A forty-year review of bacterial endocarditis in infancy and childhood

Infective Endocarditis at a Referral Children's Hospital During 19-Year Period: Trends and Outcomes

BACKGROUND

We noted a recent increase in cases of infective endocarditis (IE) at our institution. The purpose of the study is to examine the incidence, risk factors, microbiology and outcome of IE in our pediatric population.

METHODS

Retrospective review of IE cases during 2002-2020 at Children's Hospital of Michigan, Detroit.

RESULTS

68 patients with IE were identified. There was a 2-fold increase in incidence during the 2012-2020 (late period) compared to the 2002-2011 (early period). The most common predisposing conditions were congenital heart disease (CHD) in 39 (57.4%) and central venous catheter (CVC) in 19 (27.9%). CHD was more frequent in the late period (29/43, 67.4%) compared to early period (10/25, 40.0%) (p = 0.042). In CHD patients, palliative or corrective cardiac surgery was performed prior to IE diagnosis in 4/25 (16%) in early period and 23/43 (53.5%) in the late period (p = 0.004). S. aureus was the most common causative organism (35.3%) followed by streptococci (22.1%). Valve replacement or valvuloplasty was performed in 22.1% of patients. Complications occurred in 20 (29.4%). Mortality occurred in 7 (10.3%): 3 had CHD, 3 had CVC and underlying conditions and 1 had fulminant MRSA infection.

CONCLUSION(S)

The higher incidence of IE during the late period is likely due to an increase in patients with CHD who had undergone prior cardiac surgery. S. aureus was the predominant pathogen in all patients including those with CHD, followed by streptococci. IE in children continues to be associated with high rates of morbidity and mortality.

Patent Ductus Arteriosus: A Contemporary Perspective for the Pediatric and Adult Cardiac Care Provider

The burden of patent ductus arteriosus (PDA) continues to be significant. In view of marked differences in preterm infants versus more mature, term counterparts (viewed on a continuum with adolescent and adult patients), mechanisms regulating ductal patency, genetic contributions, clinical consequences, and diagnostic and treatment thresholds are discussed separately, when appropriate. Among both preterm infants and older children and adults, a range of hemodynamic profiles highlighting the markedly variable consequences of the PDA are provided. In most contemporary settings, transcatheter closure is preferable over surgical ligation, but data on longer-term outcomes, particularly among preterm infants, are lacking. The present review provides recommendations to identify gaps in PDA diagnosis, management, and treatment on which subsequent research can be developed. Ultimately, the combination of refined diagnostic thresholds and expanded treatment options provides the best opportunities to address the burden of PDA. Although fundamental gaps remain unanswered, the present review provides pediatric and adult cardiac care providers with a contemporary framework in PDA care to support the practice of evidence-based medicine.

Streptococcus pyogenes Endocarditis Associated With Varicella-Case Report and Review of the Literature

Infection with varicella zoster virus (VZV) is usually a benign and self-limiting disease. Serious complications by bacterial pathogens do occur, such as necrotising fasciitis (NF). One of the most important is Streptococcus pyogenes (or Group A Streptococcus, GAS), which colonizes epithelial surfaces, primarily of the throat and skin. In rare instances, varicella may also be associated with S. pyogenes endocarditis. Review of the literature reveals only 18 children with infective endocarditis (IE) caused by GAS since 1942. VZV as antecedent illness was found in five (28%). Fourteen (78%) had no pre-existing cardiac abnormalities. Death occurred in three (17%) children. Infective endocarditis with acute deterioration secondary to rupture of mitral valve chordae tendineae necessitating cardiac surgery has not been reported in the literature yet. We present this rare and instructive pediatric case and the results of a literature search on S. pyogenes endocarditis in children.

Original article. Childhood infective endocarditis in Khon Kaen University Hospital from 1992 to 2011

Background: Infective endocarditis (IE) is an important cause of child morbidity and mortality, but the current burden of the disease in Thai children is unknown.

Objectives: To determine the current burden of IE in Thai children.

Patients and Methods: The records of all children aged <15 years admitted to Khon Kaen University Hospital from 1992 to 2011 were reviewed.

Results: Of 69,822 admissions, 56 patients fulfilled the modified Duke criteria for definite IE giving a rate of 0.8 cases per 1,000 admissions. Age at diagnosis was 7.9 ± 3.8 years (range, 8 days to 14.8 years). There was congenital heart disease in 38 (68%) patients, rheumatic heart disease (RHD) in 10 (18%), and no previous heart disease in 8 (14%). RHD was a less frequent underlying disease during the latter half (2002-2011) of the period studied (1/34 vs. 9/22, P < 0.001). Blood cultures were positive for pathogens in 34 (61%) patients with 11 cases of Streptococcus viridians and 8 cases of Staphylococcus aureus infections. Vegetations on echocardiography were present in 46 (82%) patients. For 8 embolic events, patients with large vegetations had a higher rate (4/6) than patients with small and no vegetations (4/50) (P < 0.003). In-hospital mortality was 11%. Eight patients with S. aureus infection had a higher mortality (5/8) than 26 patients (1/26) infected with other pathogens (P < 0.001).

