Bacterial Endocarditis In Children Research Articles

Klebsiella pneumoniae Endocarditis

Introduction: Gram negative bacteria including Klebsiella species are a rare cause of bacterial endocarditis in children. Klebsiella endocarditis usually needs a predisposing factor and has a poor prognosis. Case Presentation: In this study a ten-year-old boy with ventricular septal defect, who was not immune compromised and acquired Klebsiella endocarditis is introduced. The patient had a favorable response to medical treatment and underwent a successful cardiac surgery. Discussion: Children with congenital heart disease are at risk of acquiring gram-negative endocarditis even if they have not had other predisposing factors.

Antibacterials for the prophylaxis and treatment of bacterial endocarditis in children.

Although the overall incidence of infective endocarditis in the paediatric population is considered to be low, over the last 20 years a rising trend in infective endocarditis has been observed among children. This could be due to several reasons including the availability of improved diagnostic techniques, use of continuous central venous catheters and cardiac implants increasing the risk of infection, and the survival of a greater number of infants with congenital heart disease as a result of improved medical management. The predominant causative organisms of paediatric endocarditis include staphylococci and streptococci. There is increased concern surrounding the emergence of endocarditis in children caused by methicillin-resistant Staphylococcus aureus and drug resistant strains of Streptococcus pneumoniae. The treatment approach to paediatric endocarditis is similar to that for adult patients with endocarditis because of similarities in disease pathogenesis and aetiology. The therapeutic goal is to achieve sterilisation of the cardiac vegetations. The choice of antibacterial is dependent upon the susceptibility profile of the causative organism. Vancomycin or gentamicin is recommended for enterococcal endocarditis, according to guidelines from the American Heart Association. For staphylococcal endocarditis in patients with no prosthetic valve, oxacillin or nafcillin with or without gentamicin is the treatment of choice. In the case of endocarditis caused by methicillin-resistant S. aureus, vancomycin is commonly used in patients with no prosthetic valve and a combination of vancomycin, gentamicin and rifampicin (rifampin) for patients with prosthetic material. Cefazolin or ceftriaxone is the treatment of choice for penicillin allergic paediatric patients with endocarditis caused by viridans streptococci. While there have been no major changes in endocarditis therapy for the last decade, the current focus is on the recognition of multiple-drug resistant pathogens and the use of newer agents such as quinupristin/dalfopristin in the treatment of resistant bacterial endocarditis. Prophylactic antibacterial therapy is recommended for procedures thought to be associated with the occurrence of bacteraemia involving organisms commonly associated with endocarditis. These include dental extractions and oral, respiratory tract, genitourinary, gastrointestinal or oesophageal procedures. Prophylactic antibacterials recommended by the American Heart Association during genitourinary and gastrointestinal surgical procedures in high risk patients include ampicillin + gentamicin or vancomycin + gentamicin in high risk patients with penicillin allergy. Ampicillin has been recommended for prophylaxis of bacterial endocarditis in children undergoing oral, respiratory tract or oesophageal procedures. In the case of penicillin allergy in these patients, cephalosporins, clindamycin, azithromycin or clarithromycin have been recommended. The general consensus is that antibacterial prophylaxis during dental procedure is unnecessary, and in fact propagates bacterial resistance.

Dentists are innocent! "Everyday" bacteremia is the real culprit: a review and assessment of the evidence that dental surgical procedures are a principal cause of bacterial endocarditis in children.

The literature related to three aspects of dental bacteremia has been reviewed in regard to postprocedure bleeding and bacteremia, intensity of bacteremia, and cumulative exposure to bacteremia from "everyday" events. The data on postprocedure bleeding and bacteremia show that there is no relationship between bleeding and bacteremia. Significant bacteremia can occur in the absence of clinically discernible bleeding. The intensity of bacteremia in humans is significantly less than that used in experimental endocarditis models. It is unlikely that the intensity of bacteremia following dental procedures in children could readily lead to endocarditis. The cumulative exposure to bacteremia is significantly greater from everyday procedures when compared to dental operative procedures. It is far more likely that such everyday procedures are the cause of bacterial endocarditis because the cumulative exposure is often hundreds, thousands, or even millions of times greater than that occurring following surgical procedures such as extraction of teeth. The value of antibiotic prophylaxis prior to dental treatment is questioned.

Bacterial endocarditis in children: trends in its diagnosis, course, and prognosis.

