3. Pediatrics
• Increasing number of surgical patients
• Increasing number of complex congenital
heart disease
• Increased use of prosthetic materials
• NICUs and PICUs
Epidemiology
4. Pediatrics
• Damaged endothelium
• undamaged endothelium not conducive to
bacterial colonization
• endothelium can be damaged by high-velocity
flows
• trauma to endothelium can induce
thrombogenesis, leading to nonbacterial
thrombotic endocarditis (NBTE). NBTE is more
receptive to colonization
Pathogenesis, Part 1
6. Pediatrics
• S. Viridans , Most common causative organism
• Gram negative bacilli , in Neonates and immunocompromised patients
• Prosthetic valves
Within first year of surgery: Coag-negative staph
After first year: similar to native valve endocarditis
• HACEK organisms • Hemophilus, Actinobacillus, Cardiobacterium,
Eikenella, Kingella • Frequently affect damaged valves and can cause
emboli…
Microbiology
7. Pediatrics
Diagnosis
• Traditionally based upon “positive blood
cultures in the presence of a new or changing
heart murmur”, or persistent fever in the presence
of heart disease.
• Shortcomings include culture-negative
endocarditis, lack of typical echocardiographic
findings, etc
8. Pediatrics
• No randomized controlled human trials which definitively
establishes the efficacy of antibiotic prophylaxis.
• Most cases of endocarditis are NOT attributable to an
invasive procedure
• Current recommendations are based upon literature analysis
of procedure-related endocarditis, prophylaxis studies in
experimental animal models, and retrospective analysis of
human endocarditis
Prevention of IE
14. Pediatrics
• Based on pathological and clinical criteria.
• Utilizes microbiological data, evidence of endocardial involvement, and other phenomenon
associated with infective endocarditis to estimate the probability of infective endocarditis in a
given patient.
• Has been shown to be valid and reproducible in children ..
New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic
findings.
Duke criteria
• Definitive
Pathological criteria : Microorganisms / Pathologic lesions
Clinical criteria : 2 major criteria, or 1 major and 3 minor criteria, or 5 minor
• Possible : Findings consistent with infective endocarditis that fall short of “definitive” but are not
“rejected”
• Rejected :
Firm alternative diagnosis, or
Resolution of manifestations of endocarditis with antibiotic therapy of 4 days or less, or
No pathological evidence of endocarditis at surgery or autopsy with antibiotic therapy of 4 days or less
Duke Criteria
16. Pediatrics
• Positive blood culture :
Typical microorganism consistent with IE, from two separate blood cultures • S. viridans,
S. bovis, HACEK • community-acquired S. aureus or enterocci (no primary focus) •
Persistently positive cultures • at least two positive cultures, drawn 12 hours apart • all of
three, or a majority of four or more cultures (with first and last sample drawn at least
one hour apart
• Evidence of endocardial involvement : Positive echocardiogram
oscillating intracardiac mass on valve or supporting structures, or
myocardial abscess, or
new partial dehiscence of prosthetic valve
New valvar regurgitation
Duke criteria: Major criteria
25. Pediatrics
Blood cultures
Day 1
3 samples separate venipuncture sites, can be
at same time
Day 2 and beyond
At least 2 sets every 24 – 48 hours until negative
How do you treat IE?
26. Pediatrics
ID Consult
Tailor treatment to organism
High serum concentration to penetrate vegetation
IV is preferred over IM in children
Fever should resolve within a few days, < 10
(AHA, 2005 & AHA, 2002)
How do you treat IE?
27. Pediatrics
Choose bactericidal vs. bacteriostatic
Anticipate 4-6 week course*
Broad spectrum coverage for staph, strept, & HACEK
‐ Ceftriaxone & Gentamicin
‐ If staph suspected, add beta lactam resistant PCN
Consider outpatient therapy
Repeat cultures within 8 weeks of completing abx course
(AHA, 2005)
How do you treat IE?
28. Pediatrics
Surgical indications
‐ Fistulae
‐ Staph or Fungal vegetations
‐ Risk of embolization
‐ Abscess
‐ Heart failure
‐ Mycotic aneurysm
‐ Goretex & dacron shunts likely to need replacing
(AHA, 2005)
How do you treat IE?
29. Pediatrics
2007 guideline revision
Frequent exposure is greatest risk
Prophylaxis might prevent few cases
Risk outweighs benefit
Oral health maintenance
How do you prevent IE
31. Pediatrics
Give before procedure or within 2 hours
Dental procedures
Recommended for all dental procedures
manipulating the gingival tissue or periapical region
of teeth or perforation of oral mucosa
NOT recommended for
Shedding of baby teeth
Oral trauma
Removal / placement or adjustment of orthodontic
appliances
Routine anesthetic injections
How do you prevent IE
32. Pediatrics
Skin
- Recommended for procedures on infected skin or
muscle
GI/GU procedures
‐ Not recommended
‐ Reasonable to include abx to treat enterococci in a
high risk patient
Being treated for a GI/GU infection
Urinary tract manipulation during infection (cystoscopy
How do you prevent IE
33. Pediatrics
Respiratory procedures
‐ Not recommended
‐ Reasonable to include abx for Incision or biopsy of
the respiratory mucosa tonsillectomy,
adenoidectomy, drainage of abscess or empyema
How do you prevent IE
Editor's Notes
-
Abx day count starts on date of first negative culture
