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Infective Endocarditis

A high level of suspicion is of utmost importance in the diagnosis of endocarditis, particularly in the patient at risk who may have received antibiotic treatment for the prodrome. Treatment with adequate levels of a bactericidal drug based on an identified organism will give the highest percentage of cures. Early treatment may prevent damage to cardiac structures and lessen further complications related to emboli or progressively enlarging vegetations. The combination of a high-risk patient with either resistant bacterial endocarditis or fungal

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endocarditis carries a higher morbidity and will account for most of the mortality. Although not an ideal answer, SBE prophylaxis is justified from observations in animals and should be recommended strongly to the parents and to the patient as she or he gets older.

Because an increasing number of children survive their congenital heart defects but remain at risk for acquiring SBE and because an increasing number of preterm infants and neonates are exposed to indwelling catheters, the pediatrician will continue to see IE presenting as both a diagnostic dilemma and an acute treatment problem. The emergence of children who are human immunodeficiency virus-positive or who have acquired immunodeficiency syndrome has increased the group at immunologic risk, as has an increasing population of children surviving organ transplants. These children can present more often with infections caused by nosocomial, resistant agents because of their frequent hospitalizations, and they may have a variety of opportunistic infections from organisms that normally are not pathogens. Unfortunately, a higher mortality rate can be expected among these children.

The diagnosis of IE is made even more of a challenge because it accounts for only about 1/1000 to 1/4500 hospital admissions to pediatric services. In tertiary care hospitals that have an active pediatric cardiac service, the numbers may be higher. The most important element in diagnosing endocarditis remains its early consideration as a possibility in any child who has a persistent unexplained febrile illness and its being the first consideration in a high-risk child.

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