Infective Endocarditis In Children Research Articles

Pneumococcal endocarditis in children: A nationwide survey in Japan

Background Infective endocarditis (IE) due to Streptococcus pneumoniae ( S. pneumoniae) carries a high mortality rate. However, little is known about pneumococcal IE in children and no optimal therapy has been established. Thus, we attempted to identify the clinical features of this disorder through a Japanese nationwide survey. Methods Members of the Japanese Society of Pediatrics Cardiology and Cardiac Surgery registered 170 pediatric patients with IE diagnosed during a 5-year period (1997–2001). Nine of these patients (5.3%) had pneumococcal IE. The clinical course, treatment and outcome of these 9 patients, aged 7 months to 4 years, were analyzed. Results Pneumococcal IE was associated with congenital heart disease in 7 patients and accompanied by other systemic infections including meningitis, pneumonia and otitis media, in 4 patients. Five of the 9 (55.6%) strains isolated by blood culture were penicillin-resistant S. pneumoniae strains. Seven patients were treated with carbapenem. Three underwent cardiac surgery due to cardiac failure and/or vegetation. One died due to septic shock on the first day of hospitalization. Conclusions In children, pneumococcal endocarditis is often accompanied by severe systemic infections. The majority of pediatric cases are caused by penicillin-resistant S. pneumoniae strains. Carbapenem is an effective for IE caused by penicillin-resistant S. pneumoniae. This survey might be helpful to establish proper management strategies for pediatric pneumococcal IE.

P1484 Diagnosis difficulties of infective endocarditis in children, adolescents and young adults without cardiac predisposing factors – results of a case series

P1484 Diagnosis difficulties of infective endocarditis in children, adolescents and young adults without cardiac predisposing factors – results of a case series

Mitral valve repair for infective endocarditis in children

Mitral valve repair for infective endocarditis in children

Endocarditis por Streptococcus pneumoniae resistente a penicilina en niños: Report of a case due to penicillin resistant Streptococcus pneumoniae

Despite S. pneumoniae is one of main etiologies of invasive bacterial infection in children, it rarely causes infectious endocarditis in children. Pneumococcal endocarditis is a serious condition that affects mainly the mitral valve, with a rapidly destructive nature and a high fatality rate, demanding prompt medical and surgical treatment. We report a case of pneumococcal endocarditis in a school girl coming from extreme rurality who presented both meningitis and endocarditis, and whose blood cultures isolated penicillin resistant S. pneumoniae.

Impact of age on clinical features and outcome of infective endocarditis

Some studies have demonstrated that in infective endocar-ditis (IE) older age is associated with a higher mortality rate[1, 2], higher frequency of mitral-valve involvement [3],renal failure, and cerebral embolism [4]. In the studypresented here, we aimed to analyze the clinical features ofIE and to delineate short- and long-term outcome of IE inchildren, young adults and elderly patients. Charts of allpatients definitively diagnosed with IE from January 1987through December 1996 were identified (n=228) andgrouped according to age: group I included patients aged1–15 years; group II, patients aged 16–40 years; group III,patients aged 41–60 years; and group IV, patients aged≥61 years. For each patient, data on demographics, clinicalfeatures, and outcome were collected. Statistical analyseswere performed using ANOVA, chi-square, and Coxregression for multivariable analysis of survival (SPSSCorporation, Chicago, IL, USA).None of the 228 patients analyzed had a history ofintravenous drug abuse. There were 13 patients in group I,25 in group II, 57 in group III, and 133 in group IV. Nosignificant differences in clinical symptoms, rate of surgicalintervention, and length of hospitalization were foundamong the groups (Table 1). As expected, congenital heartanomalies were common (62%) in group I, while native-valve involvement (rheumatic and degenerative heartdisease) was more frequent in the other groups (40% ingroup II and 47% in groups III and IV; p=0.001).Prosthetic-valve IE occurred more commonly in groups IIand III (36 and 32%, respectively) than in groups I (8%)and IV (16%) (p<0.001). The mitral valve was involvedmost frequently in all groups, while the aortic valve wasinvolved in 41.7 and 41.4% of cases in groups II and IV,respectively (p=NS). Blood cultures were positive in 87%of the patients.In group I, the most commonly involved and evenlydistributed microorganisms were viridans streptococci,coagulase-negative staphylococci, and gram-negativebacilli (23% for each). Gram-negative organisms (Haemo-philus influenzae, Escherichia coli, Brucella melitensis,Klebsiella pneumoniae, and Bacteroides spp) were morecommonly involved in group I compared with the othergroups (23 vs 2–5% in other groups; p=0.014; Table 1).Viridans streptococci were the microorganisms isolatedmost commonly in groups III and IV, whereas Staphylo-coccus aureus was the most frequent in group II (44%,Table 1). The percentage of patients with S. aureusendocarditis was similar in patients with IE of prostheticvalves (35%) and native valves (29%) (p=0.364).Urea levels increased significantly with age (p=0.002),while total bilirubin was inversely related to age (r=−0.181, p=0.0001). No significant differences in echocar-diographic findings were observed among the groups.Mean survival rates were 102.5±79.9 months in group I,101.9±74.5 in group II, 95.7±74.5 in group III, and 55.5±52.0 months in group IV (p=0.001). Surprisingly, in-hospital mortality rates were similar in all groups despitethe age differences (17, 13, 9 and 12% in groups I, II, IIIand IV, respectively; p=0.844; Table 1). Significantpredictors of in-hospital mortality according to univariateanalysis were hypoalbuminemia (3.1±0.8 g% vs 3.7±0.5;

