Endocarditis in Children With Congenital Heart Disease

CARDIOLOGY
Endocarditis in Children With

Congenital Heart Disease
Source: Jortveit J, Klcovansky J, Eskedal L, et al. Endocarditis in children Identifiable risk factors for IE include CHD, central venous cath-
and adolescents with congenital heart defects: a Norwegian nation- eters, rheumatic heart disease, and IV drug abuse.1 In children
wide register-based cohort study. Arch Dis Child. 2018;103(7):670–674; doi: with CHD, the most common organisms include streptococci and
10.1136/archdischild-2017-313917 staphylococci. Presentation can be subacute (prolonged course
Investigators from multiple institutions in Norway conducted a of low-grade fevers and nonspecific symptoms) or acute (high
retrospective study to assess clinical characteristics and outcomes fever and severe illness). IE is diagnosed using the revised Duke
in children with congenital heart disease (CHD) and infective en- Criteria2 or the European Society of Cardiology guidelines,3 which
docarditis (IE). The authors reviewed the Oslo University’s Clinical include both pathologic and clinical criteria. An echocardiogram
Registry for Congenital Heart Defects and used ICD-9 codes for IE should be performed in patients suspected of having IE to assess
among children with CHD born between 1994 and 2016. For the for vegetation, valve disease, abscess, conduit obstruction, ven-
identified patients, medical records were reviewed to verify the tricular function, and effusion. Treatment for IE includes antibi-
diagnosis of bacterial or fungal IE on the basis of published di- otic therapy and, if necessary, surgical intervention typically for
agnostic criteria. Other information abstracted on study children heart failure, progressive valve dysfunction, embolic phenomena,
included age, type of CHD, previous surgeries and catheteriza- and vegetation size. Mortality in children with IE ranges from 1%
tions, clinical presentation, microbiology and echocardiology test to 5%, with cyanotic CHD and S aureus infections as risk factors.4
results, and outcomes. CHD was classified as severe or nonsevere; Children with CHD are at increased risk of IE, most commonly in
severe CHD included transposition of the great arteries, tetralogy patients with complex cyanotic CHD and those who have under-
of Fallot, double outlet right ventricle, hypoplastic left heart syn- gone surgical intervention. The cardiac lesions most commonly
drome, coarctation, aortic stenosis, interrupted aortic arch, pul- reported to be associated with IE include cyanotic lesions, endo-
monary atresia/stenosis, truncus arteriosus, and tricuspid atresia. cardial cushion defects, left-sided lesions, and ventricular septal
A total of 39 children with CHD and IE were identified. The median defect. Gupta et al5 reviewed patients with a discharge diagnosis
age of study participants at the time of diagnosis was 3.1 years; 75% of children with IE from 2000 to 2010 within the United States;
had severe CHD. Among the 39 study patients, 27 had undergone the incidence was 0.43 per 100,000 with underlying cardiac con-
open chest cardiac surgery prior to the development of IE, and 26 of ditions in 54% of the population.
these children had had prosthetic materials used for CHD repair. An The current investigation of an unselected nationwide popula-
additional 2 children had undergone cardiac catheterization prior to tion found the incidence of IE was 2.2 per 10,000 person-years,
developing IE. Overall, the median time from the last cardiac inter- which was stable throughout the study period. The majority of
vention (surgery or catheterization) to diagnosis of IE was 77 days. children had severe CHD; prosthetic materials were used in 96%
Among all children with IE, fever was the presenting sign in 31 (86%); of surgeries. Patients most commonly presented with fever, pos-
3 patients (8%) had embolic phenomena. Blood cultures were pos- itive blood culture results, and vegetations at echocardiography.
itive in 30 patients (83%), including 12 (33%) that grew Viridans A large percentage required surgery.
streptococci and 8 (22%) with Staphylococcus aureus. With use of Bottom Line: IE, though rare, occurs most commonly in children
echocardiography, vegetations were seen in 22 patients (61%), and with severe CHD who frequently have undergone cardiac surgery
abscesses were identified in 2 children. All study patients were or catheter intervention.
treated with antibiotics; 13 children (38%) required cardiac surgery
as part of their treatment for IE, and 3 children (8%) died. EDITORS’ NOTE
The stable incidence of IE over the long study period provides
The authors conclude that IE in children with CHD frequently fol- reassurance that the current limitation of prophylactic antibiot-
lowed complex cardiac interventions and was associated with ics to patients at highest risk (eg, cyanotic CHD) has not had an
severe defects. adverse effect.6 The data, however, underscore the dangers of
COMMENTARY BY prosthetic material. (See AAP Grand Rounds, 2008;20[4]:44–45.6)
David Spar, MD, FAAP, Pediatrics, University of Cincinnati, References
Cincinnati, OH 1. O’Brien SE. Infective Endocarditis in Children. https://www.uptodate.com/contents/
Dr Spar has disclosed no financial relationship relevant to this commentary. This commentary does infective-endocarditis-in-children. Accessed September 2018
not contain a discussion of an unapproved/investigative use of a commercial product/device. 2. Ferrieri P, et al. Circulation. 2002;105(17):2115–2126; doi: 10.1161/01.
CIR.0000013073.22415.90
IE, an infection of the inner surface of the heart, endocardium, or 3. Habib G, et al. Eur Heart J. 2015;36(44):3075–3128; doi: 10.1093/eurheartj/ehv319
heart valves, can lead to severe morbidity and mortality. During 4. Day MD, et al. Circulation. 2009;119(6):865–870; doi: 10.1161/CIRCULATIONAHA.108.798751
transient bacteremia or fungemia, pathogens adhere to injured 5. Gupta S, et al. Congenit Heart Dis. 2017;12(2):196–201; doi: 10.1111/chd.12425
endocardium; a protective sheath of fibrin and platelets isolates 6. Weber R, et al. Pediatr Infect Dis J. 2008;27(6):544–550; doi: 10.1097/
INF.0b013e3181690374
organisms and allows for their proliferation.1
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Endocarditis in Children With Congenital Heart Disease
AAP Grand Rounds 2018;40;44
DOI: 10.1542/gr.40-4-44
Updated Information & including high resolution figures, can be found at:
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Supplementary Material Supplementary material can be found at:
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References This article cites 6 articles, 3 of which you can access for free at:
http://aapgrandrounds.aappublications.org/content/40/4/44.full#ref-list-1
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Endocarditis in Children With Congenital Heart Disease
AAP Grand Rounds 2018;40;44
DOI: 10.1542/gr.40-4-44
The online version of this article, along with updated information and services, is located on
the World Wide Web at:
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Copyright © 2018 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1099-6605.

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CARDIOLOGY

Endocarditis in Children With

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