Infective endocarditis successfully treated in extremely low birth weight infants with recombinant tissue plasminogen activator

Fibrinolytic treatment using recombinant tissue-type plasminogen activator (rt-PA) for staphylococcal infective endocarditis

Infective endocarditis (IE) is a severe illness characterized by vegetation of bacterial thrombosis. We hypothesized that adding recombinant tissue-type plasminogen activator (rt-PA) to antibiotics would contribute to good results in the treatment of IE. As an in vitro study, we injected labeled Staphylococcus aureus (S. aureus) and either rt-PA or PBS + plasminogen into a polydimethylsiloxane flow chamber with fibrin on a coverslip, and then performed immunofluorescent area assessment. As an in vivo experiment, IE model rats that had suffered mechanical damage in the aortic valve by catheter and revealed bacterial vegetation caused by S. aureus injection were treated with either a control, cefazolin (CEZ), rt-PA, or rt-PA + CEZ, for 7 days. Survival was assessed for 14 days after the appearance of vegetation, with daily monitoring of the vegetation by transthoracic echocardiography (TTE). The in vitro investigation showed that perfusion of rt-PA could detach S. aureus significantly more efficiently than PBS could. In the in vivo research, the rt-PA + CEZ group survived significantly longer than the other groups, and rt-PA + CEZ was more effective than CEZ in the dissolution of vegetation, as observed by TTE. In conclusion, adding rt-PA to antibiotic treatment could dissolve the vegetation component synergistically and improve the survival rate.

A Case of Enterococcal Patent Ductus Arteriosus-associated Endarteritis in a Preterm Neonate

INTRODUCTION

The persistent patency of the ductus arteriosus frequently occurs in premature neonates and can cause infective endocarditis (IE) or ductal endarteritis (DE) during sepsis. Even though neonatal IE and DE are believed to be a rare eventuality, their incidence has been increasing in the last decades due to the improved survival of even more preterm babies, favored by highly invasive procedures and therapies. In parallel, antimicrobial resistance is another rising problem in neonatal intensive care units, which frequently compels to treat infections with broad-spectrum or last generation antibiotics.

CASE PRESENTATION

We report the case of a preterm neonate affected by patent ductus arteriosus-associated DE that followed an episode of sepsis caused by a high-level aminoglycoside-resistant enterococcus. The neonate was successfully treated with the synergistic combination of ampicillin and cefotaxime.

DISCUSSION

IE and patent ductus arteriosus-associated DE are rising inside neonatal intensive care units and neonatologists should be aware of these conditions. Enterococcal IE and patent ductus arteriosus-associated DE sustained by high-level aminoglycoside-resistant strains can be successfully treated with the synergistic combination of ampicillin and cefotaxime even in preterm neonates.

Unusual large mass on aortic valve in an infant

Mass on the aortic valve is extremely rare in children, and the differential diagnosis includes vegetation, thrombus, and primary cardiac tumors. A rise in infective endocarditis in infants is seen due to increasing survival of children with congenital heart diseases and sick newborn infants with prolonged hospitalization. We report a 4-month-old infant born prematurely with early-onset sepsis requiring prolonged antibiotic treatment and valvular aortic stenosis presenting with sudden hemodynamic compromise due to aortic vegetation extending into the ascending aorta eroding through its posterior wall. The report details management of our case and a brief description of available alternative treatment strategies.

Fungal endocarditis in paediatrics: a review of 192 cases (1971-2016)

BACKGROUND

The aims of this article were to review the published literature on fungal endocarditis in children and to discuss the aetiology and diagnosis, with emphasis on non-invasive methods and various treatment regimes.

METHODS

We systematically reviewed published cases and case series of fungal endocarditis in children. We searched the literature, including PubMed and individual references for publications of original articles, single cases, or case series of paediatric fungal endocarditis, with the following keywords: "fungal endocarditis", "neonates", "infants", "child", and "cardiac vegetation".

