brief description of infective endocarditis in children.

1. Infective Endocarditis
in Children
Dr Yasin Abshir
MBBS (Nile University-Sudan)
Paediatric Resident at KIU-TH
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2. Outline
Introduction
Epidemiology
Etiology
Pathogenesis
Clinical Manifestation
 Diagnosis
 Complication
 Management
 Prevention
 References
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3. Introduction
• Infective endocarditis (IE) is an infection of the endocardium and/or
heart valves that involves thrombus formation (vegetation), which may
damage the endocardial tissue and/or valves.
• The process can involve native endocardium/endothelium or prosthetic
material.
• Although uncommon in children, it is important to identify and treat IE
because of its significant morbidity and mortality.
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4. Cont..
• Previously it was called bacterial endocarditis, however as many other
organisms other than bacteria also cause endocarditis, it has been
labelled as infective endocarditis.
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5.  Epidemiology
• Infective endocarditis (IE) is a rare condition, that is even more
uncommon in children.
• The incidence of pediatric IE has been estimated to be 0.43–0.69
cases per 100,000 children–year.
• This low incidence makes it difficult to obtain evidence regarding the
best diagnostic and therapeutic approach of IE at those ages.
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6. Risk factors
• Most children with IE have an identifiable risk factor for the disease:
Congenital heart disease
Central venous catheters
Rheumatic heart disease
Presence of prosthetic material
Other risk factors (Intravenous drug abuse and degenerative heart disease,
which are important predisposing factors in the adult population, are less
commonly seen in children )
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10. Etiology
• Although a variety of microorganisms can cause IE, Staphylococci and
Streptococci species are the most common pathogens associated
with IE in children.
• Fungal endocarditis is rare and is typically caused by Candida species.
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13. Pathogenesis
• IE is the result of a series of complex interactions among blood-borne
pathogens, damaged endothelium, fibrin, and platelets.
• The endocardial surface is initially injured by shear forces associated with
turbulent blood flow in children with congenital heart disease (CHD), or
indwelling central venous catheters in children without CHD.
• At the site of endothelial damage, fibrin, platelets, and occasionally red blood
cells are deposited and initially form a non infected thrombus.
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14. Cont..
• Transient bacteremia (which occurs in normal children) or
fungemia results in adherence of microbial pathogens to the
injured endocardium and thrombus.
• Subsequent fibrin and platelet deposition over the infected
vegetation result in a protective sheath that isolates the organisms
from host defenses and permits rapid proliferation of the
infectious agent.
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15. Clinical Manifestation
• The clinical presentation of pediatric IE is variable and depends upon
the extent of the local cardiac disease, degree of involvement of other
organs (e.g. embolization), and the causative agent.
• IE is generally classified as a subacute or acute process.
• The subacute presentation is characterized by:
A prolonged course of low-grade fever, and
Nonspecific complaints including
fatigue, arthralgias, myalgias, chills, weight loss, exercise intolerance, and diaphoresis
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16. Cont..
• The presence of a cluster of these symptoms in a patient at risk for IE (i.e.
those with preexisting heart disease or indwelling central venous
catheter) should raise the possibility of IE as a potential diagnosis.
• Acute — Acute IE is a rapidly progressive and fulminant disease, These
patients typically have high spiking fevers, and appear severely ill.
• An acute presentation is commonly seen in patients with IE due to S.
aureus, which can cause rapid destruction of heart valve tissue, abscess
formation, embolic phenomena, and a rapidly progressive deterioration
in hemodynamic status.
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17. Cont..
• The clinical findings of IE correspond to the underlying pathologic
phenomena of bacteremia/fungemia, valvulitis, immunologic
response, and embolization.
• Symptoms associated with bacteremia or fungemia include fever, and
vasodilation and tachycardia due to decreased systemic vascular
resistance.
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18. Cont..
• Valvulitis may result in a new or changing murmur. In some patients,
tachypnea and hypotension are signs of heart failure, which occurs
because of perforation of a valve, chordal rupture, or poor ventricular
function.
• In children with cyanotic congenital heart disease (CHD) with either a
systemic-pulmonary shunt or conduit procedure, the murmur may
not change, but a decline in systemic oxygen saturation may occur
due to obstruction of blood flow.
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19. Cont..
• Glomerulonephritis may develop in children who present with
subacute IE as a consequence of immune-mediated disease. Other
immunologic sequelae (i.e., Roth's spots, Janeway lesions, and Osler
nodes) are less common in children than they are in adults.
• In children with IE, septic emboli are common, resulting in
extracardiac infection (eg, osteomyelitis or pneumonia) or infarction
to major vessels and organs.
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20. Cont..
• In the neonate, the signs and symptoms of IE are variable and
nonspecific.
• They include feeding intolerance, tachycardia, respiratory distress,
hypotension, and a new or changing murmur. Fever may not be
present with either subacute or acute IE.
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22. Diagnosis
• The diagnosis of IE is based upon history, physical examination, blood
cultures, laboratory tests, and echocardiography.
• History:
Prior Congenital or Rheumatic heart disease.
Preceding dental, Urinary tract or intestinal procedure.
Central venous catheter.
Prosthetic heart valve.
