Andersons pediatric cardiology 1493

EndocarditisinSeverelyIllChildren
Antibiotics
UsualDose
Comments
NATIVEVALVE(COMMUNITYACQUIRED)ORLATEPROSTHETICVALVES(≥12MONTHS
POSTSURGERY)
Amoxycillin/ampicillin
200–300
Inpenicillinallergy,usevancomycinand
plus
mg/kg/dayin4–6
gentamicin.
divideddoses
InareasofhighriskofMRSAsomeauthorities
combineflucloxacillinwithvancomycinand
Flucloxacillin
200–300
gentamicinempirically.
plus
mg/kg/dayin4–6
divideddoses
Gentamicin
3mg/kgoncedaily
Vancomycin
40–60
Penicillinallergy
plusGentamicin
mg/kg/dayin
KnownMRSAorhighrisk
plusRifampicin
3–4divided

Consideraddingrifampicinwherethereisprosthetic
doses
valve/material
3mg/kgonce
daily
10mg/kg
twicedaily
EARLYPVE(<12MONTHSPOSTSURGERY)PLUSNOSOCOMIAL/HEALTHCARE–ASSOCIATED
NATIVEVALVEINFECTIONS
Vancomycin
40–60mg/kg/day
in3–4divided
doses
plusGentamicin
3mg/kgoncedaily
plusRifampicin
10mg/kgtwice
daily
plusadditionalgram240mg/kg/dayin3
negativecoversuchas
divideddoses
piperacillin/tazobactam
or
Meropeneminnosocomialor
20–40mg/kg/day
heathcare–associatedinfections in3divideddoses

Theseareguidelinesonly.Unitstreatingcasesofcomplexinfectiveendocarditisshouldhave
writtenpoliciesandprotocolsinplacespecificallytailoredforriskofcolonizationwithmultidrugresistantpathogenssuchasMRSA,ESBL,andampC-positiveEnterobacteriaceae(Coliforms)
andotherorganismssuchasPseudomonasaeruginosa.

Choiceofgram-negativeagentwilldependonknowncolonizationofpatientwithmultidrug
resistantEnterobacteriaceae(Coliforms)orprevalenceandtypeofresistanceseenin
units/institution
Wherethereisknownvancomycinintolerance,substitutewithdaptomycin.
Incasesofseveresepsiswithnosocomialinfection,considerusingamikacininsteadof
gentamicin.
ESBL,Extended-spectrumβ-lactamase;MRSA,methicillin-resistantStaphylococcusaureus;
PVE,prostheticvalveendocarditis.


SurgicalTreatment
SurgicalmanagementofIEhasbeenachallenge.105,106Advancesinsurgical
treatmentimprovedimmenselytheoutcomeofIE.Approximately50%ofadult
patientswithIEreceivesurgery106,107;thispercentageismuchhigherin
children.Inadults,almost25%ofthosewhorequiresurgerycurrentlydonot
undergosuch108;therearenosuchdatainchildren,butthispercentageis
certainlymuchlower.Perioperativemortalityinchildrenisapproximately10%.
Theoutcomesaremuchmorefavorableinchildhoodthaninadultsandreports
andrecommendationsshouldnotbemixed.
GuidelinesonInfectiveEndocarditisSurgery.
MostrecommendationsforIEsurgery,includingthoseintheESC2015IE
guidelines,theUSPediatric2015IEguidelinesandthesurgical2011,109and
updated2016GuidelinesoftheNorthAmericanSocietyofThoracicSurgeons
(STS),7arebasedonadultpatients.Therecommendationsaregenerally
extrapolatedforchildren.ThephilosophyofthecurrentpediatricIE
recommendation3isthatforpediatricpatientswithIE,thedegreeofillness
shouldnotbeconsideredalimitationtosurgicalinterventionbecausethe
alternative,todelayordefersurgery,canhavedireconsequences.
Therearedifferentscoringsystemsforriskassessmentinadults.TheSociety
ofThoracicSurgeonsriskscoreconsistingof13variables,110aswellasthe

embolicriskcalculator,111shouldnotbeusedinchildrenbecausetheyarenot
validatedforthiscohortofpatients.Therearenorandomizedcontrolstudiesin
pediatricIE.Theestablishmentofaninternationalcollaborationgroupon
pediatricIEisverynecessary.
CentersofInfectiveEndocarditisSurgery.
SurgeryforIEcarriesthegreatestriskofanyvalvesurgery,andoutcomesdiffer
widelyamongcentersandsurgeons.Thesurgeryshouldideallybecarriedoutin
high-volumecenters.Whereverpossible,apediatricendocarditisteamshouldbe
established,consistingofpediatriccardiologist,pediatriccardiothoracicsurgeon,
andaclinicalmicrobiologist/infectiousdiseasesspecialistwithaccessto
consultationwithapediatricneurologistandapediatricneurosurgeon.Because
pediatricIEismuchrarerthanadultIE,thenumberofcasesperpediatriccardiac
surgeonperyearissmallandaccumulatingexperienceisdifficult.


ObjectivesofInfectiveEndocarditisSurgery.
Surgicalobjectivesincludethefollowing:

■Radicalexcisionofallinfectedandnecrotictissue
andneighboringforeignmaterial.
■Repairofdefectscausedbydestructionanduseof
directsutureplicationorowntissue(autologous
pericardium)whereverpossible(useofartificial
chordsformitralvalverepairissafe).
■Replacementwhererepairisnotpossiblewith
attempttoavoiduseofartificialmaterialandgive
preferencetobiologicreplacementmaterial.
Ifpossible,theresectedmaterialshouldbesentforthefollowing:

■Microbiologyinvestigationwithdirectmicroscopy,

culture,andsensitivityandmolecularbroad-range
andorganism-specificPCR(thisallowsthecausative
organismtobefoundinsignificantproportionof
BCNE).112
■Histopathologyinvestigationforsignsof
inflammation,neovascularization,andorganisms.
Intraoperativeimagingshoulddesirablyincludepreoperativeand
postoperativeTEEor,ifnotpossible,epicardialechocardiography.Increasingly,
intraoperativephotographsarebeingusedfordocumentationandeducationof
patientsandfamilies.
Aftercompletedebridement,generousirrigationofthesurgicalfieldwith
normalsalineisrecommended;thebenefitofuseoflocalantimicrobialshasnot
beenproven.Drainageofneighboringareashouldbeappropriate.