RESULTS

There have been 192 documented cases of fungal endocarditis in paediatrics. The highest number of cases was reported in infants (93/192, 48%) including 60 in neonates. Of the neonatal cases, 57 were premature with a median gestational age of 27 weeks and median birth weight of 860 g. Overall, 120 yeast - fungus that grows as a single cell - infections and 43 mould - fungus that grows in multicellular filaments, hyphae - infections were reported. With increasing age, there was an increased infection rate with moulds. All the yeast infections were detected by blood culture. In cases with mould infection, diagnosis was mainly established by culture or histology of emboli or infected valves after invasive surgical procedures. There have been a few recent cases of successful early diagnosis by non-invasive methods such as blood polymerase chain reaction (PCR) for moulds. The overall mortality for paediatric fungal endocarditis was 56.25%. The most important cause of death was cardiac complications due to heart failure. Among the various treatment regimens used, none of them was significantly associated with better outcome.

CONCLUSIONS

Non-invasive methods such as PCR tests can be used to improve the chances of detecting and identifying the aetiological agent in a timely manner. Delays in the diagnosis of these infections may result in high mortality and morbidity. No significant difference was noted between combined surgical and medical therapy over exclusively combined medical therapy.

Successfully treated infective endocarditis caused by methicillin-resistant Staphylococcus Aureus in extremely low birth weight infant

Survival rates of preterm infants have improved in the past few decades, and central venous catheters play an important role in the intensive medical treatment of these neonates. Unfortunately, these indwelling catheters increase the risk of intracardiac thrombosis, and they provide a nidus for microorganisms during the course of septicemia. Herein, we report a case of persistent bacteremia due to methicillin-resistant Staphylococcus aureus in an extremely low birth weight (ELBW) infant, along with vegetation observed on an echocardiogram, the findings which are compatible with a diagnosis of endocarditis. The endocarditis was successfully treated with antibiotic therapy, and the patient recovered without major complications. We suggest a surveillance echocardiogram for ELBW infants within a few days of birth, with regular follow-up studies when clinical signs of sepsis are observed.

Recombinant tissue plasminogen activator as a novel treatment option for infective endocarditis: a retrospective clinical study in 32 children

Infective endocarditis is a life-threatening infectious syndrome, with high morbidity and mortality. Current treatments for infective endocarditis include intravenous antibiotics, surgery, and involve a lengthy hospital stay. We hypothesised that adjunctive recombinant tissue plasminogen activator treatment for infective endocarditis may facilitate faster resolution of vegetations and clearance of positive blood cultures, and therefore decrease morbidity and mortality. This retrospective study included follow-up of patients, from 1997 through 2014, including clinical presentation, causative organism, length of treatment, morbidity, and mortality. We identified 32 patients, all of whom were diagnosed with endocarditis and were treated by recombinant tissue plasminogen activator. Among all, 27 patients (93%) had positive blood cultures, with the most frequent organisms being Staphylococcus epidermis (nine patients), Staphylococcus aureus (six patients), and Candida (nine patients). Upon treatment, in 31 patients (97%), resolution of vegetations and clearance of blood cultures occurred within hours to few days. Out of 32 patients, one patient (3%) died and three patients (9%) suffered embolic or haemorrhagic events, possibly related to the recombinant tissue plasminogen activator. None of the patients required surgical intervention to assist vegetation resolution. In conclusion, it appears that recombinant tissue plasminogen activator may become an adjunctive treatment for infective endocarditis and may decrease morbidity as compared with current guidelines. Prospective multi-centre studies are required to validate our findings.

Thrombosis in the Neonatal Intensive Care Unit

Neonates have the highest risk for pathologic thrombosis among pediatric patients. A combination of genetic and acquired risk factors significantly contributes to this risk, with the most important risk factor being the use of central venous catheters. Proper imaging is critical for confirming the diagnosis. Despite a significant number of these events being life- and limb-threatening, there is limited evidence on what the appropriate management strategy should be. Evaluation and treatment of any neonate with a clinically significant thrombosis should occur at a tertiary referral center that has proper support.

Fungal Endocarditis in Neonates: A Review of Seventy-one Cases (1971-2013)

BACKGROUND

Fungal endocarditis (FE) remains an uncommon but life-threatening complication of invasive fungal infections. As data on neonatal FE are scant, we aimed to review all published experience regarding this serious infection.