In a population-based study of 41 children with bacterial endocarditis (BE), diagnosed in the period 1970 through 1989 in eastern Denmark, we analyzed trends in the diagnosis of BE and in mortality, and searched for possible prognostic factors. During this period the delay in diagnosis from first symptom to treatment did not change, but the delay from admission to treatment was significantly prolonged from 0 to 3 days, despite the introduction of echocardiography (ECHO). There was a significant improvement in the prognosis, the mortality rate having decreased from 40 to 0% [95% confidence limits: 12-74 vs. 0-26 (0.01 less than p less than 0.02)]. The improved prognosis was not explained by changes in the etiology or pattern of antibiotic resistance and may reflect a milder course of BE in children. Children with "mild anomalies"--such as bicuspid aortic valve (n = 5), coarctation of the aorta (n = 2), and prolapse of the mitral valve (n = 2)--had a significantly poorer prognosis than children with other forms of congenital heart disease (CHD) (p = 0.004), a reminder of the importance of suspecting BE in all children with unexplained long-lasting or intermittent fever, because some may have unrecognized "mild" CHD.

Bacterial endocarditis in children: clinical and laboratory findings, and the role of echocardiography in its diagnosis and management

We report clinical and laboratory findings of 15 children with bacterial endocarditis, admitted to the Department of Child Health, University of Indonesia/Cipto Mangunkusumo Hospital from February, 1987 to June, 1989. There were 8 boys and 7 girls with bacterial endocarditis, ranging in age from 10 weeks to 16 years. The diagnosis was suspected because of prolonged fever, with or without other manifestations, i.e. congestive heart failure, refractory anemia, or paroxysmal atrial tachycardia. The underlying heart disease was congenital in 12 cases and rheumatic heart disease in 3 cases. The clinical, electrocardiographic, and radiologic manifestations were generally predominated by the pre-existing heart disease. No 'characteristic' findings of bacterial endocarditis, i.e. Osler's nodes, Janeway lesions or splinter haemorrhages were detected. Positive bacterial culture was obtained in 12 cases; the most frequent bacteria isolated was Pseudomonas aeruginosa (4 cases). Streptococcus viridans was isolated in 2 cases only. Vegetation was visualized echocardiographically in 12 cases; 9 with clear cut evidence of large vegetation, and in the other 3 the vegetation was equivocal. On follow-up they disappeared gradually with clinical improvement. Large vegetation might need 2 full months to disappear echocardiographically. It is concluded that bacterial endocarditis is not a rare complication of structural heart disease in our hospital, with a high mortality rate. The availability of good resolution echocardiography has been very helpful in establishing the diagnosis as well as in following-up patients with bacterial endocarditis.

Bacterial Endocarditis Complicated by Myocardial Infarction in a Pediatric Patient

CLINICALLY apparent embolic episodes occur in about 20% of pediatric patients with bacterial endocarditis. 1,2 Emboli most frequently involve the lungs, brain, extremities, spleen, kidneys, and mesenteric vessels. 1-3 Emboli to the coronary arteries resulting in a myocardial infarction, while not uncommon in adults, 4,5 are rare in children 6 and usually result in sudden death. 6-8 The purpose of this report is to draw attention to the fact that myocardial infarction can complicate bacterial endocarditis in children, to discuss the appropriate therapy, and to document the favorable long-term outcome in a patient who survived with conservative therapy. Report of a Case A 15-year-old girl was admitted to Hartford Hospital, Hartford, Conn, in November 1978 because of acute onset of abdominal pain. At age 6 years, she had had rheumatic fever characterized by arthritis, erythema marginatum rash, and carditis that resulted in mitral insufficiency. Since then, she has received monthly

Bacterial Endocarditis Caused by Vitamin B6-Dependent Viridans Group Streptococcus

Two cases of bacterial endocarditis in children, caused by viridans group Streptococcus which requires vitamin B6 or thiol compounds for growth are reported. It is important to recognize these organisms as a possible cause of endocarditis because supplemented media are needed for their isolation and sensitivity testing. These organisms may be penicillin-sensitive, -resistant, or -tolerant. An organism is considered tolerant to an antibiotic when the minimum bactericidal concentration of that antibiotic is greater than or equal to 32 times the minimum inhibitory concentration. One of our patients relapsed when treated with a single antibiotic to which the B6-dependent viridans group Streptococcus was tolerant. If a B6-dependent viridans group Streptococcus is isolated from a patient with endocarditis, therapy should be initiated with penicillin and an aminoglycoside until sensitivities are available. Sensitity testing should include both the MIC and MBC and adequate therapy can be confirmed by determing the serum bactericidal activity.

Oral treatment of subacute bacterial endocarditis in children.

Fourteen episodes of subacute bacterial endocarditis in 11 children were successfully treated with antibiotics, which in 13 cases were given largely by mouth. It is suggested that oral treatment of bacterial endocarditis should be considered for children who are only moderately but not severely ill, and who have sensitive organisms.

Bacterial endocarditis in children under 2 years of age.

