Andersons pediatric cardiology 1498

Endocarditis.
Implantablecardiacelectronicdevices(ICEDs)constitutepermanent
pacemakers(PPMs)andimplantablecardioverterdefibrillators(ICD);cardiac
resynchronizationtherapydevicesarerarelyusedinchildren.Lead-associated
endocarditis(LAE)isusuallyalatelead-associatedinfection(>6monthsfrom
timeoftheprocedure),whereastheearlylead-associatedinfections(<6months
fromthetimeofprocedure)areusuallypocketinfections.ThereisaUK2015
guidelineforthemanagementofICEDinfections.10
Incidence.
ICED-IEconstitutes10%ofalladultIEcases,17,225,226andthishasgradually
increasedfrombeing1%in1987–1993.226TheincidenceatwhichICEDsin
adultsbecomeinfectedisapproximately2%,or4.82/1000devicedays227;the
incidenceinICDsishigherthaninPPMsandforredoprocedureshigherthan
theinitialone.Risingincidenceshavealsobeenreported,butthishastobe
carefullyadjustedtotheconstantlyrisingnumberofimplantations.228,229
Causativeagents.
Morethan80%aregram-positiveIE,lessthan20%aregram-negativeIE.Itis
theonlyIEtypewherecoagulase-negativeStaphylococcus–relatedcasesareof
similarproportionasS.aureus–relatedcases.
Theclinicalpresentationisknowntobeatypical,anddiagnosismaybe
significantlydelayed.230

■Patientspresentingatlessthan1yearfromthe
implantationaremorelikelytohavepredominant
localsymptoms,whereasthosegreaterthan1year
withpredominantsystemicinfection.231
■Vegetationsonleadswerefrequentlyobservedin
patientswithonlylocalsymptoms,232andtherefore
echocardiographyisindicatedinallcasesofpocket
infections.
■Patientswithvegetationlessthan1cmmoreoften

tendtopresentclinicallyaspocketinfection,whereas
thosewithvegetationgreaterthan1cmassystemic
infection;CONScasesofIEareassociatedwith
largervegetations.233
Echocardiographycanbenegativeinhigherpercentagesthanintheother
typesofIE,234andtransesophagealechocardiographymightbeindicatedslightly
moreoften.PET/CThasmadesignificantimprovementtothepositiveyieldin
diagnosticprocessandimprovedthesensitivityofthemodifiedDuke
criteria.36–38
RiskfactorsforICED-IEvariedbetweenstudies235–237andaredescribedas
pyrexia24hoursbeforetheimplantation,precedingtemporarypacing,
reintervention,diabetes,useofmorethanonelead,andlargerhematoma.
Outcome.
Mortalityishighincasesofantibioticmanagementonlyandmaybegreaterthan
30%.CompleteICEDsystemremovalwithin2weeksfromLAEdiagnosis
improvessignificantlyoutcomestoamortalityofapproximately5%238,239to
becomesimilartothosewithoutIE.240Surgerycarrieshighrisk.Transcatheter
removalhasbecomethepreferredapproach.241–243Thevacuumsuctionof
thrombuspriortoremovalhasbeenestablishedinadultsbuthasnotbeen
availableforchildren.Opensurgicalremovalshouldbereservedforlarge(>20
mm)lead-associatedvegetationsorwhensurgeryisindicatedforotherreasons.
ResultsforchildrenwithLAEarelikelytobemuchmorefavorablethanthese
foradultsandshouldbepublishedseparately.
NeonatalInfectiveEndocarditis

■Mostoftenrelatedtocatheters
■Systemichypotension
■Signsofgeneralizedsepsis(feedingdifficulties,

respiratorydistressorapnea,tachycardia)
■Particularlypronetosepticembolization(focal


neurologicsigns,seizures,hemiparesis)and
developmentofsatelliteinfections(meningitis,
osteomyelitis,pneumonia)
■HigherproportionoffungalIE
■Oslernodes,Rothspots,Janewaylesions,and
splinterhemorrhagesarenotseen
Prophylaxis
ProphylaxisforDentalProcedures.
IEprophylaxishasdramaticallybeenchangedsince2002French,2007AHA,3
2008UKNationalInstituteofClinicalExcellence(NICE)244/update2016,5and
2009ESC/update20151recommendationsthatreducedtheindicationsforIE
prophylaxisasperthelackofscientificevidenceforitsefficacybeingwidely
accepted.Thebasistosupportthisrecommendationis:

■Thereisnoconsistentassociationbetweenhaving
aninterventionalprocedure,dentalornondental,and
thedevelopmentofIE.
■Regulartoothbrushingalmostcertainlypresentsa
greaterriskofIEthanasingledentalprocedure
becauseofrepetitiveexposuretobacteremiawithoral
flora.
■Theclinicaleffectivenessofantibioticprophylaxis
isnotproven.
■AntibioticprophylaxisagainstIEfordental
proceduresmayleadtoagreaternumberofdeaths
throughfatalanaphylaxisthanastrategyofno

antibioticprophylaxisandisnotcosteffective.