Antibiotic Therapy for Infective Endocarditis in Childhood

Infective endocarditis is relatively uncommon in childhood, but its epidemiology has changed in the past three to four decades and its incidence has been increasing in recent years. With the improved survival rates of children with congenital heart diseases and the overall decreased frequency of rheumatic valvular heart disease in developed countries, congenital cardiac abnormalities now represent the predominant underlying condition for infective endocarditis in children over the age of two years in Western Europe and Northern America. Moreover, the complex management of neonatal and pediatric intensive care unit patients has increased the risk of catheter-related endocarditis. More specifically, the surgical correction of congenital heart alterations is associated with the risk of postoperative infections. Endocarditis in children may be difficult to diagnosis and manage. Emerging resistant bacteria, such as methicillin- or vancomycin-resistant staphylococci and vancomycin-resistant enterococci, are becoming a new challenge for conventional antibiotic therapy. Newer antimicrobial compounds recently introduced in clinical practice, such as streptogramins and oxazolidinones, may be effective alternatives in children with endocarditis sustained by Gram-positive cocci resistant to glycopeptides. Home intravenous therapy has become an acceptable approach for stable patients who are at low risk for embolic complications. However, further clinical studies are needed in order to assess efficacy and safety of these antimicrobial agents in children. This review should help outline the most appropriate antimicrobial treatments for infective endocarditis in children.

Results of surgical treatment for infective endocarditis in children

Infective endocarditis is uncommon condition, with a high degree of morbidity and mortality. It is less common in children, albeit tending to be associated with congenital cardiac malformations. We describe our experience of the need for surgical treatment in children with infective endocarditis. We analyzed retrospectively the records of 9 children aged below 16 years seen between May 2003 and March 2005 with infective endocarditis, reviewing the demographic details, clinical presentation, microbiological and echocardiographic data, operative findings, and outcome. Apart from pre-existing renal insufficiency in 1 patient, congenital cardiac malformations were the predisposing factors. Blood cultures were positive in 3, but remained negative in the other 6 patients. The indications for surgical treatment included uncontrolled sepsis, congestive heart failure, recurrent endocarditis, patch or graft dehiscence, and pseudoaneursymal formation. Death due to uncontrolled sepsis resulting in multiorgan failure occurred in 1 patient, who had tetralogy of Fallot with pulmonary atresia and major aortopulmonary collateral arteries. Another patient died late postoperatively due to cardiac failure after relapse of the endocarditis in the setting of negative blood cultures. Despite advances in antimicrobial therapy, diagnosis, and measures of treatment for infective endocarditis, complications continue to be responsible for substantial morbidity and mortality. Since blood cultures are frequently negative, clinical and echocardiographic findings should be the major determinants of strategies used for treatment. We believe that our small series of patients seen over the past two years in which surgical treatment was performed will be helpful in guiding the clinical perspectives for children with infective endocarditis.

Value and limitations of the von Reyn, Duke, and modified Duke criteria for the diagnosis of infective endocarditis in children.

