Infective Endocarditis in Children: an overview

Thomas R. Burklow, MD LTC, MC Chief, Pediatric Cardiology, Walter Reed Army Medical Center All around nice guy

Objectives
Describe the incidence of IE in various pediatric heart conditions. Review the Duke criteria of infective endocarditis Review the indications for prophylaxis and current recommendations for antimicrobial therapy. Review the efficacy and controversies in IE prophylaxis.

Background
Relatively rare in children Pre-antibiotic era: mortality was nearly 100% Mortality approaches 15-25%

Epidemiology
Increasing incidence beginning in the 80s
Increasing number of surgical patients Increasing number of complex congenital heart disease Increased use of prosthetic materials NICUs and PICUs

Pathogenesis, Part 1
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

Heart disease and IE

Disease Acyanotic Heart Disease VSD Aortic stenosis PDA Coarctation of the aorta Pulmonary stenosis VSD with other defects Atrioventricular septal defect Mitral valve abnormality Atrial septal defect Mitral valve prolapse Cyanotic Heart Disease Tetralogy of Fallot Transposition of Great Vessels Tricuspid Atresia Rheumatic Heart Disease No Heart Disease No. 194 89 25 25 21 18 16 16 11 8 143 35 9 86 75 % 21.8 10.0 2.8 2.8 2.4 2.0 1.8 1.8 1.2 0.9 16.0 3.9 1.0 9.7 8.4

Berkowitz, FE: Infective endocarditis. IN Nichols EG, Cameron DE, Greeley WJ, et al (eds): Critical Heart Disease in Infants and Children. St. Louis, Mosby-Year Book, 1995.

Pathogenesis, Part 2
Microorganism Streptococcus viridans Staphylococcus aureus Negative cultures Other streptoccal species (e.g. enterococci) HACEK and diphtheroids Gram negative bacilli Strept pneumoniae Fungi Others No. 289 225 152 55 50 45 18 14 28 % 31.3 24.4 16.4 5.9 5.4 4.8 1.9 1.5 3.0

Berkowitz, FE: Infective endocarditis. IN Nichols EG, Cameron DE, Greeley WJ, et al (eds): Critical Heart Disease in Infants and Children. St. Louis, Mosby-Year Book, 1995.

Microbiology
S. Viridans
Most common causative organism

Gram negative bacilli

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

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.

Duke Criteria
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
Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. AM J Med 96:200, 1994 Stockheim JA, Chadwick EG, Kessler S, et al. Are the Duke Criteria superior to the Beth Israel criteria for the diagnosis of infective endocarditis in children? Clin Infect Dis 27:1451, 1998

Duke criteria
Definitive
Pathological criteria Microorganisms, or 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: Major criteria

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

The echocardiogram in IE

Duke criteria: Minor criteria

Predisposition Predisposing heart condition or IV drug abuser Fever > 38.0 C Vascular phenomena arterial emboli, septic pulmonary infarct, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage, Janeways lesion Immunologic phenomena glomerulonephritis, Oslers nodes, Roths spots, rheumatoid factors Microbiologic evidence positive blood culture but does not meet major criteria as noted Echocardiographic evidence consistent with IE but does not meet major criteria as noted

Sequelae
Neurologic manifestations, 20%
Cerebral emboli, mycotic aneurysms, cerebritis, brain abscess, hemorrhage, etc.

Peripheral embolization
Ischemia, infarction, mycotic aneurysms, etc

Pulmonary infarction Renal insufficiency Congestive heart failure

Prevention of IE
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
Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: Recommendations by the American Heart Association. JAMA 277;1794: 1997

IE prophylaxis: Does it work?

Strom BL. When data conflict with practice: rethinking the use of prophylactic antibiotics before dental treatment. LDI Issue Brief 2001 Mar;6(6):1-4 Lockhart PB, Brennan MT, Fox PC, Norton HJ, Jernigan DB, Strausbaugh LJ. Decision-making on the use of antimicrobial prophylaxis for dental procedures: a survey of infectious disease consultants and review. Clin Infect Dis. 2002 Jun 15;34(12):1621-6. Seymour RA, Lowry R, Whitworth JM, Martin MV. Infective endocarditis, dentistry and antibiotic prophylaxis; time for a rethink? Br Dent J 2000 Dec 9;189(11):610-6 Strom BL, Abrutyn E, Berlin JA, Kinman JL, Feldman RS, Stolley PD, Levison ME, Korzeniowski OM, Kaye D. Dental and cardiac risk factors for infective endocarditis. A population-based, case-control study. Ann Intern Med 1998 Nov 15;129(10):761-9 Van der Meer JT, Van Wijk W, Thompson J, Vandenbroucke JP, Valkenburg HA, Michel MF. Efficacy of antibiotic prophylaxis for prevention of native-valve endocarditis. Lancet 1992 Jan 18;339(8786):135-9 Epstein JB. Infective endocarditis and dentistry: outcome-based research. J Can Dent Assoc 1999 Feb;65(2):95-6