Conclusion: The changing epidemiology of pediatric IE was toward fewer children with RHD. Mortality among children with IE was higher in those with S. aureus infection.

Surgical Management of Sternoclavicular Joint Infection

Sternoclavicular joint infection is rare and tends to present insidiously in debilitated and immunocompromised patients. Between August 1996 and July 1998, we managed 7 patients with 8 sternoclavicular joint infections. Three were women. Their age ranged from 42 to 63 years. Five of the patients had significant associated medical conditions. Six patients, including 1 with bilateral involvement, underwent surgical resection, which consisted of radical excision of the involved joint, medial third of the clavicle, first and second ribs and adjacent muscular wall, and part of the manubrium. All of them underwent delayed reconstruction with either pectoralis major or latissimus dorsi flaps. There was 1 operative mortality from continuing sepsis from another source. All the surviving patients showed no sign of local recurrent infection and no functional deficits at follow-up. We conclude that infection of the sternoclavicular joint often presents late in debilitated patients. Medical therapy often fails in these cases. Radical excision is effective in eradicating the septic focus, and functional results after reconstruction are excellent.

The Changing Epidemiology of Pediatric Endocarditis

The epidemiology of infective endocarditis (IE) appears to be related to changes in the management of children with congenital heart disease (CHD) and the virtual disappearance of rheumatic heart disease. To better understand these changes, we divide the history into: I. The pre-surgical era, II. The early years of CHD surgical intervention, correlated with introduction of antibiotics, III. The modern era of cardiac interventions. Microbiologic changes include an early predominance of viridans streptococci and an overtaking by staphylococci. Additionally, there have been advances in imaging that allow earlier detection of IE and a reduction in IE-related mortality.

Prevalence and intensity of bacteraemia following orthodontic procedures

BACKGROUND

There is a possibility that bacteria may enter the blood stream during some non-surgical manipulation procedures, which include orthodontic treatment procedures (alginate impression taking, separator placement, band cementation, and archwire change).

OBJECTIVES

The aim of this study was to determine the prevalence and intensity of bacteraemia associated with orthodontic procedures in patients seen at the Lagos University Teaching Hospital, Nigeria.

METHODOLOGY

A total of 100 subjects who presented at the Orthodontic Clinic of the Lagos University Teaching Hospital and who met the inclusion criteria were recruited for the study. Four orthodontic procedures were investigated: alginate impression taking, separator placement, band cementation and archwire placement. Subjects were randomly placed in one of the four procedure groups. Peripheral blood was collected for microbiologic analysis before the orthodontic procedures and within 2 min of completion of the procedures. The BACTEC automated blood culture system and the lysis filtration method of blood culturing were used for microbiological analysis of the blood samples. The Wilcoxon signed rank test, the McNemar χ(2) test, the Mann-Whitney U-test, and Spearman and point bi-serial correlations were used for statistical evaluation at the P<0.05 level.

RESULTS

A significant increase in the prevalence and intensity of bacteraemia was observed following separator placement. The predominant bacteria isolated from the blood cultures were Streptococcus viridans and Staphylococcus species.

CONCLUSION

Separator placement induced the highest levels of bacteraemia. Use of a 0.2% chlorhexidine mouth rinse is recommended prior to separator placement in orthodontic patients.

Two cases and a review of Streptococcus pyogenes endocarditis in children

Background

Infective endocarditis is a rare diagnosis in pediatrics. Group A beta-hemolytic Streptococcus pyogenes is known to cause a range of type and severity of infections in childhood. However, S. pyogenes is a rarely described cause of endocarditis in children. This paper presents two cases of S. pyogenes endocarditis and the largest and most up-to-date review of cases previously reported in the literature.

Case presentation

Here we describe two pediatric cases of S. pyogenes endocarditis with associated toxic shock. Case 1 was a previously well Caucasian 6-year-old female who presented with sepsis. Case 2 was an 8-month-old South Asian female who presented with sepsis and pneumonia. We present a review of the literature since the beginning of the antibiotic era of this unusual cause of bacterial endocarditis in children.

Conclusion

In addition to the two cases presented here, a total of 13 children have been reported since 1940 with endocarditis caused by S. pyogenes for which clinical details are available. Although few cases exist, literature review reveals a high mortality rate (27%) and the majority of patients who recovered had residual morbidities. We emphasize the importance of considering a diagnosis of endocarditis in cases of S. pyogenes sepsis or toxic shock in order to ensure early diagnosis and timely treatment, which are necessary for good outcomes. This information is relevant to both general and subspecialty pediatricians, especially emergency room and infectious disease physicians.

Changing spectrum of infective endocarditis in children: a 30 years experiences from a tertiary care center in Taiwan

BACKGROUND

The epidemiology of infective endocarditis (IE) changes with the medical advances. This study aimed to evaluate the trends in a pediatric cohort.

METHODS

From hospital database (1983-2011), patients <18 years who fulfilled the modified Duke criteria of IE were identified.