To compare the sensitivity of 3 different criteria-von Reyn, Duke, and modified Duke-in diagnosing infective endocarditis (IE) in children. Retrospective case study in a tertiary pediatric hospital. Between 1985 and 2001, 41 episodes of IE were documented in 40 children (median: 7 years old; range: 1 week to 18 years). The diagnosis was based on echocardiographic and microbiologic or pathologic findings. The initial echocardiogram suggested IE in 95% of the cases. Main findings were vegetations in 36, perivalvular abscess in 4, and/or new valvular leaks in 6 cases. In 31 (76%) of the 41 episodes, the causative organisms were identified directly by specimen bacteriology or blood cultures (BCs) or indirectly by polymerase chain reaction or serology. Sensitivities of the von Reyn, Duke, and modified Duke criteria in diagnosing IE were 63%, 81%, and 88%, respectively. In 10 cases (22%), the diagnosis of IE was "rejected" by the von Reyn criteria but was "definite or possible" by the Duke and modified Duke criteria. In 3 cases, the diagnosis of IE was "possible" by the Duke but "definite" by the modified Duke criteria: 2 of the 3 cases had 1 major and >or=3 minor symptoms, and 1 had Q fever. Five episodes (12%) were classified as "possible" IE by the modified Duke criteria: although major findings were present on echocardiography, no organism was identified on repeat BCs. Positive BC was the only criterion that differentiated "definite" from "possible" IE. The modified Duke classification was more sensitive in diagnosing IE in children than the von Reyn and Duke criteria. Still, 12% failed to be classified as "definite" IE by the modified Duke criteria. This illustrates the importance of positive BCs as a major IE criterion while significant echocardiographic findings are less considered by the presently used criteria.

Surgical treatment of congential heart disease associated with infective endocarditis in children

Surgical treatment of congential heart disease associated with infective endocarditis in children

Unique features of infective endocarditis in childhood.

Infective endocarditis (IE) is associated with substantial morbidity and mortality. Although it is relatively rare in children, its incidence may be increasing.1 This paper focuses on the features that are particularly relevant to infants and children, including important issues for the primary care physician. The epidemiology of heart disease in children has changed over the past 3 to 4 decades. With the increased survival rate of children with congenital heart disease (CHD) and the overall decrease in rheumatic valvular heart disease in developed countries, CHD now constitutes the predominant underlying condition for IE in children over the age of 2 years in these countries. The complexities of management of neonatal and pediatric intensive care unit patients have increased the risks of catheter-related IE. In addition, postoperative IE is a long-term risk following correction of complex CHD. The proper use of the diagnostic microbiology laboratory is critical in the diagnosis and management of children with IE. Moreover, newer diagnostic guidelines have improved sensitivity for making the diagnosis of clinically definite IE. In addition, advances in noninvasive techniques such as two-dimensional (2D) echocardiography have enhanced our ability to diagnose IE. Newer antibiotics have become available that can be used in children with IE, and home intravenous (IV) therapy has become an acceptable approach for stable patients who are at low risk for embolization. Additionally, approaches to the prevention of endocarditis have been recently modified and are reviewed in this paper. IE occurs less commonly in children than in adults and accounts for approximately 1 in 1280 pediatric admissions per year.2 Although the reported hospitalization rates for IE vary considerably among published series, the frequency of endocarditis among children appears to have increased in recent years.3 This is due in part to improved survival among children who are at risk … Address correspondence to Kathryn A. Taubert, PhD, Vice President, Department of Science and Medicine, American Heart Association, 7272 Greenville Ave, Dallas, TX 75231. E-mail: ktaubert{at}heart.org

Unique features of infective endocarditis in childhood.

Infective endocarditis (IE) is associated with substantial morbidity and mortality. Although it is relatively rare in children, its incidence may be increasing.1 The present statement focuses on the features that are particularly relevant to infants and children, including important issues for the primary care physician. The epidemiology of heart disease in children has changed during the past 3 to 4 decades. Because of the increased survival rate of children with congenital heart disease (CHD) and the overall decrease in rheumatic valvular heart disease in developed countries, CHD now constitutes the predominant underlying condition for IE in children over the age of 2 years in these countries. The complexities of management of neonatal and pediatric intensive care unit patients have increased the risks of catheter-related IE. In addition, postoperative IE is a long-term risk after correction of complex CHD. Proper use of the diagnostic microbiology laboratory is critical in the diagnosis and management of children with IE. Moreover, newer diagnostic guidelines have improved sensitivity for making the diagnosis of clinically definite IE. Advances in noninvasive techniques, such as 2-dimensional echocardiography, have enhanced our ability to diagnose IE. Newer antibiotics that can be used in children with IE have become available, and home intravenous therapy has become an acceptable approach for stable patients who are at low risk for embolization. In addition, approaches to the prevention of endocarditis recently have been modified and are reviewed in the present statement. IE occurs less often in children than in adults and accounts for ≈1 in 1280 pediatric admissions per year.2 Although the reported hospitalization rates for IE vary considerably among published series, the frequency of endocarditis among children seems to have increased in recent years.3 This is due in part to improved survival among children who are at risk for endocarditis, …

Changing Risk Factors for Pediatric Infective Endocarditis.

