Management of IE in Pediatrics

1. Clinical Features and Management
in Children
BACTERIAL ENDOCARDITIS

2. Congenital Heart Disease (CHD) :
 VSD (Commonest)
 VSD with AR
 TOF
 TricuspidAtresia
 ValvularAorticStenosis
 BicuspidAorticvalve
 Coarctation ofAorta
 PDA
 Pulmonary stenosis
AT-RISK CHILDREN
CHD with IE >> RHD with IE
Rheumatic Heart Disease (RHD) :
 Mitral valvelesions
 Aortic valvelesions
Prosthetic Valves / Pacemakers :
 Post surgical patients
 Blalock Taussig Shunt

3. HOW DOES IE PRESENT?
 History :
o Prior CHD or RHD
o Preceding dental, GU or GI
procedure
o IVDU
o Central venous catheter
o Prosthetic heart valve
 Symptoms :
o Fever
o Chills
o Chest and abdominal pain
o Arthralgia, myalgia
o Dyspnea
o Malaise, weakness
o Night sweats
o Weight loss
o CNS manifestations (stroke, seizures, headache)

4.  Signs :
o Elevated temperature
o Tachycardia
o New or changing murmur
o Heart failure
o Arrhythmias
o Clubbing
o Splenomegaly
HOW DOES IE PRESENT?
o Embolic phenomena:
 Roth spots
 Petechiae
 Splinter hemorrhages
 Osler nodes
 CNS or Ocular lesions
o Janeway lesions
o Metastatic infections:
 Arthritis
 Meningitis
 Mycotic arterial aneurysm
 Pericarditis
 Abscesses
 Septic pulmonary emboli
RARE IN CHILDREN

5. ROTH SPOTS
SPLINTER
HEMORRHAGES
Linear lesions beneath the nails
White-centered retinal hemorrhages

6. OSLER NODES
Tender, pea-size intradermal nodules in the pads of the fingers and toes

7. JANEWAY LESIONS
Painless, small, erythematous or hemorrhagic lesions on the palms and soles

8. VEGETATIONS
Vegetations on the valves

9. o Positive blood culture
o Elevated ESR
o Elevated CRP
o Anemia
o Leukocytosis
o Immune complexes
o Hypergammaglobulinemia
o Hypocomplementemia
INVESTIGATIONS
o Cryoglobulinemia
o Rheumatoid Factor
o Hematuria
o Renal failure: Azotemia, high creatinine
o CXR : Bilateral infiltrates, nodules, pleural effusions
o Echocardiography: Valve vegetations, prosthetic valve
dysfunction or leak, myocardial abscess, or new-onset
valve insufficiency

10. HOW TO DIAGNOSE IE?
DEFINITE DIAGNOSIS :
 Pathologic Criteria:
o Microorganisms demonstrated by results of cultures or
histologic examination of a vegetation, a vegetation that
has embolized, or an intracardiac abscess specimen;
(or)
o Pathologic lesions; vegetation, or intracardiac abscess
confirmed by results of histologic examination showing
active endocarditis
MODIFIED DUKE CRITERIA
 Clinical Criteria:
o 2 MAJOR criteria, or
o 1 MAJOR criterion and 3 MINOR criteria, or
o 5 MINOR criteria

11. HOW TO DIAGNOSE IE?
MODIFIED DUKE CRITERIA
POSSIBLE DIAGNOSIS :
o 1 MAJOR criterion and 1 MINOR criterion,
or
o 3 MINOR criteria
REJECTED DIAGNOSIS :
o Firm alternate diagnosis explaining evidence of
suspected IE,
or
o Resolution of IE syndrome with antibiotic therapy
for ≤4 days,
or
o No evidence of IE at surgery or autopsy, on
antibiotic therapy for ≤4 days,
or
o Does not meet criteria for possible IE

12. MAJOR CRITERIA
1. Blood culture findings positive for IE :
 Typical microorganisms consistent with IE from 2 separate blood cultures:
o Viridans streptococci, Strep gallolyticus (formerly known as S.bovis), Staph aureus, HACEK
group, or
o Community-acquired enterococci, in the absence of a primary focus, or
 Microorganisms consistent with IE from persistently positive blood culture findings, defined as:
o ≥2 positive culture findings of blood samples drawn >12 hr apart, or
o 3 or most of ≥4 separate culture findings of blood (with first and last sample drawn ≥1 hr apart)
o Single positive blood culture for Coxiella burnetii or anti-phase I lgG titer ≥1:800.

