Infective Endocarditis Successfully Treated in Extremely Low Birth Weight Infants With Recombinant Tissue Plasminogen Activator

Abstract

Increased survival of extremely low birth weight infants depends on the use of indwelling catheters. These catheters expose the infant to the risk of thrombus formation and line infection. When intracardiac thromboses become infected, the entity is indistinguishable from infective endocarditis and exposes the infant to prolonged sepsis and risk of disseminated infected emboli. Despite prolonged antiinfective therapy and removal of the infected line, resolution of the sepsis and dissolution of the vegetations is frequently not achieved. We describe 2 cases of infective endocarditis in extremely low birth weight infants successfully treated with recombinant tissue plasminogen activator in addition to prolonged antiinfective therapy. Blood cultures became sterile and vegetations disappeared within days of commencing treatment, and there were no systemic complications. A literature search detailed in the article confirms the poor outcome associated with infectious endocarditis in preterm infants. Tissue plasminogen activator may play an important role when standard care has failed.

The use of recombinant tissue-type plasminogen activator in a newborn with an intracardiac thrombus developed during extracorporeal membrane oxygenation

“…This not only results in lysis of fibrin at the site of thrombus but also cleaves nonspecific fibrinogen, resulting in risk of hemorrhage elsewhere. There are numerous reports of its use in children with intracardiac and aortic thrombi with successful outcomes [3][4][5]. However, there remain no evidence-based guidelines for its use in children or neonates.…”

Fungal Endocarditis in Neonates

“…30,48 More recently, recombinant tissue plasminogen activator (r-TPA) was administered as adjunctive therapy with liposomal AMB in 2 neonates with FE (2.8%). 18,41 The first case involved a premature infant (BW: 566 g) with Candida tropicalis endocarditis, and the second case was a premature infant (BW: 800 g) with endocarditis attributed to C. albicans fungemia.…”

The evaluation and management of postnatal thromboses

“…74,75 Placement of the catheter in the right atrium can lead to damage of the endocardium inducing either pericardial tamponade and/or the development of intracardiac thrombi. 76,77 The development of intracardiac vegetations secondary to line infections can expose the infant to prolonged infection and dissemination of septic emboli. 76 However, some centers have reported successful placement of CVLs in the right atrium if strict management guidelines are followed.…”

“…76,77 The development of intracardiac vegetations secondary to line infections can expose the infant to prolonged infection and dissemination of septic emboli. 76 However, some centers have reported successful placement of CVLs in the right atrium if strict management guidelines are followed. 75 Thrombus formation in the right atrium is an emergent concern due to the risk for dissemination of emboli into the lungs or obstruction of the right pulmonary artery.…”

“…[78][79][80][81] rt-PA has also been used successfully in the management of premature infants with infective endocarditis. 76 Specific details for dosing and management will be described later.…”