Infective endocarditis (IE) in children receiving treatment for cancer

Infective endocarditis in pediatric patients: a decade of insights from a leading Spanish heart surgery reference center

Infective endocarditis (IE) is a rare disease in children and is associated with significant morbidity and mortality. In recent years, significant changes have occurred in pediatric care that could have influenced the microbiology and presentation of IE. The aim of this work was to study epidemiological, microbiological, and clinical features of IE treated at a Pediatric Cardiac Surgery Reference Center located in Madrid (Spain) in a 10-years' period. A descriptive observational retrospective study was performed, including pediatric patients < 16 years old with definite or possible IE admitted to a reference center between January 2012 and December 2021. Thirty-two IE episodes were identified. Twenty-eight (87.5%) had congenital heart disease (CHD), 8 (25.0%) were preterm infants, 1 (3.1%) was immunocompromised and 6 (18.8%) had other chronic conditions; in 11 (34.4%) episodes more than one underlying condition was associated. In 20 (62.5%) episodes there was an indwelling central venous catheter (CVC); children with other comorbidities (preterm, immunocompromised, other chronic conditions) were more likely to have a CVC at diagnosis compared with patients with isolated CHD (p < 0.001). Thirty-six microbiological isolates were obtained in the 32 episodes; 4 (12.5%) episodes had 2 isolated microorganisms. Microbiological isolates were 20 (55.6%) Gram-positive bacteria (GPB), 10 (27.8%) non-HACEK Gram-negative bacteria (GNB), 1 (2.8%) HACEK-group bacterium, 4 (11.1%) fungi and 1 (2.8%) Coxiella burnetii. In 10 (31.3%) episodes, patients were colonized by multidrug-resistant bacteria (MDRB) and the etiology of IE in 3 (30.0%) of those episodes was the colonizing MDRB. MDRB colonization was associated with MDRB IE (p = 0.007). The most common complication was septic embolism: 11 (34.4%) episodes (9 pulmonary and 2 cerebral). In-hospital mortality was 6.3% (n = 2), all of them due to underlying conditions and not to IE or its complications. Clinical features and complications of IE episodes caused by non-HACEK GNB and those caused by GPB were compared, finding no statistically significant differences.    Conclusion: Risk factors for developing IE, the proportion of embolic complications, and mortality rate were consistent with previously published findings. Proportion of IE cases attributed to non-HACEK GNB was higher than previously reported, suggesting an evolving epidemiology of IE. One-third of children colonized with MDRB subsequently developed IE caused by the same MDRB strains, so empirical coverage of MDRB organisms must be considered when IE is suspected in MDRB colonized patients. No significant differences in clinical features and complications were observed when comparing IE episodes caused by non-HACEK GNB and those caused by GPB, however larger cohort studies are needed. What is Known: • Infective endocarditis (IE) is a rare disease in children, associated with significant morbidity and mortality. • The main risk factor for developing IE in children is an underlying congenital heart disease. What is New: • With current changing epidemiology in pediatric IE, a higher proportion of IE caused by non-HACEK Gram-negative bacteria should be expected. • A significant percentage of children colonized by multidrug-resistant bacteria can develop an IE due to those bacteria.