METHODS

Neonatal FE cases published in PubMed (1971-2013) as single cases, or case series were identified using the terms "fungal endocarditis, neonates and cardiac vegetation." Data on predefined criteria including demographics, predisposing factors, mycology, sites of cardiac involvement, therapy and outcome were collected and analyzed.

RESULTS

The dataset comprised 71 neonates with FE. Median birth weight was 940 g [interquartile range (IQR): 609], median gestational age 27 weeks (IQR: 6) and median postnatal age at diagnosis 20 days (IQR: 20). Ninety-two percent of the patients were premature. Right atrium was the most common vegetation site (63%). Seventy-one percent of the cases reported were associated with previous central venous catheters. Candida albicans was the most predominant fungal species (59%). Amphotericin B monotherapy was used in 42.2% and fluconazole in 2.8%. Amphotericin B with flucytosine (25.3%) was the most frequent combined regimen. Surgical treatment was conducted in 28%. Overall mortality was 42.2%. Initiation with combined antifungal treatment was associated with lower mortality than monotherapy (24.2% vs. 51.7%, respectively, P = 0.036).

CONCLUSIONS

Neonatal FE most frequently occurs in very premature infants and is associated with central venous catheters. C. albicans is the predominant fungus. Although outcome has been dismal, it may be improved with combined antifungal therapy.

Treatment of neonatal fungal infective endocarditis with recombinant tissue plasminogen: activator in a low birth weight infant case report and review of the literature

With advances in medical sciences, an increase in survival rates of low birth weight; increased incidence in use of catheter and antibiotics, and total parenteral nutrition are reported, therefore, the rate of fungal infections in late and very late onset neonatal sepsis have increased. Although fungal endocarditis rarely occur in newborns, it has a high morbidity and mortality. Antifungal therapy is often insufficient in cases who develop fungal endocarditis and surgical treatment is not preferred due to its difficulty and high mortality. Herein, fungal endocarditis in a preterm newborn treated with single-dose recombinant tissue plasminogen activator in addition to antifungal therapy is presented and relevant literature has been reviewed. The vegetation completely disappeared following treatment and no complication was observed.

Management of neonatal thrombosis

Neonates have one of the highest risks for thromboembolism among pediatric patients. This risk is attributable to a combination of multiple genetic and acquired risk factors. Despite a significant number of these events being either life threatening or limb threatening, there is limited evidence on appropriate management strategy. Most of what is recommended is based on uncontrolled studies, case series, or expert opinion. This review begins with a discussion of the neonatal hemostatic system, focusing on the common sites and imaging modalities for the detection of neonatal thrombosis. Perinatal and postnatal risk factors are presented and management options discussed.

The use of recombinant tissue-type plasminogen activator in a newborn with an intracardiac thrombus developed during extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation (ECMO) support is often used to support infants and children with hemodynamic or respiratory failure. One of the major obstacles of safely treating a child with ECMO is balancing the risk of hemorrhage with the potential for thrombus development. Managing thrombosis in the setting of ECMO is challenging and has no defined algorithm. The use of recombinant tissue-type plasminogen activator (tPA) for thrombolysis has been previously described in cases where thrombi have developed despite adequate anticoagulation. In such situations, the risk of hemorrhage must be carefully balanced with the benefit of dissolving the clot and reestablishing flow. We present a case of an infant who required ECMO because of severe primary pulmonary hypertension and subsequently developed a right atrial thrombus adjacent to the ECMO cannula. The patient was treated with tPA with immediate improvement but had fatal intracranial hemorrhage almost 3 days after the tPA was administered. In this report, we review the current literature on tPA use during ECMO support and suggest a rational approach.