RESULTS

We enrolled 112 patients (M/F 57/55) with 116 IE episodes. About 86 patients (74.1%) had preexisting cardiac lesions and 23 patients (19.6%) were immunocompromised hosts. Prior dental procedure was noted in 12 (10.3%) patients, including 4 with simple ventricular septal defect. The overall mortality was 10.7%. The risk factors included vegetations in both ventricles (odds ratio = 7.81, P = .019) and prior use of broad-spectrum antibiotics (odds ratio = 3.75, P = .055). Approximately one-third of the patients (29.3%) required surgical intervention. We identified an increasing trend in the proportion of hospital-acquired IE (from 12% during 1983-1991 to 39% during 2002-2011), and the spectrum of offending pathogens showed a trend for fewer Streptococcus species, more Staphylococcus aureus and increased pathogen diversity. The leading pathogens were Gram-negative bacilli in hospital-acquired IE and Streptococcus species in community-acquired IE. Hospital-acquired IE was associated with younger age, a higher proportion of immunocompromised patients, a history of central line indwelling and higher mortality. In contrast, more surgical intervention and embolic events occurred in community-acquired IE patients.

CONCLUSIONS

The mortality of pediatric IE remains high. Dental procedures were noted in one-tenth of the patients. Although increased S. aureus-caused episodes and pathogen diversity were noted, Streptococcus species remain the most common pathogen.

[Infective endocarditis in sub-Saharan african children, cross-sectional study about 19 cases in Ouagadougou at Burkina Faso]

INTRODUCTION

Infective endocarditis is a transplant of a microorganism on a most often injured endocardium. It is rare in children. This work aimed to determine the frequency of endocarditis of the child, to describe clinical presentation, data from echocardiography, microbiological profile and clinical course.

PATIENTS AND METHODS

From May 1 2010 to April 30 2011, we consecutively included children received for infective endocarditis in two medical centers in the city of Ouagadougou: Saint-Camille medical center and teaching hospital Yalgado-Ouedraogo. We investigated the functional and general signs and treatment already received. The physical examination looking for an infectious syndrome, pneumonia, heart failure and entrance doors. Blood cultures, blood count, creatinine, blood chemistry, HIV status, electrocardiogram, chest radiography and cardiac Doppler ultrasound were systematic. The diagnosis of the disease was based on Duke criteria.

RESULTS

Nineteen endocarditis in children were reported, that is 1.7% of admissions. The average age was 4.7 ± 2.6 years (extremes: 1 and 14). The sex ratio was 1.7 for girls. The clinical presentation was a common infectious syndrome. Impaired general condition and congestive heart failure were present on admission in six cases, respectively. The front door was dental in nine cases (47.4%), skin in four cases (21%) and ENT in three cases (15.8%). A peripheral vein was implicated in one case. In the two other cases, no front door had been found. HIV serology was positive in four cases. As for the blood cultures, they were positive in 13 cases. The germs found were Streptococcus in 10 cases and staphylococcus in three cases. Echocardiography had revealed vegetations in 18 cases. These vegetations were localized on the mitral in nine cases. Multiple locations were found in four cases. Underlying heart disease was dominated by rheumatic valve disease (68.4%), healthy heart forms were found in two cases. Treatment consisted of antibiotics, antipyretic treatment and that of heart failure as appropriate. The evolution was marked by five deaths (26.3%) in an array of septic shock. Death was more important in congenital heart disease.

CONCLUSION

Infective endocarditis of the child is common in our practice. The clinical syndrome is common infectious. Streptococcus and Staphylococcus are the two germs found. The main door is dental. Hence, dental care should be promoted for better prevention of infective endocarditis in our context.

Infective endocarditis following percutaneous pulmonary valve replacement: diagnostic challenges and application of intra-cardiac echocardiography

BACKGROUND

Infective endocarditis (IE) following percutaneous pulmonary valve replacement (PPVR) with the Melody valve is rarely reported. Furthermore, there are challenges in this diagnosis; especially echocardiographic evidence of vegetation within the prosthesis may be difficult.

METHOD AND RESULT

This study is a retrospective review of all patients with Melody valve implantation in a tertiary centre. Between November 2006 and November 2012, 43 procedures were performed in 42 patients (mean age 25 years, 6-67 years). At a median follow-up of 27 months (2-66 months), six patients were suspected for IE. However, repeated transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) showed no evidence of IE and the patients were diagnosed as possible cases according to the modified Duke's criteria. Two patients did not respond to antibiotic treatment and underwent intra-cardiac echocardiography (ICE), which clearly demonstrated vegetations. These two cases required surgical explantation, while the other four patients were treated medically without complications.

CONCLUSION

IE after Melody valve implantation is uncommon, but difficult to verify since TTE and TEE often cannot demonstrate vegetations inside the stent. ICE should be considered in suspected cases of IE following PPVR with negative TTE and TEE examinations in order to early tailor the best treatment for the individual patient suspected for IE.

Infective Endocarditis in Children With Congenital Heart Disease

Background—

The American Heart Association guidelines for prevention of infective endocarditis (IE) in 2007 reduced the groups of congenital heart disease (CHD) patients for whom antibiotic prophylaxis was indicated. The evidence base in CHD patients is limited. We sought to determine the risk of IE in children with CHD.

