IE in pediatrics.These modalities include cardiac computed tomographyand magnetic resonance imaging.
ManagementTreatment of IE in pediatric patients should be providedthrough collaboration among infectious disease specialists,cardiologists, and cardiac surgeons. Specific therapy is de-termined on a case by case basis and involves the use ofantimicrobial agents and, when necessary, surgical inter-vention. The goal of IE therapy involves the eradication
of offending agents which typically requires prolongedcourses of antibiotics.
Antibiotic TherapyTo prevent further endocardial damage and complications,it is imperative that antibiotic therapy be initiated promptlyin patients with suspected IE. Antibiotic regimens for IEare based on the patient’s age, clinical presentation, cardiacstatus, and organisms most commonly isolated in infec-tions. Intravenous bactericidal antibiotics are necessaryfor the treatment of IE, and high serum levels are requiredto eliminate bacterial growth at the site of infection.
Before identification of a pathogen and after appropri-ate volume blood cultures are obtained, empiric vanco-mycin and gentamicin therapy is recommended becausethis regimen provides coverage against the most commonpathogens of IE, S aureus and viridans streptococci. If aspecific pathogen is identified in culture, the antibioticregimen can be tailored based on susceptibility profiles.Typically, 4 to 6 weeks of therapy is recommended inuncomplicated cases of IE; however, longer courses arerequired in patients who have prosthetic valves. Clinicalresponse to therapy should be monitored closely to deter-mine whether antibiotic modification or surgical inter-vention is necessary.
SurgerySurgical interventions to remove vegetations or replacevalves can be life-saving in the management of certaincases of IE. Surgery should be considered in patients withintractable heart failure, prosthetic valve endocarditis,and uncontrolled infection (persistent fever and positiveblood culture results for more than 5-7 days) and forthose at high risk of embolic events. The America HeartAssociation (AHA) has published extensive guidelines forthe antimicrobial and surgical management of IE, whichare the ultimate resource for definitive management de-cisions. (5)
ProphylaxisIn 2007, the AHA revised the recommendations for anti-microbial prophylaxis before dental and surgical proceduresfor the prevention of IE because current evidence does notsupport the widespread use of antimicrobial prophylaxis.(2) These recommendations advise prophylaxis only tothose patients with the greatest risk of an adverse outcomefrom IE, as listed in Table 3.
Antibiotic prophylaxis regimens in those circumstanceslisted are recommended for procedures that have a highpotential to result in bacteremia with organisms associated
Figure. Echocardiogram of a 21-month-old girl with Staphy-lococcus aureus bacteremia. A vegetation is present on theanterior mitral valve.
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with IE. In general, when determining the necessityfor IE prophylaxis, the mucosal location of the procedure(ie, oropharynx, respiratory, skin, and musculoskeletal),the risk for resulting bacteremia, and the colonizing organ-isms must be taken into account. Antibiotic prophylaxisis no longer recommended solely for IE prevention forgastrointestinal or genitourinary tract procedures. For allhigh-risk procedures, prophylactic antibiotics should begiven immediately before the procedure or up to 2 hoursafter the procedure.
Pediatricians commonly encounter questions about IEprophylaxis regarding dental procedures. Although previ-ously recommended with routine teeth cleanings, thenew 2007 guidelines only recommend prophylaxis withdental procedures that involve manipulation of gingivaltissues or perforation of the oral mucosa only for thosepatients at high risk, listed in Table 3. For oral medica-tions, amoxicillin (50 mg/kg) is the recommended anti-biotic for these procedures because it covers the mostlikely cause of IE found in the oral mucosa, viridans strep-tococci. A single dose is given 30 to 60 minutes beforethe procedure is performed. In penicillin allergic children,
clindamycin (20 mg/kg) or azithromycin (15 mg/kg)can be used.
PrognosisDespite advances in medicine, IE remains a significantcause of morbidity and mortality in children, and recov-ery from IE depends on the clinical state of the patient,site of infection, and pathogenic organism. Of the mostcommon bacteria responsible for IE, S aureus has beenassociated with poorer prognosis. A recent study reportedthat with S aureus involvement, 31% of patients had sig-nificant morbidity and almost 50% died. (6) Fungal IE,which is more common in patients with prosthetic valves,has the poorest prognosis of infecting organisms.