Evaluation and Treatment of Neonatal Thrombus Formation in 17 Patients

Introduction: Thrombosis is a rare but serious event in neonates. Perinatal risk factors associated with the developing hemostatic system increase the risk of thromboembolism. Treatment protocols vary between different centers. In this study, thrombosis and subsequent treatment were evaluated in 17 neonates hospitalized in a neonatal intensive care unit. This is the largest series reported to date. Method: From January 2007 to December 2009, thrombosis was diagnosed in 17 newborns hospitalized in a neonatal intensive care unit. Most were treated with recombinant tissue plasminogen activator (r-tPA) and enoxaparin as anticoagulant therapy. Results: Eleven courses of r-tPA therapy were administered to 10 patients. Sixteen patients received low-molecular-weight heparin (LMWH) treatment. None of the patients had hemorrhagic complications due to therapy. Recurrence was observed in 1 patient 1.5 months after the first course of r-tPA and retreatment was performed. A complete decrease in thrombus size was achieved in 9 patients and a partial decrease in 5 patients. One patient died before treatment was initiated; another died at the end of the first day of treatment and thus could not be evaluated. One patient who had a homozygous mutation for factor V Leiden did not respond to treatment and the extremity involved was amputated. Conclusions: Thrombosis in neonates is a multifactorial disorder. Treatment consisting of r-tPA and an anticoagulant was shown to be a safe and effective approach to clot dissolution in neonates.

Staphylococcus aureus Septicemia with a fatal transmural myocardial infarction in a 27-week-gestation twin infant: a case study

Septicemia, one of the major causes of morbidity and mortality in the neonatal period, often has a rapid and fulminant course. Low-birth-weight infants with persistent Staphylococcus aureus septicemia, possibly associated with percutaneous central venous catheters, may develop metastatic infections including endocarditis with large vegetations. This article describes a neonate with S. aureus bacteremia that resolved with treatment who died secondary to decreased left ventricular function. At autopsy, organizing microthrombi were seen within both atria, the left ventricle, and the left coronary arterial system. Extensive infarcts were noted throughout the entire myocardium of the left ventricle. It was suspected, but not proven, that the thrombotic sequelae from septicemia caused this neonate's death.

The use of recombinant tissue plasminogen activator in the management of infective intracardiac thrombi in pre-term infants with thrombocytopaenia

Bacterial endocarditis complicated by the development of intra-cardiac thrombus presents a difficult management dilemma in the pre-term infant. Here we present our experience with three infants who had this condition, all of whom were successfully managed using therapy with recombinant tissue plasminogen activator (r-TPA). Therapy in one of the infants was particularly instructive, as the condition was further complicated by severe thrombocytopaenia, making the decision to treat using r-TPA difficult.

Intracranial hemorrhage following thrombolytic use for stroke caused by infective endocarditis

BACKGROUND AND PURPOSE

Stroke is one of the most common neurological manifestations of infective endocarditis. The use of intravenous tissue plasminogen activator (t-PA) in the management of acute ischemic stroke is the accepted standard of practice. Current guidelines for intravenous (IV) t-PA therapy in acute ischemic stroke do not exclude patients with infective endocarditis. We present three patients who received IV t-PA for acute ischemic stroke in the setting of infective endocarditis and developed multifocal intracranial hemorrhage as a complication.

CONCLUSION

Infective endocarditis related strokes are associated with a higher risk of hemorrhagic complications and our experience suggests that IV t-PA use may potentiate that risk.

The evaluation and management of postnatal thromboses

In the pediatric population, neonates have the highest risk for thromboembolism (TE), most likely due to the frequent use of intravascular catheters. This increased risk is attributed to multiple risk factors. Randomized clinical trials dealing with management of postnatal thromboses do not exist, thus, opinions differ regarding optimal diagnostic and therapeutic interventions. This review begins with an actual case study illustrating the complexity and severity of these types of cases, and then evaluates the neonatal hemostatic system with discussion of the common sites of postnatal thrombosis, perinatal and prothrombotic risk factors, and potential treatment options. A proposed step-wise evaluation of neonates with symptomatic postnatal thromboses will be suggested, as well as future research and registry directions. Owing to the complexity of ischemic perinatal stroke, this topic will not be reviewed.

The evaluation and management of neonatal coagulation disorders

Neonatal hemostatic abnormalities can present diagnostic and therapeutic challenges to the physician. Developmental deficiencies and/or increases of certain coagulation proteins, coupled with acquired or genetic risk factors, can result in a hemorrhagic or thromboembolic emergency. The timely diagnosis of a congenital hemorrhagic or thrombotic disorder can avoid significant long-term sequelae. However, due to the lack of randomized clinical trials addressing the management of neonatal coagulation disorders, treatment strategies are usually empiric and not evidence-based. In this chapter, we will review the neonatal hemostatic system and will discuss the most common types of hemorrhagic and thrombotic disorders. Congenital and acquired risk factors for hemorrhagic and thromboembolic disorders will be presented, as well as current treatment options. Finally, suggested evaluations for neonates with either hemorrhagic or thromboembolic problems will be reviewed.