Methods and Results—

We performed a population-based analysis to determine the cumulative incidence and predictors of IE in children (0–18 years) with CHD by the use of the Quebec CHD Database from 1988 to 2010. In 47 518 children with CHD followed for 458 109 patient-years, 185 cases of IE were observed. Cumulative incidence of IE was estimated in the subset of 34 279 children with CHD followed since birth, in whom the risk of IE up to 18 years of age was 6.1/1000 children (95% confidence interval, 5.0–7.5). In a nested case-control analysis, the following CHD lesions were at highest risk of IE in comparison with atrial septal defects (adjusted rate ratio, 95% confidence interval): cyanotic CHD (6.44, 3.95–10.50), endocardial cushion defects (5.47, 2.89–10.36), and left-sided lesions (1.88, 1.01–3.49). Cardiac surgery within 6 months (5.34, 2.49–11.43) and an age of <3 years (3.53, 2.51–4.96; reference, ages 6–18) also conferred an elevated risk of IE.

Conclusions—

In a large population-based cohort of children with CHD, we documented the cumulative incidence of IE and associated factors. These findings help identify groups of patients who are at the highest risk of developing IE.

Pulmonary endarteritis, cerebral abscesses, and a single ventricle: An uncommon combination

Endocarditis of the right side of the heart is otherwise uncommon in children. Pulmonary endarteritis as a complication of congenital heart disease is even rarer. Herein, we report the case of pulmonary endarteritis with a 7 mm ×5 mm vegetation, involving the main pulmonary artery in a 4-year-old male child, with cyanosis and a 1-week history of fever and rapidly-progressive hemiparesis. A full segmental echocardiography demonstrated a double inlet left ventricle with left-sided subaortic hypoplastic right ventricle (Van Praagh's A-III type – Single Ventricle). Additionally, CT scan of the brain revealed bilateral cerebral abscesses. To the best of our knowledge, the occurrence of pulmonary endarteritis and cerebral abscesses in a case of single ventricle is hitherto unreported. This article underlines the importance of heightened clinical awareness and meticulous echocardiography in cases of congenital heart disease so that relatively rare complications may not be missed.

The patent ductus arteriosus in term infants, children, and adults

During fetal life, the ductus arteriosus is a normal and essential structure that connects the pulmonary artery to the distal aortic arch, permitting right ventricular ejection into the aorta. After birth, with commencement of pulmonary blood flow and a 2-ventricle circulation, a variety of physiological and biochemical signals normally result in complete closure of the ductus. Persistent patency of the ductus arteriosus may impair systemic cardiac output and result in deleterious effects on the cardiovascular system and lungs. Although surgery is still the treatment of choice for most premature infants with patent ductus arteriosus (PDA), transcatheter techniques have largely supplanted surgery for closure of PDA in children and adults. This article is a review of the PDA in term infants, children, and adults, with focus on the clinical manifestations and management.

Large patent ductus arteriosus in an adult complicated by pulmonary endarteritis and embolic lung abscess

Patent ductus arteriosus in the adult is an extremely rare clinical phenomenon. We report the case of a 34-year old man who developed pulmonary endarteritis and subsequent embolic lung abscess secondary to a large patent ductus arteriosus. This brief report also provides an overview of the natural history, potential complications, optimal therapy, and diagnostic dilemmas associated with this persistent congenital cardiac defect in adults.

Neisseria sicca endocarditis requiring mitral valve replacement in a previously healthy adolescent

Infective endocarditis due to Neisseria sicca, a normal inhabitant of the upper respiratory tract, is rarely reported but associated with embolic phenomena and large vegetations often requiring surgical intervention. We report a previously healthy 12-year-old girl who presented with prolonged fever and altered mental status. The patient developed rapidly progressive respiratory insufficiency and cardiovascular instability, and echocardiography demonstrated a large vegetation on the mitral valve. She developed worsening mitral regurgitation with resultant pulmonary hemorrhage and underwent mitral valve replacement. Her blood culture was positive for N. sicca. This infection should be considered in patients with prolonged high fever and multiorgan dysfunction. Despite a typically severe course, reported mortality is low.

Infective endocarditis in congenital heart disease

Congenital heart disease (CHD) has become the leading risk factor for pediatric infective endocarditis (IE) in developed countries after the decline of rheumatic heart disease. Advances in catheter- and surgery-based cardiac interventions have rendered almost all types of CHD amenable to complete correction or at least palliation. Patient survival has increased, and a new patient population, referred to as adult CHD (ACHD) patients, has emerged. Implanted prosthetic material paves the way for cardiovascular device-related infections, but studies on the management of CHD-associated IE in the era of cardiovascular devices are scarce. The types of heart malformation (unrepaired, repaired, palliated) substantially differ in their lifetime risks for IE. Streptococci and staphylococci are the predominant pathogens. Right-sided IE is more frequently seen in patients with CHD. Relevant comorbidity caused by cardiac and extracardiac episode-related complications is high. Transesophageal echocardiography is recommended for more precise visualization of vegetations, especially in complex type of CHD in ACHD patients. Antimicrobial therapy and surgical management of IE remain challenging, but outcome of CHD-associated IE from the neonate to the adult is better than in other forms of IE.

