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

21.8
10.0
2.8
2.8
2.4
2.0
1.8
1.8
1.2
0.9

143
35
9
86
75

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

No.

Streptococcus viridans

289

31.3

Staphylococcus aureus

225

24.4

Negative cultures

152

16.4

Other streptoccal species (e.g. enterococci)

55

5.9

HACEK and diphtheroids

50

5.4

Gram negative bacilli

45

4.8

Strept pneumoniae

18

1.9

Fungi

14

1.5

Others

28

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):956
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