BACTERIAL ENDOCARDITIS IN CHILDREN WITH HEART DISEASE

Abstract

We have reviewed the literature and our experience with 58 patients with bacterial endocarditis superimposed upon pre-existing heart disease, observed during the 30-year period, January 1930 through December 1959. There has been no change in the relative incidence of bacterial endocarditis in children with heart disease observed at the Babies Hospital since the introduction of antibiotics. Twenty-one patients (0.49/1,000 admissions) were observed from 1930 through 1943 and 37 patients (0.52/1,000 admissions) from January 1944 through December 1959. In the majority (40) infection was superimposed upon a congenital malformation of the heart, while in 17 there was evidence of rheumatic heart disease. In one, a rheumatic infection complicated a congenital anomaly. The history usually revealed unexplained fever and fatigue in a child known to have heart disease. Additional symptoms often reflected the nature of the underlying cardiac pathology. Patients with tetrad of Fallot developed symptoms secondary to hypoxia which in some instances was later shown to be attributable to vegetations at sites resulting in obstruction to pulmonary blood flow. The pathogenesis of bacterial endocarditis is defined in terms of bacteremia superimposed upon abnormal endocardial or endothelial surfaces; the further role of hemodynamic trauma secondary to congenital or acquired lesions is discussed. The results of bacteriologic studies were as vital in confirming the diagnosis and planning treatment as in the management of patients with meningitis. Blood cultures were usually positive in the first sample obtained (86%) and always by the sixth. Bacterial endocarditis is uncommon in the presence of sterile blood cultures providing an adequate number (six), each of sufficient quantity (10 ml), are obtained sufficiently long after antibiotics have been discontinued and providing they are incubated in aerobic and anaerobic media for 3 weeks. In children, the most important prognostic features were (1) recognition of the disease, (2) the nature of the infecting organism, and (3) adequate antibiotic treatment. In seven instances in our experience the correct diagnosis had not been considered prior to necropsy examination. Among the patients with bacterial endocarditis treated with antibiotics, recovery occurred in each of the 20 due to viridans streptococci, in 1 due to gamma-streptococci, and in 3 of the 8 due to Staphylococcus aureus. The principles of management are discussed and suggestions outlined for antibiotic therapy of children with bacterial endocarditis. Penicillin alone is recommended for infection due to viridans streptococci, if the organisms are highly sensitive, whereas for infection due to Staphylococcus coccus aureus a combination of chloramphenicol, erythromycin and penicillin is advocated as initial therapy. The importance of the use of antibiotics in therapeutic dosage for prophylaxis in patients with heart disease prior to dental manipulation or other surgical procedures is stressed.