Outcome of cardiac thrombi in infants

Use of central lines in the neonatal intensive care unit (NICU) has led to the formation of intracardiac thrombi. A paucity of data exists on the management of neonatal cardiac thrombi, with the few reported cases focusing on outcomes following thrombolytic therapy. This study was undertaken to evaluate the outcome of cardiac thrombi in neonates who do not receive thrombolytic therapy. Nineteen patients younger than 3 months of age diagnosed with cardiac thrombi were included. All 19 patients had a central line. Management consisted of a combination of antibiotics and low-molecular-weight heparin (n = 16) or surgical removal (n = 2). In one case, no treatment was instituted. One patient was lost to follow-up after partial resolution of the thrombus. Complete thrombus resolution occurred in 18 patients, 9 with negative blood cultures and 9 with positive blood cultures. It took longer for resolution of thrombi associated with positive blood cultures than for sterile thrombi. No patient had evidence of thrombus embolization. From these data we concluded that the natural history of cardiac thrombi is resolution. Infected thrombi require more prolonged therapy. Surgery is seldom required and thrombolytics are not usually necessary for clot resolution.

Treatment of infective endocarditis with recombinant tissue plasminogen activator

Infective endocarditis (IE) caused by microbial infection is virtually always fatal if untreated. High-dose and long-term antibiotic treatment is required to eradicate microorganisms. If increased risk of embolic events, persistent infection, and progressive cardiac failure are present, surgery is indicated. However, surgery can carry an increased risk of mortality and morbidity in critically ill children of whom other treatment options such as administering, a thrombolytic agent; recombinant tissue plasminogen activator (r-tPA) could be an alternative choice. Here, we report a 14-year-old male with Down syndrome and acute myeloblastic leukemia, diagnosed with IE characterized by two large vegetations on aortic and mitral valves, who was successfully treated with r-tPA.

Fungal endocarditis in neonates and children

Fungal endocarditis in the neonate and pediatric population is associated with a high degree of morbidity and mortality, with diagnosis in the majority of cases made postmortem. The aim of this article is to review published literature on fungal endocarditis in children and to discuss the incidence due to a wide range of fungi, primarily Aspergillus and Candida species, as well as its diagnosis, including the importance of molecular-based approaches and various treatment regimes.

Aspirin treatment for neonatal infectious endocarditis

We describe a term female neonate with Serratia marcescens endocarditis. Despite adequate antibiotic therapy for 8 days, the bacteremia persisted and there was an increase in vegetation size. Treatment with aspirin was initiated, with resolution of the bacteremia and a gradual decrease in vegetation size. We conclude that in neonatal endocarditis, aspirin may be beneficial additional treatment.

Successful treatment of infective endocarditis with recombinant tissue plasminogen activator

OBJECTIVES

In a prospective study, we examined the effect of treatment with recombinant tissue plasminogen activator (r-TPA) on survival and morbidity in a series of high-risk children with infectious endocarditis (IE) after prolonged treatment with indwelling catheters. We hypothesized that r-TPA is an adjunctive therapy for dissolution of infected thrombi in drug-resistant IE.

STUDY DESIGN

In the prospective 3-year study (1998-2001), we identified high-risk children with chronic illness and prolonged treatment with indwelling catheters who developed IE and overwhelming sepsis. Patients were allocated to receive r-TPA after persistent and enlarging intracardiac vegetations and failure to respond to conventional medical management. Complications associated with treatment, survival, and cardiac morbidity were observed.

RESULTS

Seven infants were treated prospectively with r-TPA. All infants responded promptly to treatment, with resolution of the intracardiac vegetations within 3 to 4 days of commencement and without any adverse complications. All patients survived without long-term cardiac morbidity.

CONCLUSION

Recombinant tissue plasminogen activator may offer a safe alternative to surgical intervention in the high-risk infant with IE.