13. MAJOR CRITERIA
2. Evidence of endocardial involvement :
 Echocardiographic findings positive for IE (TEE recommended in patients with prosthetic valves,
rated at least possible IE by clinical criteria or complicated IE [paravalvular abscess]; TTE as 1st
test in other patients), defined as follows:
o Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets,
or on implanted material in the absence of an alternative anatomic explanation, or
o Abscess, or
o New partial dehiscence of prosthetic valve.
 New valvular regurgitation; worsening or changing of pre-existing murmur not sufficient.

14. MINOR CRITERIA
o Predisposition: Predisposing heart condition, or intravenous drug use
o Fever: Temperature > 38°C (100.4°F)
o Vascular phenomena: Major arterial emboli, septic pulmonary infarcts, mycotic aneurysm,
intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions
o Immunologic phenomena: Glomerulonephritis, Osler nodes, Roth spots, and rheumatoid factor
o Microbiologic evidence: Positive blood culture finding but does not meet a major criterion as noted
above (excludes single positive culture findings for coagulase-negative staphylococci and
organisms that do not cause endocarditis) or serologic evidence of active infection with organism
consistent with IE.

15. HOW SERIOUS IS IE?
o Mortality remains high at 20-25%, despite use of antibiotics.
o Serious morbidity occurs in 50-60% of children with documented infective
endocarditis.
o The most common is heart failure caused by vegetations involving the aortic or
mitral valve.
o Myocardial abscesses and toxic myocarditis may also lead to heart failure.

16. HOW DO YOU TREAT IE?
IE Suspected
NOT acutely ill Acutely ill
Obtain blood
cultures,
consider starting
antibiotics
Start antibiotics,
obtain blood
cultures prior
if possible

17. TREATMENT PRINCIPLES
o Antibiotic therapy should be instituted immediately (Targeted / Empirical).
o Even small delays are associated with greater likelihood of severe complications.
o A total course of 4-6 weeks of treatment is usually recommended.
o Bactericidal rather than bacteriostatic.
o High serum bactericidal levels must be maintained long enough to eradicate organisms.
o Resolution with staphylococcal disease takes longer.

18. ENDOCARDITIS DRUGS
o Culture Negative Endocarditis
o Native Valve Endocarditis
o Late Prosthetic Valve Endocarditis
(>1year after surgery)
Ampicillin / Sulbactam PLUS
Gentamicin
With or Without Vancomycin
Alternative :
Vancomycin PLUS
Gentamicin
o Nosocomial Endocarditis
o Early Prosthetic Valve Endocarditis
(≤1 y after surgery)
Vancomycin PLUS Gentamicin
PLUS
Cefipime / Ceftazidime
Prosthetic material :
Rifampicin

19. ORGANISMS DRUGS
Highly susceptible Streptococci
Penicillin G (or) Ceftriaxone
Other options : Vancomycin (or) Cefazolin
Relatively resistant Streptococci / Enterococci
Penicillin G / Ampicillin PLUS Gentamicin
Enterococci : Vancomycin PLUS Gentamicin
Staphylococci Aureus / CONS
Penicillin G
Nafcillin / Oxacillin
Vancomycin / Cefazolin
Penicillin Resistant
Nafcillin / Oxacillin PLUS Gentamicin for 5 days (or)
Vancomycin / Cefazolin
MRSA Vancomycin (or) Daptomycin
Vancomycin Resistant
Daptomycin
All Prosthetic Valve:
Anti-Staph PLUS Rifampicin PLUS Gentamicin for 2weeks
Gram negative enteric
Cefipime / Ceftazidime / Cefotaxime / Ceftriaxone PLUS Gentamicin
HACEK
Ceftriaxone / Cefotaxime (or) Ampicillin Sulbactam
Ampicillin PLUS Gentamicin / Amikacin

