Infectious endocarditis in children: changing pattern in a developing country

Prolonged Fever, Travel, and the Changing Examination in an 8-year-old Girl.

<i>Circulation</i> : Clinical Summaries

Infective endocarditis (IE) is frequently suspected but infrequently diagnosed disease in children. Clinicians often order echcardiograms to rule out IE. In the era of cost containment, clinically efficient strategies must be developed. We hypothesized that transthoracic echocardiography (TTE) is only useful in children in whom there is a high clinical suspicion of IE based on history, physical examination and persistently positive blood cultures. The objective of this study is to determine the role of TTE as a screening test for suspected IE in children. Echocardiographic reports and medical records were reviewed for 166 consecutive patients who underwent TTE to rule out IE from 1/93 to 7/96. Fever was the main indication for TTE (114 patients, 69%). Fifty seven (34%) patients had congenital heart disease and 89 (54%) patients had indwelling venous catheters. Twenty six (16%) were diagnosed and treated as IE. TTE was positive for vegetation in 12 patients (46% of IE patients and 7% of the total). The other 14 patients were diagnosed on a clinical basis as well as having persistently positive blood cultures. Using logistic regression and classification trees, we determined which variables were predictive of IE. Fever, leukocytosis, splenomegaly, hematuria, heart failure, murmurs, immune compromised status, or elevated acute phase reactants were not predictive of the outcome. Malaise defined as fatigue and the general feeling of illness, was the most predictive variable of IE (sensitivity 77% and specificity 95%). The presence of indwelling catheters without malaise was indicative of no IE in 77/77 patients. The presence of a second positive blood culture or malaise increased the sensitivity for IE to 100% with only 50(instead of 166) patients requiring TTE under these criteria. TTE has poor sensitivity as a screening test for IE. Multiple positive blood cultures in a setting of clinical illness adequately defines the need for TTE.

Introduction. The frequency of infective endocarditis (IE) in children with congenital heart disease (CHD) is 15– 140 times higher than that in the overall population and varies from 2 to 18% according to different authors. The aim. To define the main groups of causative agents of infective endocarditis in children and adults in order to build up an antibiotic treatment algorithm. Materials and methods. The analysis of examination findings and treatment outcomes in 124 patients was conducted from 2014 to 2019. These patients received medical treatment at the Ukrainian Children`s Cardiac Center (UCCC), Kyiv. The patients were divided into two groups by age: group 1 included children aged from 6 days to 18 years (62 [50.0%]), group 2 comprised adults aged from 18 to 79 years (62 [50.0%]). Results and discussion. Forty-nine isolates were recovered from 124 patients during the analysis of microbiological study results. The frequency of bacterial IE causative agents was 26 (41.9%) in group 1, and 17 (27.4%) in group 2. Comparative analysis of the spectrum of IE pathogens revealed differences in the two study groups. Coagulase-negative staphylococcus was the most common causative agent in group 1 (46.7% of all isolated strains; n = 12) and in group 2 (44.4%; n = 8). Staphylococcus aureus in children was detected in 5 (8.1%) cases, whereas in adults only in 2 (11.1%) cases. Pathogens of the Enterococcus spp. family (E. faecalis) were recovered in both study groups: in 6.5% (n = 2) and 16.6% (n = 3) of the patients, respectively. Gram-negative flora was detected in 3 (9.7%) patients of group 1 and, in 2 (11.1%) patients of group 2. Fungal flora was more commonly found in children (7 [22.6%] cases represented by the Candida family), whereas in adults only 1 (5.6%) case represented by the Mucor family was revealed. Conclusions. Etiological structure of the infective endocarditis pathogens in both groups was represented mainly by gram-positive bacteria, with S. epidermidis (24.5%) being the most essential. The changes were revealed in the species composition of the pathogens in group 1 with fungal microflora dominance: Candida parapsilosis in 9.7%, C. albicans and C. famata in 6.5% of the total number of plated cultures in this group. The difference in surgical operations due to possible IE in both groups was established based on the specific features of operations determined by the age factor.

