Infective endocarditis in childhood

Abstract

A total of 37 cases of infective endocarditis, in children aged two days to 13 years, were seen from 1971 to 1983 at the Children's Hospital, Camperdown. Structural heart disease was known to preexist in 95%. Cyanotic congenital heart disease was present in 15 children, of whom 11 had been palliated by a systemic-to-pulmonary artery shunt. In five children, there was infection of a prosthetic valve. Identifiable precipitants of infection were rare. In particular, no child had had a preceding dental procedure within three months, while only 19% had had recent cardiac surgery. Organisms were identified by blood culture in 92%, the majority being streptococci (43% of cases) and staphylococci (27% of cases). While 59% of all organisms were penicillin sensitive, six of the seven early postoperative children were infected with organisms not sensitive to antibiotics, given for wound infection prophylaxis in the perioperative period. The overall death rate was 13.5%. Of the children infected with Staphylococcus aureus, 40% died, while no child with Streptococcus viridans endocarditis died. Of the survivors, four needed urgent valve replacement, and three had major central nervous system complications. Using these figures, a current profile of patients with infective endocarditis is presented.

Infective endocarditis in congenital heart disease

“…The ratio of unrepaired cyanotic to non-cyanotic CHD of around 1:2 [65,83,108,110,111,116] is comparable to that of cyanotic to non-cyanotic CHD in children [63].…”

“…The most frequent signs and symptoms of IE in CHD are fever (>80%), often of low grade, malaise, fatigue, weight loss or failure to thrive, splenomegaly, myalgia, arthralgia, headache, chills, nausea, and vomiting [1,8,9,20,21,33,34,38,42,47,58,65,67,68,72,74,79,83,84,88,97,99,100,107,108,110,111,116,119,122,127,137]. Specific clinical findings are less frequent (<20%).…”

“…IE by itself predisposes in 2.7% for a second IE episode at the same location [9]. Medical procedures, including dental care [8,33,34,38,42,65,68,69,72,74,83,84,88,97,99,108,116,119,122], cardiac surgery [8, 38, 65, 67-69, 72, 74, 83, 88, 97, 99, 108, 116, 119, 137], catheter-related procedures [68,69,72,83,88,97,116,119,137], and other non-cardiac invasive procedures [33, 38, 42, 65, 67-69, 72, 74, 83, 84, 122, 137] are potential causes for bacteremia in up to 46%, 18%, 20%, and 20% in cases of CHD-associated IE, respectively. Until recently, antimicrobial prophylaxis was recommended for these procedures [134].…”

“…In children, incidence of IE is considerably lower with 0.34 to 0.64 cases per 100,000 children per year [34,43,110] and male-to-female ratio is 1.2:1 [1,8,9,20,21,33,34,38,42,47,58,65,67,68,72,74,79,83,84,88,97,99,100,107,108,110,111,116,119,122,127,137]. We reviewed 32 original articles reporting 2,361 IE episodes in 2,298 patients during an observation time of 43,426 patient-years [1,8,9,20,21,33,34,38,42,47,58,65,67,68,72,…”

“…Amoxicillin prophylaxis reduces bacteremia in children after dental procedures from 84% to 33% [85]. Prophylaxis, however, may fail due to patient-related factors (compliance) in up to 40%, physician-related factors (knowledge) in 50%, and ineffective drugs against rare pathogens in 66% [33,38,42,65,68,69,72,73,83,84,88,97,108,116,119,122,137]. Nowadays, bacteremia from daily care activities is judged a far greater risk [134].…”