Dr. Murtaza KamalMBBS, MD, DNB

Division of NeonatologyDepartment of Pediatrics

Safdarjung Hospital & VMMC, New DelhiDOP- 13/10/2015

Neonatal Endocarditis

Definition

“Endocarditis caused by microorganisms (bacteria or fungi) involving either the heart or the great vessels (i.e, endarteritis); the pathology also may include abscess formation”

Peds in review.AAP;Nov 2012

Pathogenesis

Vegetations seen on :

• Low pressure side of the defect • Around the defectOpposite side of the defect

Bacteremia

• Localized infection (abscess/ osteomyelitis/ pyelonephritis)

Damaged endothelium

• Significant pressure gradient/

turbulence• Thrombus formation• Platelet and fibrin

deposition (nidus)

Risk factorsMain –Central venous catheter (parentral

nutrition)Congenital Heart disease-8% (compared to

upto 80% in older children and adults)Necrotising enterocolitis

Key point: In neonates it is mostly associated with normal heart

Micro-organismsGram positive:

S.aureusCONSStaphylococcus

Gram Negative:K.pneumonieEnterococcus faecalisSerratie marcescens

Fungi:Candida albicans

Clinical featuresHigh index of suspicion neededNon specific (Tachycardia, respiratory distress)FeverHepato-splenomegalySkin abscessesNew or changing heart murmursCongestive heart failureArtheritisPresence of embolic phenomenon

OsteomyelitisMeningitisPneumonia

Investigations CBC:

Anemia LeukocytosisThrombocytopenia

Non specific Elevated erythrocyte sedimentation rateElevated C-reactive proteinHematuriaProteinuria

Blood culture Must be obtained when IE is suspected

Blood cultures will be positive in 85 – 95% of cases(if pretreatment with antibiotics : yield 50% -60%)

Volume-1 to 3 ml Not necessary to time blood sampling with

fever because bacteremia in IE usually is continuous

Draw three cultures, with 1 hour separating first and last, before administering antibiotics

EchocardiographyTypes include:

Transthoracic echocardiogram (TTE)

Transesophageal echocardiogram (TEE)-90%Sn

Vegetations mostly on right side(75%)-mostly junction of SVC and rt.atria

Treatment (Principles)Bactericidal antibiotics must be usedProlonged therapy is necessary (weeks)Treatment is best started after multiple sets of

blood cultures have been taken.Urgency in the initiation of therapy is required Synergistic combinations of antibiotics are used

when available.Antibiotics are generally needed in higher

concentration than routine sepsis as they need to penetrate the vegetation to reach the enmashed bacteria

Organism Suggested regimen

S. viridans Sensitive to penicillin Penicillin G 200,000 U/ kg /day in 4- 6 doses IV (maximum 20 million units) for 4-6 weeks/ ceftriaxone (100mg/kg/day0) OD for 4 wk .

S. viridans Resistant to penicillin Penicillin G as above plus gentamicin 4 – 6mg/kg/day in 2-3 doses, IM for 2-4 weeks

S. aureus coag + Sensitive to penicillin Penicillin as for S. viridans given for 6 –8 weeks

S. aureus coag + Resistant to penicillin Methicillin 200 mg/kg/ day in 4 –6 doses IV for 6-8 weeks plus gentamicin 4 –6 mg/kg/day in 2-3 doses IV for 2 weeks.

S. aureus coag + Resistant to methicillin Vancomycin 50 mg/kg/day in 4 doses, IV for 6- 8 weeks

Enterococci (S. fecalis) Ampicillin 200 mg/kg/day in 6 doses, IV for 6 weeks plus gentamicin 4-6 mg/kg/day in 2-3 doses IV for 2-4 weeks.

Pseudomonas aeruginosa Carbenicillin 400 – 600 mg/kg/day in 4-6 doses (max 20 – 30 g) IV plus gentamicin 4-6 mg/kg/day in 2-3 doses, IV or piperacillin / ceftazidime + gentamicin .

Candida or aspergillus Amphotericin B – test dose : 0.25 mg/kg IV over 4- 6 hours gradually increasing upto 1mg/kg (max 50mg) per day. Mix with 5% dextrose in water in a concentration of 0.1 mg/ml plus 5 – fluorocytosine 150 mg/kg/day PO in 4 doses.

Culture negative ceftriaxone + gentamisin+ naficillin ( if staph suspected)

Serial Echocardiography recommendations

● Systemic candidiasis● Persistently positive blood culture esp.

if central line is inserted for parentaral nutrition

● Neonates with septicemia/DIC with cardiac murmur

Prognosis● Depends on:

– Early diagnosis– Status at the time of diagnosis– Effective treatment with appropriate

antibiotics● Mortality upto 60%

Acinetobacter Endocarditis● Acinetobacter- Gram negative pleomorphic coccobacilli ● Ubiquitous in environment and in hospital settings● Infections caused- Difficult to treat (ability to develop

resistance to antimicrobials) ● Has been found in various types of infections, a very few

case reports of native valve endocarditis has been reported in adults, but none in the neonatal group

● Acinetobacter vegetations are usually located on the surfaces of mitral and aortic valves (which is in contrast to our baby in which it was on the tricuspic valve)

Acinetobacter Endocarditis(cont.)

● An intravascular catheter is an important source of acinetobacter bacteremia and central venous catheter is an independent risk factor for NIE (both of which were lacking in our case)

● With regards to treatment, imipenum is the most active agent against acinetobacter (but in our case it was sensitive to colistin in all the samples and the baby responded to colistin as well)

Unique features of Fungal Endocarditis

Mostly involves neonates-Preterms(92%)Rt atrium-MC vegetation site (63%)MC cause-Central venous catheterisation (71%)Candida albicans-MC(59%)Surgery needed in 28% casesMedical treatment:

Amphotericin b-42.2%Fluconazole -2.8%AMB+Flucytocine -25.3%

Overall mortality-42.2%Total cases reported-71

Pediatr Infect Dis J.2015 Apr 30 (Epub)

Take home messageAll neonates with persistent or recurrent

sepsis in an intensive care setting should be worked up for IE

High risk of suspicion with early diagnosis and treatment may affect the outcome favorably

Thank you