Infective endocarditis in children is an uncommon infection. Three major groups of children are at risk: 1) those with underlying congenital heart disease, 2) those with central vascular catheters, and 3) children infected with certain virulent organisms. Although the overall incidence of infective endocarditis has increased, the population of children involved has changed. Children with corrected congenital heart disease are at risk during the early postoperative period. Children in whom vascular shunts or grafts are employed remain at the highest risk for endocarditis. Use of central vascular catheters increases risk in children with underlying heart disease and those with normal hearts. Finally, certain pathogens attack the heart valves and cause high morbidity and mortality.

Infective endocarditis in children — incidence, pattern, diagnosis and management in a developing country

Background: In developing countries, patients with infective endocarditis are referred late, there is low yield of blood cultures and incidence of rheumatic heart disease is still high. Objective: Evaluate clinical pattern, assess diagnostic criteria in our settings and determine outcome. Setting: A tertiary referral center for paediatric and adult cardiology. Patients and methods: All children with infective endocarditis admitted to a single center from April 1997 to March 2000 were analysed. The diagnosis was based on Duke’s criteria, which proposed two major and six minor criteria. Minor criteria were expanded to include raised acute phase reactants and presence of newly diagnosed or increasing splenomegally. The patients were stratified as definite, possible and rejected cases. Results: Of 1402 hospital admissions, 45 patients fulfilled the diagnostic criteria for infective endocarditis giving an incidence of 32 per 1000 hospital admissions. The mean age was 7.9±4 years (4 months to 16 years) with only two patients under 1 year of age. Rheumatic heart disease was the underlying lesion in 24 patients (53%) while congenital heart lesions occurred in 20 patients (45%). Previous antibiotic treatment was given in 26 patients (58%) definitely. Blood cultures were positive in 21 patients (47%); Streptococcus Viridans being the most common organism, while vegetations on echocardiography were present in 32 patients (71%). Surgery was undertaken in four patients and five patients left against medical advise. Of 10 patients with aortic valve involvement, there were three deaths (30%) and overall mortality was 13% (six patients). Conclusions: The incidence of infective endocarditis is 32 per 1000 (3.2%) hospital admissions in a tertiary paediatric cardiology referral center. Rheumatic heart disease is still the most common underlying heart lesion. Blood cultures are positive in less than 50% of cases and echocardiography in expert hands is a more sensitive tool in our set up. Mortality is still high and aortic valve involvement in particular, carried poor prognosis.

Paediatric infective endocarditis: 19-year experience at a tertiary care hospital in a developing country.

A retrospective study was undertaken to study children who presented with infective endocarditis (IE) to a university teaching hospital in Beirut, Lebanon, between January 1977 and May 1995. Of 41 patients with IE (24F, 17M), 28 (68%) were diagnosed between 1977 and 1985. Patients' ages ranged from 3 to 18 y (mean age 11.3+/-2.8 y), and 13 patients were <10 y of age. Clinical presentations included: fever (in 88%), heart failure (in 39%), neurologic findings (in 20%) and embolic phenomena (in 22%). Nineteen patients (46%) had underlying congenital heart disease (CHD) with tetralogy of Fallot and pulmonary stenosis being the most common. Sixteen patients (39%) had underlying rheumatic heart disease (RHD). A total of 5 children (12%) with normal cardiac anatomy had IE. One had underlying acquired viral myocarditis with mitral insufficiency. Echocardiography showed vegetations in 60%. Blood cultures were positive in 31 patients (76%). IE occurred in three patients following cardiac surgery. In one patient it occurred within 2 mo of surgery and in the other two it occurred within 6 mo. Streptococcus viridans and Staphylococcus aureus were the two most commonly isolated bacteria. Overall mortality rate was 29% (not statistically significant between patients presenting between 1977-1985 and 1986-1995; p = 0.17). There was no statistically significant difference in mortality among the groups (five in the group with CHD, six with RHD and one with structurally normal heart). This study demonstrates that RHD is an important underlying cause of IE in children in our community. This finding is similar to those in other developing countries and different from those in developed countries. Distribution of pathogens and CHD in our study is comparable to some reports in the literature, except for the higher proportion of patients with underlying pulmonary stenosis. Bacterial endocarditis prophylaxis should be emphasized in patients with RHD or pulmonary stenosis.