Complications of IE can cause serious morbidity, andin pediatric patients, heart failure is most commonly seen.Embolization to any organ can occur, resulting in dam-age and possible infections at the site. Left-sided (mitralvalve) lesions, large (>10 mm) vegetations, and infec-tions with S aureus, Candida species, and AACEK are as-sociated with a high risk of embolization. Additionalcomplications seen in IE include mycotic aneurysms, ab-scesses that cause complete heart block, meningitis, oste-omyelitis, renal abscess, and seizures.
Case DiscussionsPediatricians must suspect IE in patients with prolongedfever and evidence of vascular involvement in childrenwithout CHD. The patient in case 1 had bacteremiaexhibited by 3 positive blood culture results for gram-positive coccus that was later identified as S aureus. ECHOassisted in establishing a diagnosis of IE because the pa-tient was found to have a mitral valve vegetation. On thebasis of the positive blood culture results and the ECHOresults, the patient met Duke criteria for definite IE.
S aureus IE is associated with a high mortality and isthe most common cause of IE in patients without CHD.Having a high index of suspicion and initiating antibiotictherapy in a timely manner are crucial in the treatment ofthese children.
In case 2, the high-risk CHD patient with a biopros-thetic valve had a new-onset diastolic murmur and signsof heart failure that prompted suspicion for IE. Given herCHD and bioprosthetic valve, she is at high risk for IE. Thevegetation seen on ECHO verified her diagnosis accordingto the Duke criteria, and antibiotic therapy was initiated.Because of her deteriorating status, she underwent surgicalvalve replacement. Histopathologic test results from thevegetation revealed neutrophils, macrophages, and gram-positive cocci, later identified as S mitis. Viridans
Table 3. Conditions for WhichProphylaxis for IE IsRecommendeda
Prosthetic cardiac valve or prosthetic material used forcardiac valve repair
Previous IECHDb
Unrepaired cyanotic CHD, including palliative shunts andconduits
Completely repaired defect with prosthetic material ordevice during the first 6 months after the procedure
Repaired CHD with residual defects at the site oradjacent to the site of a prosthetic patch or prostheticdevice
Cardiac transplantation recipients who develop cardiacvalvulopathy
CHD¼congenital heart disease; IE¼infective endocarditis.aFrom Wilson W, Taubert KA, Gewitz M, et al. Prevention of infectiveendocarditis: guidelines from the American Heart Association:a guideline from the American Heart Association Rheumatic Fever,Endocarditis, and Kawasaki Disease Committee, Council onCardiovascular Disease in the Young, and the Council on ClinicalCardiology, Council on Cardiovascular Surgery and Anesthesia, andthe Quality of Care and Outcomes Research Interdisciplinary WorkingGroup. Circulation. 2007;116:1736-1754.bAntibiotic prophylaxis is no longer recommended for any other formof CHD, except those listed above.
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streptococci are a common cause of late valve endocardi-tis, which occurs more than 6 months after surgery.
References1. Bernstein D. Infective endocarditis. In: Kliegman RM, StantonBF, St. Geme SW, Schor NF, Behrman RE, eds. Nelson Textbook ofPediatrics. 19th ed. Philadelphia, PA: Elsevier Saunders; 2011:1622–16262. Wilson W, Taubert KA, Gewitz M, et al; American HeartAssociation Rheumatic Fever, Endocarditis, and Kawasaki DiseaseCommittee; American Heart Association Council on Cardiovascu-lar Disease in the Young; American Heart Association Council onClinical Cardiology; American Heart Association Council onCardiovascular Surgery and Anesthesia; Quality of Care and Out-comes Research Interdisciplinary Working Group. Prevention ofinfective endocarditis: guidelines from the American Heart Associ-ation: a guideline from the American Heart Association RheumaticFever, Endocarditis, and Kawasaki Disease Committee, Council onCardiovascular Disease in the Young, and the Council on Clinical
