Endocarditis - Infective Endocarditis in Children: an...

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Infective Endocarditis in Children: an overview Thomas R. Burklow, MD LTC, MC Chief, Pediatric Cardiology, Walter Reed Army Medical Center All around nice guy
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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.
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Background Relatively rare in children Pre-antibiotic era: mortality was nearly 100% Mortality approaches 15-25%
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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
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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
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Heart disease and IE Disease No. % Acyanotic Heart Disease VSD 194 21.8 Aortic stenosis 89 10.0 PDA 25 2.8 Coarctation of the aorta 25 2.8 Pulmonary stenosis 21 2.4 VSD with other defects 18 2.0 Atrioventricular septal defect 16 1.8 Mitral valve abnormality 16 1.8 Atrial septal defect 11 1.2 Mitral valve prolapse 8 0.9 Cyanotic Heart Disease Tetralogy of Fallot 143 16.0 Transposition of Great Vessels 35 3.9 Tricuspid Atresia 9 1.0 Rheumatic Heart Disease 86 9.7 No Heart Disease 75 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.
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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.
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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
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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
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Endocarditis - Infective Endocarditis in Children: an...

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