CONCLUSION

Primary prevention of IE is vital and includes good dental health and skin hygiene; antibiotic prophylaxis is indicated only in high-risk patients undergoing oral mucosal procedures.

Pediatric infective endocarditis: Has Staphylococcus aureus overtaken viridans group streptococci as the predominant etiological agent?

BACKGROUND

Viridans group streptococci (VGS) have traditionally been the most common etiological agents of infective endocarditis (IE). Advances in cardiovascular surgery and the increasing use of long-term central venous catheters may have altered the epidemiology of pediatric IE.

METHODS

A chart review of children younger than 17 years of age with IE was completed at the Stollery Children's Hospital (Edmonton, Alberta) between 1985 and 2004. The literature was reviewed to look for changes over time in the most common etiological agents of pediatric IE.

RESULTS

There were 31 cases of definite IE and nine cases of possible IE at the Stollery Children's Hospital, 19 of which were nosocomial. Thirty cases (75%) had congenital heart disease. The etiological agents were Staphylocccus aureus (n=16), VGS (n=5), coagulase-negative staphylococci (n=3), enterococcus (n=3), other streptococci (n=8), Enterobacter cloacae (n=1) and Stenotrophomonas maltophilia (n=1), while three cases were culture negative. Two deaths were due to S aureus IE. Review of the literature identified an increasing number of case series in which S aureus was the predominant etiological agent, but VGS still predominated in some recent series.

CONCLUSION

Congenital heart disease remains the primary risk factor for pediatric IE. Prospective population-based studies are required to determine whether S aureus has become the predominant pathogen.

Antibiotic sandwich patch for ventricular septal defect complicated by endocarditis

Infective endocarditis in patients with ventricular septal defects can prove life threatening due to acute heart failure or septic embolization. Persistent postoperative risk is bacterial colonization of prosthetic material. We designed the Antibiotic Sandwich Patch to reduce this risk, using a double layer of autologous pericardium containing antibiotic powder. Five patients were managed with this technique for closure of ventricular septal defects complicated by acute infective endocarditis. No colonization of the patches occurred after a median follow up of 1.5 years. This technique reduced the risk of bacterial colonization of the antibiotic sandwich patch, offering an additional surgical option.

To close or not to close: the very small patent ductus arteriosus

Patent ductus arteriosus (PDA) accounts for approximately 10% of all congenital heart diseases, with an incidence of at least 2-4 per 1000 term births. Closure of the large, hemodynamically significant PDA is established as the standard of care, and can be performed safely and effectively using either surgical or transcatheter methods. The appropriate management of the very small, hemodynamically insignificant PDA is less clear. Routine closure of such defects has been advocated to eliminate or reduce the risk of infective endocarditis (IE). However, the risk of IE in patients with a small PDA appears to be extremely low, and IE is treatable. Although closure of the small PDA is generally safe and technically successful, it is unknown whether this treatment truly improves the risk:benefit balance compared with observation. In this article, we review the published literature on the natural history and treatment outcomes in individuals with a PDA, the epidemiology and outcomes of IE, particularly in association with PDA, and the rationale and evidence for closure of the very small PDA.

It's not easy being green: the viridans group streptococci, with a focus on pediatric clinical manifestations

The viridans group streptococci (VGS) are a heterogeneous group of organisms that can be human commensals, colonizing the gastrointestinal and genitourinary tracts in addition to the oral mucosa. VGS are generally considered to be of low pathogenic potential in immunocompetent individuals. However, in certain patient populations, VGS can cause invasive disease, such as endocarditis, intra-abdominal infection, and shock. Within the VGS, the rates and patterns of antimicrobial resistance vary greatly depending upon the species identification and the patient population. In general, Streptococcus mitis group organisms are resistant to more antimicrobial agents than the other VGS species. This review addresses current VGS taxonomy, in addition to the current methodologies being used in clinical microbiology laboratories for identification of VGS. Automated systems struggle overall with species level identification and susceptibility testing for VGS. Matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) identification is emerging as a potential alternative for organism identification. A review of recent pediatric-specific data regarding the clinical manifestations of VGS revealed that the Streptococcus anginosus group (SAG) organisms may be important pathogens in pediatric patients and that the VGS may contribute to disease in patients with cystic fibrosis. It also appears that rates of antimicrobial resistance in VGS in pediatric patients are surpassing those of the adult population.

Severe backache as a presenting sign of bacterial endocarditis

We report on two patients whose presenting sign of bacterial endocarditis was a sudden and severe backache. According to the literature, 25-44% of patients with bacterial endocarditis have musculoskeletal symptoms and in about 27% these symptoms are the first sign of the disease. The most probable pathogenetic mechanism of these symptoms is arterial microembolization consisting of bacteria and immune complexes.