Infective endocarditis in paediatric population

Infective endocarditis is very uncommon in children; however, when it does arise, it can lead to severe consequences. The biggest risk factor for paediatric infective endocarditis today is underlying congenital heart defects. The most common causative organisms are Staphylococcus aureus and the viridans group of streptococci. The spectrum of symptoms varies widely in children and this produces difficulty in the diagnosis of infective endocarditis. Infective endocarditis in children is reliant on the modified Duke criteria. The use of blood cultures remains the most effective microbiological test for pathogen identification. However, in blood culture-negative infective endocarditis, serology testing and IgG titres are more effective for diagnosis. Imaging techniques used include echocardiograms, computed tomography and positron emission tomography. Biomarkers utilised in diagnosis are C-reactive protein, with recent literature reviewing the use of interleukin-15 and C-C motif chemokine ligand for reliable risk prediction. The American Heart Association (AHA) and European Society of Cardiology (ESC) guidelines have been compared to describe the differences in the approach to infective endocarditis in children. Medical intervention involves the use of antimicrobial treatment and surgical interventions include the repair and replacement of cardiac valves. Quality of life is highly likely to improve from surgical intervention.Conclusion: Over the past decades, there have been great advancements in clinical practice to improve outcomes in patients with infective endocarditis. Nonetheless, further work is required to better investigative and manage such high risk cohort. What is Known: • The current diagnostic techniques including 'Duke's criteria' for paediatric infective endocarditis diagnosis • The current management guidelines utilised for paediatric infective endocarditis What is New: • The long-term outcomes of patients that underwent medical and surgical intervention • The quality of life of paediatric patients that underwent medical and surgical intervention.

Infections caused by coryneform bacteria in pediatric oncology patients

BACKGROUND

Invasive infections caused by coryneform bacteria are uncommon but have been reported with increasing frequency in recent decades, especially in immunocompromised persons. Because pediatric experience is limited, we examined the epidemiology and clinical characteristics of these infections in children undergoing cancer therapy.

METHODS

Using strict case definitions, 17 coryneform bacterial infections were identified in 16 children during a 13-year period; there were 12 episodes of bacteremia and 5 skin or soft tissue infections.

RESULTS

The median age of children with bloodstream infections was 11.2 years, and that of children with skin or soft tissue infections was 3.5 years. Most were receiving cancer therapy at the time of their infections, were outpatients at the onset of their infections, had central venous catheters, and were not neutropenic. No patient died as a result of infection and most had relatively mild signs and symptoms. All patients responded promptly to antimicrobial therapy and, although 3 infections relapsed, there was only 1 serious complication. The most common species isolated were Corynebacterium striatum, C. amycolatum, and Microbacterium species.

CONCLUSIONS

The epidemiologic and clinical features of coryneform bacterial infections in immunocompromised children differ in several important respects from the previously reported characteristics of these infections in adults.

Nuevas tendencias de la endocarditis pediátrica

OBJECTIVES

To evaluate the epidemiology, etiology and outcome of endocarditis in a cohort of pediatric patients and to compare the main characteristics with our previous experience.

MATERIAL AND METHODS

Patients aged less than 18 years of age diagnosed with endocarditis at the Sainte-Justine Hospital, University of Montreal between 1-1986 and 12-2000 were studied. The recent case series was compared with our previous experience from 1960-1985.

RESULTS

Fifty-six children with endocarditis were included in the 1986-2000 series: 35 children with congenital heart disease, 15 with serious underlying disease and six healthy children. The mean age was 7 years and 10 months. Fifty-four percent of the patients were boys. The incidence of endocarditis increased from 1.5 cases/year in the 1986-2000 series to 4 cases/year in the 1986-2000 series. In the 1986-2000 series, 10 (17.9 %) patients had a central catheter. Sixteen (28.6 %) patients had a vascular prosthesis. Blood cultures were positive in 50 patients (89 %): Streptococci were found in 48 % of the patients and Staphylococci in 34 %. Echocardiography was positive in 36 of 55 patients (65.4 %). All children were treated with intravenous antibiotics for a mean of 43 +/- 15 days. There were no recurrences. Significant morbidity developed in 26 patients (46 %). Embolic phenomena were seen in 11 children (20 %). Twelve patients (21 %) needed surgery. Of the six healthy children, five developed complications. Overall, seven children (12.5 %) died; all were older than 6 years of age. Comparing our experience from 1960-1985 with that from 1986-2000 revealed that morbidity decreased from 85.7 % to 46.4 % and mortality decreased from 27 % to 12.5 %.

CONCLUSIONS

Physicians must recognize that children with underlying immunodeficiency and those with central catheters have an increased risk of endocarditis. Healthy children with endocarditis have a greater risk of complications. Morbidity and mortality due to endocarditis has diminished considerably in recent years.