Among children the incidence of infective endocarditis (IE) is highest in those with congenital heart disease. The use of prosthetic devices for correcting heart defects and prolonged use of central venous catheters are major risk factors.
Staphylococcus aureus has replaced viridans group Streptococcus as the most common cause of IE in children older than 1 year. Gram-negative oropharyngeal flora, so-called AACEK (previously HACEK) organisms, is a less common cause. Nutritionally variant streptococci, now comprised of Abiotrophia species, can rarely cause IE.
IE can present as subacute illness progressing over a few weeks or as acute illness with sepsis-like presentation. Physical signs are mainly the manifestations of valvular damage, embolic phenomenon, and immune complex-mediated involvement of different body systems. The hallmark diagnosis of IE is serial positive blood cultures obtained, over a period of time, from different venipuncture sites.
Echocardiography is paramount to evaluating IE. Two-dimensional imaging can detect vegetations as small as 2 mm. Transthoracic echocardiography is adequate for initial rapid imaging. Transesophageal echocardiography can be more useful in evaluating patients with complex congenital cardiac anatomy.
The Modified Duke Criteria can help make or reject the diagnosis of IE. Major criteria are based on blood cultures and echocardiography results. Minor criteria are based on predisposing heart conditions, fever, and signs of vascular and immunologic phenomena.
Patients with life-threatening IE can develop heart failure and may have sepsis-like presentation. The most urgent evaluation in the emergency department (ED) is hemodynamic status. If heart failure is suspected, echocardiography and several closely spaced blood cultures should be obtained without delay. Hemodynamic support and transfer to a critical care unit may be necessary.
Presumptive antibiotic treatment is based on the patient’s age, clinical presentation, preexisting cardiac status, recent surgery, and local antimicrobial sensitivity. Reviewing and defining the choice of parenteral therapy with an infectious disease specialist is warranted. Comprehensive treatment guidelines are issued and updated by the American Heart Association.
In the ED, immediate consultation with cardiology and cardiovascular surgery may be warranted in patients with left-sided native valve endocarditis, prosthetic valve endocarditis, heart failure, and recurrent emboli and those with tricuspid valve vegetation at least 20 mm in diameter.
KeywordsInfective endocarditis in children Endocarditis microbiology Endocarditis diagnosis Endocarditis treatment Endocarditis complications
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