The role of transthoracic echocardiography in the diagnosis of infective endocarditis in children.

Infective endocarditis (IE) is frequently suspected but infrequently diagnosed in children. Clinicians often order echocardiograms to "rule out" IE. In an era of cost constraint, clinically efficient strategies must be developed to eliminate unnecessary tests. We hypothesized that transthoracic echocardiography (TTE) is only useful in children in whom there is a high clinical suspicion of IE based on history, physical examination, and persistently positive blood cultures. To determine the role of TTE as a screening test for suspected IE in children. Echocardiographic reports and medical records were reviewed retrospectively for 173 consecutive patients who underwent TTE to rule out IE from January 1993 to August 1996. Persistent fever was the predominant symptom leading to a suspicion of IE (120 patients [69.4%]). Fifty-seven (32.9%) of the 173 patients had congenital heart disease and 95 patients (54.9%) had indwelling venous catheters. Twenty-six patients (15.0%) were diagnosed and treated for IE. Twelve (46.2%) of these 26 patients had vegetations seen on TTE. The conditions of the remaining 14 patients were diagnosed clinically and these patients had persistently positive blood cultures. By univariate analysis, the risk factors associated with the diagnosis of IE were malaise, congestive heart failure, new or changing heart murmur, leukocytosis, hematuria, and the presence of 2 or more positive blood cultures for the same organism. The risk factors associated with positive TTE were malaise, congestive heart failure, new or changing heart murmur, leukocytosis, hematuria, and 2 or more positive blood cultures. The presence of an indwelling catheter or immunocompromised status were not predictive of vegetation or IE. Transthoracic echocardiography has poor sensitivity as a screening test for IE in patients with low clinical probability of the disease. A diagnostic algorithm for IE is suggested based on these data.

Are the Duke criteria superior to the Beth Israel criteria for the diagnosis of infective endocarditis in children?

Accurate diagnosis of infective endocarditis may be difficult. The Beth Israel criteria and the newer Duke criteria assign probability to the diagnosis of infective endocarditis on the basis of the presence of common features and manifestations. We reviewed 111 cases of pediatric infective endocarditis diagnosed and treated over 19 years. Each case was classified by the two criteria, and the results were compared. Of 111 cases, 73 (66%) and 18 (16%) were classified as definite by the Duke criteria and the Beth Israel criteria, respectively. No cases were rejected by the Duke criteria, while 21 (19%) of 111 were rejected by the Beth Israel criteria. In 18 pathologically proven cases, reanalysis without pathological data showed that the Duke criteria had significantly greater sensitivity (83%) than the Beth Israel criteria (67%) (P < .03). Echocardiographic evidence was required in 22 cases for definite classification by the Duke criteria; none were rejected, however, when echocardiographic findings were ignored. Our results suggest that the Duke criteria are superior to the Beth Israel criteria for the diagnosis of pediatric infective endocarditis.

Lacrimal-duct-probing-induced bacteremia: should children with congenital heart defects receive antibiotic prophylaxis?

To determine the incidence of bacteremia following lacrimal-duct probing in children, and to evaluate the potential need for antibiotic prophylaxis in children who are at an increased risk of infectious endocarditis (IE). In a prospective study beginning in October 1994, 40 consecutive children requiring lacrimal-duct probing performed by a single pediatric ophthalmologist received preoperative lacrimal and blood cultures followed by postoperative probe-induced transient bacteremia that was defined as a negative preoperative blood culture, followed by a positive postoperative blood culture of the same bacteria identified in the positive lacrimal culture. The overall infection rate as described above was 7 of 40 children (17.5%) with a 95% confidence interval of 7.3% to 32.8%. Of these, four children had positive postoperative cultures for Haemophilus influenzae (10.0%) and 3 were positive for Streptococcus pneumoniae (7.5%) One child had a negative preoperative blood and lacrimal culture with a postoperative blood culture positive for Streptococcus viridans. This study shows a significant incidence of lacrimal-probe-induced bacteremia with organisms that have been documented as etiological agents for IE in children. IE, although less common in children, remains a serious, potentially life threatening infection with high mortality. Although lacrimal-duct probing has never been clearly associated with documented endocarditis, it is the authors' recommendation that it be prudent for patients who are at known high risk for endocarditis to receive SBE prophylaxis considering the low cost/benefit ratio.