20. DRUGS DOSE FREQUENCY MAX DOSE/DAY
Penicillin G 2-3L U/kg/24 hr Q4-6H 24 million units
Ampicillin 200-300 mg/kg/24 hr Q6-8H 12 grams
Nafcillin / Oxacillin 200 mg/kg/24 hr Q4-6H 12 grams
Ceftriaxone 100 mg/kg/24 hr Q12H 2 grams
Cefipime 100-150 mg/kg/24 hr Q8-12H 6 grams
Cefazolin 100 mg/kg/24 hr Q8H 2-4 grams
Ceftazidime 100-150 mg/kg/24 hr Q8H 2-4 grams
Gentamicin 3 mg/kg/24 hr Q8H -
Vancomycin 40 mg/kg/24 hr Q8-12H 2 grams
Daptomycin 6 mg/kg/24 hr Q24H -
Rifampicin 20 mg/kg/24 hr Q24H 900 mg

21. SURGICAL INTERVENTION
Echocardiographic features that suggest potential need for surgical intervention:
 Vegetation :
o Persistent vegetation after systemic embolization
o Anterior mitral valve leaflet vegetation, particularly if it is highly mobile with size >10 mm
o One or more embolic events during the 1st 2 weeks of antimicrobial therapy
o Increase in vegetation size despite appropriate antimicrobial therapy
 Valvular Dysfunction :
o Acute aortic or mitral insufficiency with signs of ventricular failure
o Heart failure unresponsive to medical therapy
o Valve perforation or rupture
 Perivalvular Extension :
o Valvular dehiscence, rupture, or fistula
o New heart block
o Large abscess or extension of abscess despite appropriate antimicrobial therapy

22. PREVENTION OF IE
REVISED AMERICAN HEART ASSOCIATION (AHA) GUIDELINES - 2007
o The primary reasons for these revised recommendations were that,
(1) IE is much more likely to result from exposure to the more frequent random
bacteremias associated with daily activities than from a dental or surgical procedure.
(2) Routine prophylaxis may prevent “an exceedingly small” number of cases.
(3) Risk of antibiotic-related adverse events exceeds the benefits of prophylactic therapy.
o Improving general dental hygiene - important factor in reducing the risk of IE resulting from
routine daily bacteremias.
o The current recommendations limit the use of prophylaxis to those patients with cardiac
conditions associated with the greatest risk of an adverse outcome.

23. PREVENTION OF IE
REVISED AMERICAN HEART ASSOCIATION (AHA) GUIDELINES - 2007
o Prophylaxis is recommended for “all dental procedures that involve manipulation of gingival
tissue or the periapical region of teeth or perforation of the oral mucosa.”
o Prophylaxis is considered reasonable for many invasive respiratory tract procedures as they
cause bacteremia.
o Prophylaxis is considered for patients with permanently damaged valves from RHD.
o Prophylaxis is recommended for patients undergoing cardiac surgery with placement of
prosthetic materials.
o In contrast to prior recommendations, prophylaxis for GI or GU procedures is NO longer
recommended in the majority of cases.

24. PREVENTION OF IE
REVISED AMERICAN HEART ASSOCIATION (AHA) GUIDELINES - 2007
Cardiac conditions : Prophylaxis with dental procedures is reasonable :
o Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
o Previous infective endocarditis
 Congenital Heart Disease (CHD) :
o Unrepaired cyanotic CHD, including palliative shunts and conduits
o Completely repaired CHD with prosthetic material or device, whether placed by surgery
or catheter intervention, during the 1st 6 months after the procedure
o Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic
patch, or prosthetic device (which inhibit endothelialization)
o Cardiac transplantation recipients who develop cardiac valvulopathy