The Changing Epidemiology of Pediatric Endocarditis at a Children’s Hospital Over Seven Decades

Abstract

This study sought to determine whether improvements in the care of children with congenital heart disease (CHD) have changed the epidemiology of infective endocarditis (IE). A retrospective study of patients 18 years of age and younger treated for IE from 1992 to 2004 (era 3) was conducted at the authors' children's hospital in New York City. This study was compared with two previous studies conducted at the same hospital from 1930 to 1959 (era 1) and from 1977 to 1992 (era 2). During the three eras, IE was diagnosed for 205 children with a median age of 8 years during eras 1 and 2, which decreased to 1.5 years during era 3, partly because of IE after cardiac surgery for young infants. In era 3, nonstreptococcal and nonstaphylococcal pathogens associated with hospital-acquired IE increased. Complications from IE declined during era 3, but after the widespread availability of antibiotics in 1944, crude mortality rates were similar in eras 1 (32%), 2 (21%), and 3 (24%). However, in era 3, mortality occurred only among subjects with hospitalacquired IE. The epidemiology of pediatric IE has changed in the modern era. Currently, IE is Conflicts of interest statementThe authors have no conflicts of interest to disclose. NIH Public Access Author ManuscriptPediatr Cardiol. Author manuscript; available in PMC 2011 August 1. NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript most likely to occur among young children with complex congenital heart disease. Pediatric IE remains associated with high crude mortality rates when it is acquired in the hospital. KeywordsCongenital heart disease; Endocarditis; Pediatrics Infective endocarditis (IE) in children is relatively rare but causes significant morbidity and mortality when it occurs. Several case series have demonstrated that the epidemiology of pediatric IE has changed in parallel with advances in medical care [1,2,12,15,20,25,34]. As the incidence of rheumatic fever has declined in developed countries due to reduction in overcrowded living conditions and improvements in diagnosis and care of pharyngitis caused by group A streptococci [26,28], the importance of rheumatic heart disease as an underlying risk factor for pediatric IE has substantially decreased. Surgical advances for children with congenital heart disease (CHD), including the introduction of bioprosthetic or synthetic materials, have improved the outcomes and life expectancy of such children, thereby increasing the number of children at risk for IE [2,9,18].The increased use of central venous catheters (CVCs) among hospitalized children, including premature infants, also has expanded the pediatric population at risk for IE [18]. Finally, the escalating complexity of hospitalized patients coupled with the use of broadspectrum antibiotics has led to the emergence of multidrug-resistant organisms causing hospital-acquired endocarditis [17,18].Our children's hospital serves as a referral center for infants and children with CHD. Two previous case series have described the epidemiolo...

Infective Endocarditis in the Pediatric Patient: A 60-Year Single-Institution Review

“…1,4,[9][10][11] In our study, there was only 1 case of Enterococcus faecalis endocarditis (2%), compared with 7% to 16% reported in other series. 4,9,11 This may be due to the relatively few infants in our study, since E faecalis infection has been shown to be more common in infantile endocarditis. 9 Relatively rare bacteria were found in some of our recent IE cases.…”

“…This trend in rheumatic heart disease has been shown in several other case series. 4,[8][9][10][11] A major risk factor for IE in patients with CHD is prior surgical intervention. In our study, there was a history of cardiovascular surgery in 34% of pa- …”

“…1,4,[9][10][11] In both of our cohorts, approximately 80% of patient deaths (15 of 19 patients in cohort 1, 4 of 5 patients in cohort 2) occurred in patients with CHD. The overall 1-year mortality was significantly (PϽ.001) lower in the modern era (4%) compared with the historical era (38%).…”

“…2,3 Advancements in cardiac surgery for congenital defects include the increased use of bioprosthetic and synthetic materials that may further increase the risk for development of IE in patients with CHD. 4 Advances in echocardiography since the 1980s have allowed for improved anatomic delineation of vegetations in patients with IE and have helped in decisions between medical or surgical intervention. Finally, antibiotic prophylaxis for high-risk patients has been recommended by the American Heart Association since 1955.…”

Original article. Childhood infective endocarditis in Khon Kaen University Hospital from 1992 to 2011

“…It is a significant cause of morbidity and mortality in children and adolescents despite advances in the management and prophylaxis of the disease with antimicrobial agents [2][3][4][5]. Although IE is relatively uncommon in children compared with adults, accounting for 0.5−0.8 cases per 1,000 pediatric admissions [1][2][3][4][5], the incidence of pediatric IE is believed to be increasing [1]. This is due in part to improved survival among children who are at risk for IE, such as those with congenital heart disease (CHD) and hospitalized newborn infants [1][2][3][4].…”