Patent ductus arteriosus with infective endocarditis at age 92

This report describes a 92-year-old woman patient with patent ductus arteriosus (PDA). She seems to be the oldest patient with PDA hitherto reported in the medical history. She developed infective endocarditis (IE) and congestive heart failure, and died at the age of 92. At autopsy, the PDA was found to the left of the origin of the left subclavian artery. Both left and right ventricles were hypertrophied with markedly dilated pulmonary arteries. IE involving the aortic valve extended to the sinus of Valsalva and pericardium, inducing pericarditis and cardiac tamponade. IE also resulted in systemic septic embolization.

Pneumococcal endocarditis in children: A nationwide survey in Japan

BACKGROUND

Infective endocarditis (IE) due to Streptococcus pneumoniae (S. pneumoniae) carries a high mortality rate. However, little is known about pneumococcal IE in children and no optimal therapy has been established. Thus, we attempted to identify the clinical features of this disorder through a Japanese nationwide survey.

METHODS

Members of the Japanese Society of Pediatrics Cardiology and Cardiac Surgery registered 170 pediatric patients with IE diagnosed during a 5-year period (1997-2001). Nine of these patients (5.3%) had pneumococcal IE. The clinical course, treatment and outcome of these 9 patients, aged 7 months to 4 years, were analyzed.

RESULTS

Pneumococcal IE was associated with congenital heart disease in 7 patients and accompanied by other systemic infections including meningitis, pneumonia and otitis media, in 4 patients. Five of the 9 (55.6%) strains isolated by blood culture were penicillin-resistant S. pneumoniae strains. Seven patients were treated with carbapenem. Three underwent cardiac surgery due to cardiac failure and/or vegetation. One died due to septic shock on the first day of hospitalization.

CONCLUSIONS

In children, pneumococcal endocarditis is often accompanied by severe systemic infections. The majority of pediatric cases are caused by penicillin-resistant S. pneumoniae strains. Carbapenem is an effective for IE caused by penicillin-resistant S. pneumoniae. This survey might be helpful to establish proper management strategies for pediatric pneumococcal IE.

Infective endocarditis in patients with congenitally malformed hearts: characterization of the syndrome in a developing country

OBJECTIVE

Cardiac surgery for correction or palliation of congenital cardiac disease in infancy and childhood remains a privilege that is rarely accessible to two-thirds of the world's population. This imbalance has created a unique spectrum of illness in patients with underlying congenital cardiac disease and complicating infective endocarditis in developing countries, including Pakistan. In this study, we characterize endocarditis as seen in such patients presenting in Karachi.

PATIENTS AND SETTINGS

We reviewed retrospectively patients admitted to Aga Khan University with underlying congenitally malformed hearts and endocarditis between 1991 and 2004.

RESULTS

We identified 48 patients with endocarditis according to the modified Duke Criterions, with just over half the cases (54%) classified as definite endocarditis. Of the patients, 23 (49%) patients were more than 16 years old. Uncorrected left-to-right-shunts, tetralogy of Fallot, and congenital mitral valvar disease were the most common underlying defects. Patients with cyanotic defects, particularly of the complex type, were underrepresented (4%). Only 11 (22.9%) of the patients had a previous palliative or corrective surgery. In one-third of the patients (16), streptococcal species were identified as the microbiologic cause of endocarditis, and 22 (45.8%) had culture-negative endocarditis. In contrast, Staphylococcus aureus and enterococci caused endocarditis in only one patient each. There were no differences in mortality or complications between cyanotic and acyanotic congenital defects. Surgery was performed in nine (18.7%) patients with endocarditis, and of these, 13 (27.1%) died.

CONCLUSIONS

In contrast to the developed world, endocarditis in the developing countries, such as Pakistan, complicates uncorrected left-to-right shunts and tetralogy of Fallot, probably because patients with complex cyanotic defects fail to survive long after birth due to the lack of available surgery. Almost half of patients had culture-negative endocarditis, likely related to several factors.

Clinical features remain important for the diagnosis of infective endocarditis in the modern era

BACKGROUND

Infective endocarditis (IE) can be difficult to diagnose, due to multiple (often non-specific) presenting features.

AIM

To assess the predictive accuracy of classical clinical features and blood investigations readily available at the time of presentation.

DESIGN

Cross-sectional analysis.

METHODS

We studied 29 IE cases and 79 controls (clinically suspicious contemporaneous cases where IE was subsequently excluded) from a hospital-based group of patients referred to a cardiac department with possible infective endocarditis. Patients were identified from the echocardiography database. Cases were defined by final diagnosis. Symptoms, signs, risk factors for IE and blood investigations were recorded from case notes and examined by univariate and multivariate analyses.

RESULTS

The sensitivity, specificity, and positive and negative predictive values of transthoracic echocardiography (TTE) for detection of IE in clinically suspected cases were 71%, 98%, 57% and 99%, respectively. Univariate analyses revealed a significant association between IE and several clinical features. Under multivariate analysis, previous heart valve surgery (OR 13.3, 90%CI 3.2-55.6), positive blood cultures (OR 17.2, 90%CI 4.9-58.8), signs of embolism (OR 11.4, 90%CI 3.0-43.5), a new, altered or changing murmur (OR 10.3, 90%CI 2.8-38.5) and splenomegaly (OR 18.2, 90%CI 3.6-90.9) were independent predictors for IE.