The risk of bacterial endocarditis in infants with bacterial sepsis was assessed by review of clinical and autopsy records (1930 to 1972). There were 12 cases of bacterial endocarditis among 847 patients (1.4%) dying with bacterial sepis; a single survivor was noted during the entire period. Of the 12 autopsy patients, six had underlying congenital heart disease (CHD). Among 61 patients with bacterial sepsis associated with CHD, six acquired bacterial endocarditis (10%), whereas in 786 infants with sepsis but without underlying heart disease, only six developed bacterial endocarditis (0.8%) (P less than .01). There is a high mortality in infants with bacterial endocarditis, and an increased risk of it in infants with sepsis and CHD.

Bacterial endocarditis due to an unusual species of encapsulated Neisseria. Neisseria mucosa endocarditis.

A 9-year-old boy with bacterial endocarditis due to an unusual species of Neisseria is reported. Biochemical and morphologic characteristics of this Neisseria are compared with the organisms of earlier reports. The present organism, an encapsulated Neisseria, most closely resembles N mucosa. The difficulty in distinguishing between acute rheumatic fever and bacterial endocarditis in children and the need for obtaining multiple blood cultures in these cases are emphasized.

BACTERIAL ENDOCARDITIS IN CHILDREN WITH HEART DISEASE

We have reviewed the literature and our experience with 58 patients with bacterial endocarditis superimposed upon pre-existing heart disease, observed during the 30-year period, January 1930 through December 1959. There has been no change in the relative incidence of bacterial endocarditis in children with heart disease observed at the Babies Hospital since the introduction of antibiotics. Twenty-one patients (0.49/1,000 admissions) were observed from 1930 through 1943 and 37 patients (0.52/1,000 admissions) from January 1944 through December 1959. In the majority (40) infection was superimposed upon a congenital malformation of the heart, while in 17 there was evidence of rheumatic heart disease. In one, a rheumatic infection complicated a congenital anomaly. The history usually revealed unexplained fever and fatigue in a child known to have heart disease. Additional symptoms often reflected the nature of the underlying cardiac pathology. Patients with tetrad of Fallot developed symptoms secondary to hypoxia which in some instances was later shown to be attributable to vegetations at sites resulting in obstruction to pulmonary blood flow. The pathogenesis of bacterial endocarditis is defined in terms of bacteremia superimposed upon abnormal endocardial or endothelial surfaces; the further role of hemodynamic trauma secondary to congenital or acquired lesions is discussed. The results of bacteriologic studies were as vital in confirming the diagnosis and planning treatment as in the management of patients with meningitis. Blood cultures were usually positive in the first sample obtained (86%) and always by the sixth. Bacterial endocarditis is uncommon in the presence of sterile blood cultures providing an adequate number (six), each of sufficient quantity (10 ml), are obtained sufficiently long after antibiotics have been discontinued and providing they are incubated in aerobic and anaerobic media for 3 weeks. In children, the most important prognostic features were (1) recognition of the disease, (2) the nature of the infecting organism, and (3) adequate antibiotic treatment. In seven instances in our experience the correct diagnosis had not been considered prior to necropsy examination. Among the patients with bacterial endocarditis treated with antibiotics, recovery occurred in each of the 20 due to viridans streptococci, in 1 due to gamma-streptococci, and in 3 of the 8 due to Staphylococcus aureus. The principles of management are discussed and suggestions outlined for antibiotic therapy of children with bacterial endocarditis. Penicillin alone is recommended for infection due to viridans streptococci, if the organisms are highly sensitive, whereas for infection due to Staphylococcus coccus aureus a combination of chloramphenicol, erythromycin and penicillin is advocated as initial therapy. The importance of the use of antibiotics in therapeutic dosage for prophylaxis in patients with heart disease prior to dental manipulation or other surgical procedures is stressed.

Myocardial lesions in subacute bacterial endocarditis.

Excerpt Recently Saphir, Katz and Gore1stressed that the myocardial lesions in subacute bacterial endocarditis may be of more than academic interest. With the possibility of eliminating the infecti...

The use of penicillin in the treatment of subacute bacterial endocarditis in children

Summary The histories of four children with subacute bacterial endocarditis due to Str. viridans , who were treated with penicillin, have been reported in detail. The reports in the literature of ten other children treated in a similar manner have been reviewed. Among this group of fourteen children only one died, and he had received inadequate dosage. A favorable outcome was achieved with total doses ranging from approximately 1.5 million to 11 million units of penicillin, administered in daily amounts of 80,000 to 300,000 units. The route of administration seemed to make no difference in the outcomeof this group of children, and no other drugs such as the sulfonamides or heparin seemed necessary.

Rheumatic manifestations in subacute bacterial endocarditis in children

Rheumatic manifestations in subacute bacterial endocarditis in children