Infectious endocarditis in children: changing pattern in a developing country

AbstractBackgroundThere is a reported change in the profile of infectious endocarditis and a reduction in its mortality in the developed world. We present our experience of infectious endocarditis in children seen in the last 5 years in the developing world.MethodsRecords of 43 consecutive children with infectious endocarditis admitted to this centre were analysed retrospectively. Diagnosis was based on presence of any two of the following: fever with no extracardiac features; vegetations on echocardiography; Positive blood culture with no extracardiac focus; and embolic episodes.ResultsThe age at diagnosis ranged from 40 days to 16 years (mean 8.5 years); Of the patients 3 were under 2 years of age; 28 were males and 15 females. Congenital heart disease was the underlying cause in 32 (74%), and rheumatic heart disease in 11 children. All except the youngest presented with fever. Blood cultures were positive in 16 (37%). Vegetations were detected by cross-sectional echocardiography in all except 1 child. After treatment 31 (72%) responded to a combination of penicillin and aminoglycoside. Emergency surgery was undertaken in 9 (21%). Three patients (7%) died, and all of these had fungal endocarditis.ConclusionsBlood cultures give a low yield, but cross-sectional echocardiography is a sensitive tool in the diagnosis of infectious endocarditis. Most children respond to penicillin and an aminoglycoside. An aggressive surgical approach in complicated cases lowers the mortality.

The Utility of Transthoracic Echocardiography in the Diagnosis of Infective Endocarditis in Children 90

Infective endocarditis (IE) is frequently suspected but infrequently diagnosed disease in children. Clinicians often order echcardiograms to rule out IE. In the era of cost containment, clinically efficient strategies must be developed. We hypothesized that transthoracic echocardiography (TTE) is only useful in children in whom there is a high clinical suspicion of IE based on history, physical examination and persistently positive blood cultures. The objective of this study is to determine the role of TTE as a screening test for suspected IE in children. Echocardiographic reports and medical records were reviewed for 166 consecutive patients who underwent TTE to rule out IE from 1/93 to 7/96. Fever was the main indication for TTE (114 patients, 69%). Fifty seven (34%) patients had congenital heart disease and 89 (54%) patients had indwelling venous catheters. Twenty six (16%) were diagnosed and treated as IE. TTE was positive for vegetation in 12 patients (46% of IE patients and 7% of the total). The other 14 patients were diagnosed on a clinical basis as well as having persistently positive blood cultures. Using logistic regression and classification trees, we determined which variables were predictive of IE. Fever, leukocytosis, splenomegaly, hematuria, heart failure, murmurs, immune compromised status, or elevated acute phase reactants were not predictive of the outcome. Malaise defined as fatigue and the general feeling of illness, was the most predictive variable of IE (sensitivity 77% and specificity 95%). The presence of indwelling catheters without malaise was indicative of no IE in 77/77 patients. The presence of a second positive blood culture or malaise increased the sensitivity for IE to 100% with only 50(instead of 166) patients requiring TTE under these criteria. TTE has poor sensitivity as a screening test for IE. Multiple positive blood cultures in a setting of clinical illness adequately defines the need for TTE.

Infective endocarditis in infants and children.

Due to changing characteristics of infective endocarditis in the past two decades, we, retrospectively analysed 28 cases of infective endocarditis in children of age less than 15 years at Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar from December, 1983 to November, 1993. The incidence of disease was observed as 1.5 cases/1000 children admitted with a M:F ratio of 2:1. Three patients were of age less than 2 years (group I) as 25 were above 2 years of age (group II). The two groups had significant difference in portal of entry of infection, infective microorganisms, echocardiography and prognosis. Congenital heart disease was the commonest underlying cardiac lesion in 24 (85.71%) patients. Portal of entry of infection was apparent in 35.71% only; dental route being more frequent in group II. Streptococcus viridans (in 9 cases) followed by staphylococcus aureus (in 4 cases) were the two common organisms isolated. Patients were treated, for a period of 4-6 weeks with a over all mortality rate of 25%. Factors associated with poor prognosis were age < 2 years, staphylococcal infection ad negative blood cultures. Heart failure resistant to medical therapy was a leading cause of death.