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Key Features

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Essentials of Diagnosis
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  • Positive blood culture

  • Intracardiac oscillating mass, abscess, or new valve regurgitation on echocardiogram

  • Fever

  • Elevated erythrocyte sedimentation rate or C-reactive protein

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General Considerations
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  • Bacterial or fungal infection of the endocardium

    • Rare

    • Usually occurs in the setting of a preexisting abnormality of the heart or great arteries

    • May occur in a normal heart during septicemia or as a consequence of infected indwelling central catheters

  • The frequency of infective endocarditis (IE) appears to be increasing for following reasons

    • Increased survival in children with congenital heart disease (CHD)

    • Greater use of central venous catheters

    • Increased use of prosthetic material and valves

  • Children without preexisting heart disease are also at increased risk for IE because of

    • Increased survival rates for children with immune deficiencies

    • Long-term use of indwelling lines in ill newborns and patients with chronic diseases

    • Increased injection drug use

  • Children at greatest risk

    • Those with unrepaired or palliated cyanotic heart disease (especially in the presence of an aorta to pulmonary shunt)

    • Those with implanted prosthetic material

    • Those who have had a prior episode of IE

  • Common causative organisms

    • Viridans streptococci (30–40% of cases)

    • Staphylococcus aureus (25–30%)

    • Fungal agents (about 5%)

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Clinical Findings

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  • Fever, malaise, and weight loss

  • Joint pain and vomiting are less common

  • New or changing murmur

  • Splenomegaly

  • Hepatomegaly

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Diagnosis

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  • Laboratory findings

    • Multiple positive blood cultures

    • Elevated erythrocyte sedimentation rate or C-reactive protein

    • Hematuria

  • Transthoracic echocardiography can identify large vegetations in some patients

  • However, transesophageal imaging has better sensitivity

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Treatment

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  • Appropriate antibiotic therapy should be initiated as soon as IE is suspected

  • Therapy can be tailored once the pathogen and sensitivities are defined

  • Vancomycin or a β-lactam antibiotic, with or without gentamicin, for a 6-week course is most common regimen

  • Surgical excision of the infected area and prosthetic valve replacement must be considered if heart failure occurs and progresses despite adequate antibiotic therapy

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Outcome

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Prevention
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  • Conditions requiring antibiotic prophylaxis

    • Prosthetic cardiac valves

    • Prior episode of IE

    • CHD

    • Cardiac transplant with valvulopathy

  • IE prophylaxis is not recommended for

    • Gastrointestinal or genitourinary procedures

    • Body piercing

    • Tattooing

  • Recommended prophylaxis

    • 50 mg/kg of oral amoxicillin for patients < 40 kg

    • 2000 mg of oral amoxicillin for those > 40 kg

    • Dose is to be given 1 hour prior to procedure

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Prognosis
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  • Factors associated with a poor outcome

    • Delayed diagnosis

    • Presence of prosthetic material

    • Perioperative associated IE

    • S aureus infection

  • Mortality for bacterial endocarditis in children ranges from 10% to 25%, with fungal infections having a much greater mortality (50% or more)

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Reference

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Wilson  W  et al: Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease ...

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