DISCUSSION

Clinical features at presentation continue to be important for the diagnosis of IE. Features such as positive blood cultures, signs of embolism and a changing heart murmur should be used to guide investigation and treatment of IE prior to echocardiography, or when TTE is negative.

Clinical course and complications of infective endocarditis in patients growing up with congenital heart disease

BACKGROUND

Although a high number of patients with congenital heart disease (CHD) undergo surgical palliation or definite correction up to adolescence, adult congenital heart disease (ACHD) may remain a potential lifelong risk factor for infective endocarditis (IE) in patients growing up with congenital heart disease (GUCH).

METHODS

In a retrospective case study of a tertiary care center long-term clinical course and complications of patients with IE and GUCH were analysed.

RESULTS

Data of 52 patients with CHD, who fulfilled the Saiman criteria for infective endocarditis and were treated between April 1986 and March 2001, were identified: Risk factors for infective endocarditis were previous cardiovascular operation (51.9%), use of foreign material (38.5%), dental or other surgical procedures without recommended antibiotic prophylaxis (25.0%), or cardiac catheterization (5.8%). Staphylococcal (38.9%) or streptococcal species (35.2%) were cultivated in most cases as causative microorganisms. Complications were: recurrence of IE (7.7%), septic embolisms (30.8%) leading to central nervous complications (7.7%), embolism of pulmonary arteries (7.7%), renal arteries (1.9%), arteries of the extremities (9.6%), or infarction of spleen (1.9%). Other cardiac (23.1%) or extracardiac (13.5%) complications were frequent. The need of re-operations during or after IE was high (67.3%). The hospital mortality was 1.9%, late mortality was 7.7%.

CONCLUSIONS

Patients with IE and CHD show a broad clinical spectrum of cardiac and extracardiac complications. They may lead to a complicative short- and long-term course with the potential risk of death and a high number of re-operation. Efforts have to be made to improve long-term outcome of patients with ACHD by an interdisciplinary cooperation.

Pulmonary endarteritis and subsequent embolization to the lung as a complication of a patent ductus arteriosus--a case report

The authors describe a case of pulmonary endarteritis and subsequent embolization to the lungs as a complication of a patent ductus arteriosus (PDA). Although 2-dimensional echocardiography has been shown to be of great value in the diagnosis of patients with infective endocarditis, echocardiographic detection of vegetation within the pulmonary artery and subsequent embolization to the lung is extremely rare and, to our knowledge, has been previously reported only in a few cases. In brief, our case not only shows the importance of echocardiography in making this rare diagnosis but also emphasizes the role of echocardiography as an effective means of following up such a case.

Analysis of infective endarteritis in patent ductus arteriosus

This study reports on infective endarteritis in 14 children with patent ductus arteriosus over a period of 6 years. Infective endarteritis mostly involved the small ducts and was previously undiagnosed. These patients were given antibiotic treatment for a variable period of 4 to 10 weeks, and all except 1 underwent subsequent closure.

Infective endocarditis

Despite improvements in health care, the incidence of infective endocarditis has not decreased over the past decades. This apparent paradox is explained by a progressive evolution in risk factors; while classic predisposing conditions such as rheumatic heart disease have been all but eradicated, new risk factors for infective endocarditis have emerged. These include intravenous drug use, sclerotic valve disease in elderly patients, use of prosthetic valves, and nosocomial disease. Newly identified pathogens, which are difficult to cultivate--eg, Bartonella spp and Tropheryma whipplei--are present in selected individuals, and resistant organisms are challenging conventional antimicrobial therapy. Keeping up with these changes depends on a comprehensive approach, allying understanding of the pathogenesis of disease with the development of new drugs for infective endocarditis. Infection by staphylococci and streptococci is being dissected at the molecular level. New ideas for antimicrobial agents are being developed. These novel insights should help redefine preventive and therapeutic strategies against infective endocarditis.

Infective endocarditis in Arkansan children from 1990 through 2002

BACKGROUND

Recent medical and surgical advances have increased the potential risk of endocarditis. Epidemiology, pathogens, morbidity and/or mortality may have evolved in the past decade in pediatric patients diagnosed with endocarditis.

METHODS

Retrospective reviews of medical records from Arkansas Children's Hospital were done to identify patients with infective endocarditis from January 1990 through December 2002. Basic demographic and clinical data were gathered and reviewed.

RESULTS

Of 76 patients identified, 57 were included based on diagnostic criteria. Congenital heart disease with (56%) and without (25%) correction were the most common risk factors. Echocardiograms revealed vegetations in 67%. Echocardiograms remain relatively deficient in patients with complex cyanotic heart disease (50% positive) vs. those with normal anatomy (83% positive). Streptococci (30%) and Staphylococcus aureus (21%) were the most common organisms identified overall; however, we observed a predominance of enterococci in infants <2 years of age (41%). Our study revealed a reduced rate of complications, especially of the central nervous system (7% vs. 25 and 33% in prior studies); however, our rate of S. aureus was lower (21% vs. 32 and 39%), and this pathogen continues to be associated with a higher incidence of complications.