Infective endocarditis is very uncommon in children; however, when it does arise, it can lead to severe consequences. The biggest risk factor for paediatric infective endocarditis today is underlying congenital heart defects. The most common causative organisms are Staphylococcus aureus and the viridans group of streptococci. The spectrum of symptoms varies widely in children and this produces difficulty in the diagnosis of infective endocarditis. Infective endocarditis in children is reliant on the modified Duke criteria. The use of blood cultures remains the most effective microbiological test for pathogen identification. However, in blood culture-negative infective endocarditis, serology testing and IgG titres are more effective for diagnosis. Imaging techniques used include echocardiograms, computed tomography and positron emission tomography. Biomarkers utilised in diagnosis are C-reactive protein, with recent literature reviewing the use of interleukin-15 and C-C motif chemokine ligand for reliable risk prediction. The American Heart Association (AHA) and European Society of Cardiology (ESC) guidelines have been compared to describe the differences in the approach to infective endocarditis in children. Medical intervention involves the use of antimicrobial treatment and surgical interventions include the repair and replacement of cardiac valves. Quality of life is highly likely to improve from surgical intervention.Conclusion: Over the past decades, there have been great advancements in clinical practice to improve outcomes in patients with infective endocarditis. Nonetheless, further work is required to better investigative and manage such high risk cohort. What is Known: • The current diagnostic techniques including 'Duke's criteria' for paediatric infective endocarditis diagnosis • The current management guidelines utilised for paediatric infective endocarditis What is New: • The long-term outcomes of patients that underwent medical and surgical intervention • The quality of life of paediatric patients that underwent medical and surgical intervention.

Indications for echocardiography in the diagnosis of infective endocarditis in children

Infective endocarditis is a rare disease in children, and it can result in significant morbidity and mortality. The epidemiology of infective endocarditis in children has shifted in recent years with less rheumatic heart disease, more congenital heart disease survival, and increased use of central venous catheters in children with chronic illness. Less commonly, infective endocarditis occurs in children with no preexisting cardiac disease or other known risk factors. We present a "case of" 10 year-old girl with no known cardiac disease or any other risk factors who was diagnosed with infective endocarditis according to modified Duke criteria. Blood cultures grew haemophilus parainfluenza. She had prolonged fever for 2 weeks after starting antibiotics, even though her blood culture became sterile 48 hours after treatment. We emphasize the importance of maintaining high index of suspicion for endocarditis in febrile children, even those without cardiac anomalies or other apparent risk factors.

Infective endocarditis (IE) is a rare disease with high mortality and morbidity. In recent years, an increase in the frequency of infective endocarditis has been observed due to the increase in the survival of cases with congenital heart diseases (CHDs) and the use of central catheters. In addition to revealing the incidence of IE in our clinic, this study aimed to evaluate the demographic characteristics, predisposing factors, clinical, laboratory, microbiological, and echocardiographic findings, and the complications of follow-up of our patients diagnosed with IE in light of the literature. Thirteen patients with IE who were hospitalized in Pediatric Cardiology Clinic, Pamukkale UniversityMedical Faculty Hospital between January 2016 and August 2021 were retrospectively reviewed. The patients included in the study were evaluated in terms of demographic characteristics, predisposing factors, clinical, laboratoryand microbiological findings, echocardiography data, surgical intervention needs, and complications. The incidence of IE in our clinic was defined as the rate of IE among patients admitted to the hospital and reported as the number of patients with IE per 100,000 hospital admissions. The median age of these 13 patients was 11 (7-14) years, and the male/female ratio was 6/7. The five-year IE incidence in Pediatric Cardiology Clinic, Pamukkale UniversityMedical Faculty Hospital, was found to be 2.5 in approximately 100,000 hospital admissions. A predisposing factor was detected in all patients. Six patients (46%) had CHDs, and four patients (31%) had acquired heart disease. The other three (23%) patients were receiving immunosuppressive therapy, and these patients had long-term port catheters.Eight (62%) patients had positive blood cultures.Streptococcusviridans, Streptococcus gordonii, Staphylococcus aureus, coagulase-negativeStaphylococcus, Brucella spp, and Candida albicans were isolated in the blood cultures of these patients. IE-related complications developed in seven (54%) patients. Five (38%) had heart failure, three patients (23%) had thromboembolic events, two (15%) had glomerulonephritis, and one (8%) had thrombophlebitis. Four patients were referred to early surgery. Two patients with recurrent IE attacks were referred to surgery after their treatment was completed. The incidence of IE has shown an increase recently with increased rates of survival attributable to corrective surgeries performed for congenital heart diseases, increased prosthetic materials used in cardiac surgeries, and increased use of permanent catheters. In our study, theincidence of IE was found to be 2.5 in 100,000 hospital admissions. Our results have shown that rheumatic heart diseases, besides CHDs, are still an important risk factor for Turkey. Due to the low number of cases in IE studies in the pediatric population, there is a need for further studies to be conducted in large series in this field.

