Infective endocarditis in childhood: a seven-year experience

Abstract

Introduction: The epidemiology, clinical features, treatment and outcomes of infective endocarditis (IE) are reviewed.

Methods: A retrospective descriptive study was performed involving patients treated for IE at a paediatric tertiary centre in Singapore, between May 1997 and April 2004. Duke criteria were used to retrospectively evaluate the diagnosis of IE in these cases. Data analysis was performed using SPSS for Windows.

Results: There were a total of 27 children with IE in the seven-year study period. Of these, 24 (88.9 percent) had congenital heart disease, one had rheumatic valvular heart disease and two had normal anatomy. Fever (81.5 percent) was the primary presenting symptom, while splenomegaly (40.7 percent) and septic spots (22.2 percent) were the most common physical findings. C-reactive protein was raised in all cases with a mean of 100.1mg/L. Blood cultures were positive in 77.8 percent of cases and the most common organism identified was Viridans Streptococcus species (25.9 percent). Vegetations were detected on echocardiography in 55.5 percent of cases. According to the Duke criteria, 48.1 percent of our patients fulfilled the clinical diagnosis of definite IE and 51.9 percent had possible IE. The median duration of parenteral antibiotics was 31 days. Major complications were seen in seven (25.9 percent) patients, of whom five had either left heart vegetations or a right-to-left shunt physiology.

Conclusion: IE is an uncommon infection in childhood and occurs primarily in patients with congenital heart disease. Rheumatic heart disease is rarely a predisposing cause in our local children. Early diagnosis of IE is challenging and depends on a high index of suspicion. Useful clues include the presence of splenomegaly, septic emboli, microscopic haematuria and high C-reactive protein level greater than 100mg/L. The Duke criteria for the diagnosis of IE are relevant locally, but if modified with an expanded list of minor criteria including the above useful clues, may increase the sensitivity of diagnosing definite IE. The presence of left-sided heart vegetations is a strong predictor of complications and must be treated aggressively.