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23. • Laboratory findings — Nonspecific laboratory findings that support
the diagnosis of IE include:
Low hemoglobin/hematocrit demonstrating anemia (either hemolytic or
anemia of chronic disease), which is a common feature of IE.
Elevated erythrocyte sedimentation rate and C-reactive protein indicative of
inflammation
Urinalysis showing hematuria, proteinuria, and red cell casts. is suggestive of
glomerulonephritis, a minor diagnostic criterion
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24. • Electrocardiography (ECG)
• ECG is generally not helpful in the diagnosis of IE with the exception of IE with
periannular extension, in which prolongation of the PR interval or frank heart
block can occur.
• Chest radiography
• The chest radiograph is often normal. Nonspecific findings may include
cardiomegaly, pulmonary edema, and focal pulmonary infiltrates in patients
with pulmonary septic emboli.
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25. • Blood cultures — Blood cultures are performed in all patients since
one of the two major diagnostic criterion is positive blood cultures for
typical organisms associated with IE from at least two separate
specimens.
• The critical information for appropriate treatment of infective
endocarditis is obtained from blood cultures .
• Echocardiography — An echocardiogram should be performed on all
patients in whom there is a reasonable suspicion of IE, as it may
detect the presence of a vegetation, a major diagnostic Duke
criterion.
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26. Modified Duke Criteria
• Clinical Criteria:
2 major criteria, or
1 major criterion and 3 minor criteria, or
5 minor criteria
• Possible Infective Endocarditis:
1 major criterion and 1 minor criterion, or
3 minor criteria
• Rejected Diagnosis of Infective Endocarditis:
Firm alternate diagnosis explaining evidence of suspected IE, or
Resolution of IE syndrome with antibiotic therapy for ≤4 days, or
No evidence of IE at surgery or autopsy, on antibiotic therapy for ≤4 days, or
Does not meet criteria for possible IE
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28. Complication
• Complications seen in children with IE are generally similar to those
seen in adults.
• however, as a general rule, these complications occur less commonly
in children compared with adults.
Cardiac complications
• Heart failure
• Perivalvular abscess
Metastatic infection
Mycotic aneurysms
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 Stroke
 Acute kidney injury (AKI)

29. • Fungal endocarditis is difficult to manage and has a poorer prognosis.
It has been encountered after cardiac surgery, in severely debilitated
or immunosuppressed patients, and in patients on a prolonged
course of antibiotics.
• The drugs of choice are amphotericin B (liposomal or standard
preparation) and 5-fluorocytosine.
• Surgery to excise infected tissue is occasionally attempted, but often
with limited success. Recombinant tissue plasminogen activation may
help lyse intracardiac vegetations and avoid surgery in some high-risk
patients.
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30. Management
• In general, the principles of treatment of IE in children are the same
as in adults.
• In patients with acute IE, blood cultures should be obtained as quickly
as possible so appropriate antibiotic therapy can be started.
• Antibiotic choice, dose, and duration of treatment are dependent
upon the underlying causative microbial agent.
• Complete eradication of the organisms requires 4 to 6 weeks of
antibiotic treatment.
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31. • Initial empirical therapy is started with the following antibiotics while
awaiting the results of blood cultures.
• Initial empirical therapy should be:
Flucloxacillin/Methicillin+Gentamycin
• If methicillin resistant S.aureus is suspected then
Voncomycin+Gentamycin
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32. • The final selection of antibiotics for native valve IE depends on the
organism isolated and the results of an antibiotic sensitivity test.
• Antibiotic regimens for common bacterial pathogens in pediatric IE
are:
Viridans group streptococci and Streptococcus bovis
Aqueous penicillin or (if penicillin is unavailable)
Ampicillin Or
Ceftriaxone
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33. Enterococci
Aqueous penicillin Or
Ampicillin Plus Gentamicin
Staphylococci
Nafcillin or oxacillin.
Vancomycin
Gram-negative organisms
Ceftriaxone
Cefotaxime
Ampicillin Plus Gentamicin
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34. • Surgical intervention
• Determination of the need for surgical intervention should be individualized
using a multispecialty approach, including:
• Involvement of experts in infectious disease, cardiology, and cardiothoracic surgery.
• The most common reasons for surgical intervention include congestive heart
failure, progressive valve dysfunction, and embolic phenomena
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35. Prevention
• Strategies to prevent IE in children include:
Oral hygiene for prevention of oral disease and
Antimicrobial prophylaxis for high-risk patients when
undergoing invasive procedures.
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36. Take Home Message
IE in children is not uncommon.
Common in children with CHD
Neonates: Poor outcome
Blood culture+ECHO has important role in diagnosis
Treatment adherence necessary
Prognosis is not bad if treated properly
Knowledge of condition requiring prophylaxis and
drugs for it necessary.
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37. References
• Nelson Textbook of pediatrics 21th Edition
• Up-to-date 2023
• Namuyonga, J., Beaton, A., Lubega, S., Tenywa, E., Okello, E.,
Omagino, J., & Lwabi, P. (2016). PM267 Spectrum of Infective
Endocarditis Among Children at the Uganda Heart Institute. Global
Heart, 11(2), e115-e116.
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38. Thank You
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