BACKGROUND: Infective endocarditis (IE) was a significant cause of morbidity and mortality, particularly in children with congenital heart disease (CHD). Infective endocarditis could occur in all ages with higher in children below 1-year-old, including neonates. Various clinical manifestations of IE in children make it difficult to make a prompt diagnosis and appropriate management. Finding in echocardiography could help clinicians determine the diagnosis of IE. Systemic embolization could cause many complications that may present as chief complaint underlying patient hospitalization. CASE PRESENTATION: We present case series of diverse manifestation of IE in children in Bandung, West Java, Indonesia. Two cases had a history of structural heart disease, while one case with no history of any structural heart disease before. CONCLUSION: Wide range of symptoms that could occur in children with IE, made it challenging to make a proper diagnosis.

Infective endocarditis in children: A 10-year multicentric study

Background and aimsIn the absence of classical features (fever, cardiac murmur, and peripheral vascular stigmata) the diagnosis of infective endocarditis (IE) may be difficult. Current clinical guidelines for the diagnosis and management of IE recommend the use of modified Duke criteria. Correct and prompt diagnosis of IE is crucial for the treatment and outcome of the patients.The aim of this study was to evaluate the presence and the individual value of each criterion of the modified Duke criteria in our patients with infective endocarditis.MethodsWe performed a prospective observational study between January 2008 – June 2014, in which we enrolled consecutive adult patients admitted for suspicion of IE to the Hospital of Infectious Diseases and at the Heart Institute . We used and extensive database in order to collect demographic data, laboratory and echocardiography results, evolution and outcome of the patients. Using the modified Duke criteria we identified 3 categories of IE: definite, possible and rejected. In order to evaluate the importance of each criterion in the diagnosis of IE we tested two hypotheses. First, we excluded each criterion from the final diagnosis and we counted how many cases felt into a lower category. Second, after adding each major and minor criterion, we tested how many cases would have been classifiable as definite IE.ResultsThe study included 241 adult patients with a mean age 58.16 years and sex ratio male/female 1.94. According to the modified Duke criteria 137 patients had definite IE, 79 patients had possible IE and 25 cases had rejected IE We had blood cultures positive IE in 109 cases and blood culture negative IE (BCNE) in 132 (71.21%) cases. Antibiotic treatment prior to blood culture was recorded in 152 (63.07%) patients. In the absence of the echocardiography major criterion, 43% of cases would become possible. After extraction of major microbiological criterion, only one third of definite cases would become possible. Minor criteria such as fever and predisposition contributed to the diagnosis only in 10% of cases. In the presence of vascular or immunological phenomena, or in the presence of minor microbiological criterion, half of the possible IE cases could become possible.ConclusionTwenty-years after their launch, the Duke criteria for the diagnosis of IE continue to be important tools. Low index of suspicion of IE and inappropriate use of antibiotics may have a great negative impact on the diagnosis of IE. Nowadays, the scarcity of classical Osler manifestations - bacteremia, fever and peripheral stigmata - makes the diagnosis of IE a challenge.

Infective endocarditis in children: A 10-year multicentric study

Infective endocarditis (IE) remains a diagnostic and therapeutic challenge associated with high morbidity and mortality. We evaluated the microbial profile and clinical manifestation of IE in children. A retrospective study examining pediatric IE cases treated between 2000 and 2017 at the Department of Pediatric Cardiology, KU Leuven, was conducted. Clinical presentation, treatment, complications, outcome of IE, underlying microorganisms and congenital heart defects were reviewed. Fifty-three patients were diagnosed with IE. Overall, 19 patients (36%) required cardiac surgery. Seven patients (13%) died. Eighty-seven percent of patients had an underlying congenital cardiac defect. Eighteen (34%) children presented with prosthetic graft IE. A causative organism was found in 49 (92%) cases: viridans group streptococci were identified in 17 (32%), Staphylococcus aureus in 13 (25%) and coagulase-negative staphylococci in 11 (20%) children. Community-acquired (CA) IE increased significantly from 8 (33%) cases in 2000-2007 to 20 (74%) cases in 2008-2017 (P < 0.01). Even with viridans streptococci being significantly more prevalent in the CA group (P < 0.01), we did not observe an increase of streptococcal IE from 2008 to 2017. Seventeen (32%) patients presented with hospital-acquired IE during the first year of life with 14 (82%) children after surgery and a prevalence of coagulase-negative staphylococci (53%). The incidence of pediatric IE was similar over the investigated time period with a shift toward CA IE. Streptococci and staphylococci accounted for the majority of cases in both periods. Awareness of IE and its prevention is crucial in patients after implantation of prosthetic grafts.

Characterization and clinical assessment of 571 febrile intravenous drug users at risk for infective endocarditis presenting to an urban emergency department

Infective Endocarditis: how many ultrasonography studies are necessary to reach the diagnosis? A real world scenario (2008-2017)