Cardiology, Council on Cardiovascular Surgery and Anesthesia, andthe Quality of Care and Outcomes Research InterdisciplinaryWorking Group. Circulation. 2007;116(15):1736–17543. Day MD, Gauvreau K, Shulman S, Newburger JW. Character-istics of children hospitalized with infective endocarditis. Circula-tion. 2009;119(6):865-8704. Levasseur S, Saiman L. Endocarditis and other intravascularinfections. In: Long SS, Pickering LK, Prober CG, eds. Principlesand Practice of Pediatric Infectious Diseases. 4th ed. MarylandHeights, MO: WB Saunders; 2012:256–2655. Baddour LM, Wilson WR, Bayer AS, et al; Committee onRheumatic Fever, Endocarditis, and Kawasaki Disease; Council onCardiovascular Disease in the Young; Councils on Clinical Cardi-ology, Stroke, and Cardiovascular Surgery and Anesthesia; Amer-ican Heart Association; Infectious Diseases Society of America.Infective endocarditis: diagnosis, antimicrobial therapy, and man-agement of complications: a statement for healthcare professionalsfrom the Committee on Rheumatic Fever, Endocarditis, andKawasaki Disease, Council on Cardiovascular Disease in the Young,and the Councils on Clinical Cardiology, Stroke, and Cardiovas-cular Surgery and Anesthesia, American Heart Association: en-dorsed by the Infectious Disease Society of America. Circulation.2005;111(23):e394–e4346. Johnson JA, Boyce TG, Cetta F, Steckelberg JM, Johnson JN.Infective endocarditis in the pediatric patient: a 60-year single-institution review. Mayo Clin Proc. 2012;87(7):629-635
Suggested ReadingHoen B, Duval X Clinical practice. infective endocarditis. N Engl J
Med. 2013;368(15):1425-1433Li JS, Sexton DJ, Mick N, et al. Proposed modifications to the
Duke criteria for the diagnosis of infective endocarditis. ClinInfect Dis. 2000;30(4):633–638
Penk JS, Webb CL, Shulman ST, Anderson EJ. Echocardiographyin pediatric infective endocarditis. Pediatr Infect Dis J. 2011;30(12):1109-1111
Rosenthal LB, Feja KN, Levasseur SM, Alba LR, Gersony W,Saiman L. The changing epidemiology of pediatric endocarditisat a children’s hospital over seven decades. Pediatr Cardiol.2010;31(6):813-820
Summary
• On the basis of strong research evidence, 3 or moreblood cultures, with adequate volumes, should beobtained before starting antibiotic therapy to aid inthe diagnosis of infective endocarditis (IE). (4)
• On the basis of strong research evidence fromobservational studies, antimicrobials are thefoundation of IE therapy and should be administeredas soon as possible in patients for whom IE issuspected. (7)
• On the basis of some research evidence and consensus,only those at high risk for IE (Table 3) should receiveantimicrobial prophylaxis before dental or surgicalprocedures. (2)
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1. Which of the following patients is most likely to have infective endocarditis (IE)?
A. A toddler with a bicuspid aortic valve and a new murmur.B. A 5-year-old with a bicuspid aortic valve, positive blood culture result, and a liver abscess.C. A 10-year-old with repaired tetralogy of Fallot, fever, glomerulonephritis, and conjunctival hemorrhages.D. A 2-month-old former 25-week premature infant with fever and 2 blood cultures yielding Streptococcus
viridans.E. A 12-year-old with a mobile mass on his mitral valve.
2. In a patient with IE which of the following findings warrant a heart operation?
A. Tricuspid valve vegetation and severe valve regurgitation.B. Mitral valve vegetation, 2 days of positive blood culture results, and fever.C. Aortic valve vegetation and osteomyelitis.D. Moderate mitral regurgitation, severe exercise intolerance, and tachypnea.E. Pulmonic valve vegetation, fever, and fatigue.
3. A 9-year-old febrile child with chest pain and tachycardia had IE associated with a ventricular septal defectpatch when she was 5 years old. Which of the following laboratory tests is most likely to lead to the primarydiagnosis?
A. Transthoracic echocardiography.
B. Three separate blood cultures (5 mL each) performed during a fever spike.C. Transesophageal echocardiography.D. Electrocardiography, troponin measurement, and b-natriuretic peptide measurement.E. Three blood cultures (5 mL each) performed at least 1 hour apart.
4. Which of the following is most likely to be a presenting sign or symptom of IE?
A. Vertigo.B. Palpitations.C. Pallor.D. Heart failure.E. Vomiting.
5. Which of the following sign or symptom is classic for IE that develops late in the disease?
A. Splenomegaly.B. New murmur.C. Small retinal hemorrhages.D. Malaise.E. Arthralgia.
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DOI: 10.1542/pir.35-4-1622014;35;162Pediatrics in Review
Leigh Bragg and Ana AlvarezEndocarditis
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