Endocarditis prophylaxis recommended

High-risk

Prosthestic cardiac valves Previous bacterial endocarditis Complex cyanotic heart disease Surgically constructed systemic-pulmonary shunts or conduits

Moderate-risk
Most other congenital heart disease Acquired valvar dysfunction Hypertrophic cardiomyopathy Mitral valve prolapse WITH regurgitation and/or thickened leaflets

Endocarditis prophylaxis NOT recommended

Isolated secundum ASD Surgically repaired VSD, ASD, or PDA after 6 months (no residua) s/p CABG MVP without MR Previous Kawasaki disease w/o valvar dysfunction Previous rheumatic fever w/o valvar dysfunction Pacemakers and AICDs Flow murmurs

Dental procedures and IE prophylaxis: Recommended

Dental extractions Periodontal procedures Dental implants and reimplantation of avulsed teeth Endodontic proceures Subgingival placement of antibiotic fibers and strips Initial placement of orthodontic bands (not brackets) intraligamentary local anesthetic injections Prophylactic cleaning

Dental procedures and IE prophylaxis: Not recommended

Restorative dentistry Non-intraligamentary local anesthetic injections Taking oral impressions Fluoride treatments Oral radiographs Orthodontic appliance adjustment Shedding primary teeth

Other procedures and IE prophylaxis: Recommended

Respiratory
T&A Surgical procedures involving respiratory mucosa Rigid bronchoscopy

Gastrointestinal
Sclerotherapy Esophageal stricture dilation ERCP with biliary obstruction Surgery involving biliary tract or intestinal mucosa

Genitourinary tract
Prostatic surgery, cystoscopy Urethral dilation

Other procedures and IE prophylaxis: Not Recommended

Respiratory
Endotracheal intubation PE tubes Flexible bronchoscopy

Gastrointestinal
Transesophageal echocardiography Endoscopy (with or without biopsy) Circumcision

Genitourinary tract
Vaginal hysterectomy, and vaginal or Caesarean deliveries In uninfected tissues: urethral catheterization, uterine D&C, therapeutic abortions, sterilization procedures, insertion or removal of IUDs

How about Tattoos and Body piercing?

Ear piercing
43% of respondents had ear piercing Only 6% took antibiotics 23% reported infections but no IE reported

Tattoos
5% of respondents had tattoos No antibiotics or infections reported

Physicians
Majority of physicians did not approve of piercing or tattoos 60% felt that IE prophylaxis use was appropriate
Cetta F, Graham LC, Lichtenberg RC, Warnes CA. Piercing and tattooing in patients with congenital heart disease. J Adolesc Health 1999;24:160

References
Bayer AS, Bolger AF, Taubert KA, Wilson W, Steckelberg J, Karchmer AW, et al. Diagnosis and Management of Infective Endocarditis and Its Complications. Circulation. 1998;98:2936-2948. Berkowitz, FE: Infective endocarditis. IN Nichols EG, Cameron DE, Greeley WJ, et al (eds): Critical Heart Disease in Infants and Children. St. Louis, Mosby-Year Book, 1995. Cetta F, Graham LC, Lichtenberg RC, Warnes CA. Piercing and tattooing in patients with congenital heart disease. J Adolesc Health 1999;24:160 Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: Recommendations by the American Heart Association. JAMA 277;1794: 1997 Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. AM J Med 96:200, 1994 Epstein JB. Infective endocarditis and dentistry: outcome-based research. J Can Dent Assoc 1999 Feb;65(2):95-6 Lockhart PB, Brennan MT, Fox PC, Norton HJ, Jernigan DB, Strausbaugh LJ. Decision-making on the use of antimicrobial prophylaxis for dental procedures: a survey of infectious disease consultants and review. Clin Infect Dis. 2002 Jun 15;34(12):1621-6. Seymour RA, Lowry R, Whitworth JM, Martin MV. Infective endocarditis, dentistry and antibiotic prophylaxis; time for a rethink? Br Dent J 2000 Dec 9;189(11):610-6 Stockheim JA, Chadwick EG, Kessler S, et al. Are the Duke Criteria superior to the Beth Israel criteria for the diagnosis of infective endocarditis in children? Clin Infect Dis 27:1451, 1998 Strom BL, Abrutyn E, Berlin JA, Kinman JL, Feldman RS, Stolley PD, Levison ME, Korzeniowski OM, Kaye D. Dental and cardiac risk factors for infective endocarditis. A population-based, case-control study. Ann Intern Med 1998 Nov 15;129(10):761-9 Strom BL. When data conflict with practice: rethinking the use of prophylactic antibiotics before dental treatment. LDI Issue Brief 2001 Mar;6(6):1-4 Taubert KA and Dajani AS. Infective Endocarditis IN Garson A, Bricker JT, Fisher DJ, and Neish SR, eds. The Science and Practice of Pediatric Cardiology. Williams and Wilkins. Baltimore. 1998. Pp. 768-779. Van der Meer JT, Van Wijk W, Thompson J, Vandenbroucke JP, Valkenburg HA, Michel MF. Efficacy of antibiotic prophylaxis for prevention of native-valve endocarditis. Lancet 1992 Jan 18;339(8786):135-9