CONCLUSIONS

Infective endocarditis continues to present a difficult challenge in pediatrics; its associated pathogens and outcomes have changed little in the past decade.

Infective aortitis associated with the nonpatent remnant of a ductus arteriosus

Infective aortitis is a rare condition, which occurs most commonly in association with some form of structural abnormality of the heart or vessel wall. We describe the successful excision of an infected, nonpatent remnant of the ductus arteriosus.

Survey of prophylaxis and management of infective endocarditis in patients with congenital heart disease: Japanese nationwide survey

Guidelines for the prevention and management of infective endocarditis (IE) in children with congenital heart disease (CHD) have not been established, so the aim of this study was to clarify the incidence, practical prevention and management of IE in patients with CHD in Japan through a nationwide survey. A written questionnaire was sent to members of the Japanese Society of Pediatric Cardiology and Cardiac Surgery and information was obtained from 236 cardiologists in 228 institutions. Four hundred and eight patients with IE were hospitalized during 1997 to 2001 (1/173 admissions with CHD including those hospitalized for cardiac catheterization or surgery). Prevention of IE for CHD was undertaken by 92% of cardiologists, usually oral penicillins (73%) and less frequently cephems (18%) were prescribed. The Duke criteria were used as clinical criteria by 38%. Blood culture was performed once only by 40%. Penicillins and aminoglycosides (38%) were frequently administered for management of culture-negative IE. There were variations in the dose and duration of antibiotics for prevention and management of IE. It appears that the prevalence of IE in CHD is rising and the nationwide survey revealed more variations in practical prevention and management of IE in patients with CHD than expected. The results should be helpful in making future guidelines for management of IE in CHD.

Pulmonic valve endocarditis

Pulmonic valve endocarditis is an extremely rare infection that shares epidemiologic, clinical, radiologic, microbiologic, and prognostic features with tricuspid valve endocarditis. We report a case of pulmonic valve infection on a structurally normal heart and review the English-language literature on this subject.

Infective endocarditis

Infective Endocarditis (IE) is a known and a well-described complication of congenital and acquired heart disease. Its onset may be related to a procedure (which is commonly dental) or to poor dental hygiene. Use of antibiotics prior to the procedure prevents IE. General awareness of dental hygiene and use of prophylactic antibiotic is as much a responsibility of the Pediatrician as it is of the Pediatric Cardiologist. This article reviews the changing epidemiology, pathophysiology, clinical manifestations, and the microbiology of IE. Duke criteria for diagnosis of IE and the role of echocardiography in diagnosis of IE are discussed. There is special emphasis on the prevention of IE.

Antibacterials for the prophylaxis and treatment of bacterial endocarditis in children

Although the overall incidence of infective endocarditis in the paediatric population is considered to be low, over the last 20 years a rising trend in infective endocarditis has been observed among children. This could be due to several reasons including the availability of improved diagnostic techniques, use of continuous central venous catheters and cardiac implants increasing the risk of infection, and the survival of a greater number of infants with congenital heart disease as a result of improved medical management. The predominant causative organisms of paediatric endocarditis include staphylococci and streptococci. There is increased concern surrounding the emergence of endocarditis in children caused by methicillin-resistant Staphylococcus aureus and drug resistant strains of Streptococcus pneumoniae. The treatment approach to paediatric endocarditis is similar to that for adult patients with endocarditis because of similarities in disease pathogenesis and aetiology. The therapeutic goal is to achieve sterilisation of the cardiac vegetations. The choice of antibacterial is dependent upon the susceptibility profile of the causative organism. Vancomycin or gentamicin is recommended for enterococcal endocarditis, according to guidelines from the American Heart Association. For staphylococcal endocarditis in patients with no prosthetic valve, oxacillin or nafcillin with or without gentamicin is the treatment of choice. In the case of endocarditis caused by methicillin-resistant S. aureus, vancomycin is commonly used in patients with no prosthetic valve and a combination of vancomycin, gentamicin and rifampicin (rifampin) for patients with prosthetic material. Cefazolin or ceftriaxone is the treatment of choice for penicillin allergic paediatric patients with endocarditis caused by viridans streptococci. While there have been no major changes in endocarditis therapy for the last decade, the current focus is on the recognition of multiple-drug resistant pathogens and the use of newer agents such as quinupristin/dalfopristin in the treatment of resistant bacterial endocarditis. Prophylactic antibacterial therapy is recommended for procedures thought to be associated with the occurrence of bacteraemia involving organisms commonly associated with endocarditis. These include dental extractions and oral, respiratory tract, genitourinary, gastrointestinal or oesophageal procedures. Prophylactic antibacterials recommended by the American Heart Association during genitourinary and gastrointestinal surgical procedures in high risk patients include ampicillin + gentamicin or vancomycin + gentamicin in high risk patients with penicillin allergy. Ampicillin has been recommended for prophylaxis of bacterial endocarditis in children undergoing oral, respiratory tract or oesophageal procedures. In the case of penicillin allergy in these patients, cephalosporins, clindamycin, azithromycin or clarithromycin have been recommended. The general consensus is that antibacterial prophylaxis during dental procedure is unnecessary, and in fact propagates bacterial resistance.