Infective endocarditis in Children

By ULY CLINIC staff

Infective endocarditis is a bacterial or fungal infection of the endocardial layer of the heart which can involve native or prosthetic valve and congenital defects/shunts. The infection reach the heart valves through blood(hematogenous) and infect the heart

The common origin of infection maybe from mouth, skin, intestine, respiratory tract, urinary tract

Diagnostic Criteria

For definitive IE you need:

Two major Criteria OR
One major and three minor Criteria OR
Five minor Criteria.

For possible bacterial IE you need

One major and one minor Criteria OR
Three minor Criteria.

Modified Dukes Criteria.

Major Criteria

Positive blood cultures of typical organisms of infective endocarditis from
at least two separate blood cultures.
Evidence of endocardial involvement by echocardiogram (trans-thoracic
echo/trans-oesophageal echo.)

Minor Criteria.

Fever >38°C
Presence of RHD, CHD
Vascular phenomena: major arterial emboli, septic pulmonary infarcts,mycotic aneurysm, intracranial haemorrhage, conjunctival haemorrhage.
Immunological phenomena: Glomerulonephrites, Osler’snodes, Roth’sspots, Rheumatoid factor.
Serologic evidence of active infective endocarditis or blood culture notmeeting major Criteria

Investigations

Blood cultures atleast 2-3 over 24 hours period (not only with temperature spikes)
FBP
Acute phase reactants (CRP and ESR)
Urinalysis
Chest X Ray
ECG and Echocardiogram

Treatment

Pharmacological treatment

Use bactericidal antibiotics for at least 6 weeks.

Benzyl Penicillin IM or IV 50,000U/kg 6 hourly for 6 weeks AND
Gentamicin IV or IM 7.5mg/kg OD for 2 weeks

If patient is allergic to penicillin Give Vancomycin IV 10mg/kg 6 hourly for 4 weeks.

For patients with enterococcal or resistant streptococcal endocarditis

Give Ampicillin IV or IM 50mg/kg 6 hourly AND
Gentamicin IV or IM 7.5mg/kg once a day 6 weeks.

Patients with Staphylococcal endocarditis

Give Cloxacillin IM or IV 50mg/kg OR
Flucloxacillin IM or IV 50mg/kg 6 hourly AND
Gentamicin IM or IV 7.5mg/kg once a day for 6 weeks.

For patients with Penicillin resistant organisms’

Give Ceftriaxone IV 100mg/kg in once a day AND
Gentamicin IM or IV 7.5mg/kg once a day for 6 weeks

Antibiotic prophylaxis against bacterial endocarditis

Patients with CHD undergoing dental, gastro intestinal or genito-urinary procedures should receive antibiotic prophylaxis before the procedure.
Oral/nasal/pharyngeal procedures.

Local anaesthesia

Amoxicillin PO 50mg/kg one hour pre-op. single dose only.
Penicillin sensitive patients: Clindamycin PO 20mg/kg one hour pre-op dose only.

General anaesthesia

Ampicillin/Amoxicillin IV 50mg/kg at induction single dose only
Penicillin sensitive patients: Clindamycin IV infusion 20mg/kg or oral single dose only.
Vancomycin IV 20 mg/kg infuse over one hour single dose only.

Gastro-intestinal/Genito-urinary procedures

Ampicillin/Amoxicillin IV 50mg/kg at induction single dose only AND
Gentamicin IV or IM 7.5 mg/kg.

Information for parents of children with congenital heart diseases

1. Immunization

Congenital Heart Disease is not a contraindication to immunization–Indeed it could be urged that immunization is more important still.

2. Exercise restriction

All children with CHD except those with aortic stenosis should be allowed to exercise.

3. Non-cardiac surgery

Non cardiac surgery can be undertaken in a child with CHD regardless of the type of lesion or type of operation contemplated unless the patient is in frank cardiac failure or has severe pulmonary hypertension

Last updated on 26.09.2020

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References

Tanzanian Standard treatment guideline for children 2017 edition page 108-110