Follow patients with Staphylococcal aureus bacteremia closely for development of a new murmur
Follow patients with Staphylococcal aureus bacteremia closely for development of a new murmur: Excerpt from Avoiding Common Pediatric Errors
Author:
Ellen Hamburger, MD
What to Do - Gather Appropriate Data
In the past several decades, S. aureus has become the primary pathogen responsible for infective endocarditis (IE). Improved dental care, hygiene, and
the growing incidence of nosocomial infections and intravascular devices are
associated with this bacteriologic shift. Among children with staphylococcal
bacteremia, as many as 20% develop endocarditis, including patients with
no predisposing cardiac valvular disease. Given this high complication rate,
any patient with staphylococcal bacteremia should be followed closely for
the development of a new murmur or other signs of endocarditis. Those
patients with a new or changed murmur should undergo echocardiography.
Persistent fever despite appropriate antibiotic therapy should also prompt
the search for cardiac involvement even when patients have other foci of
infection (such as skin) or the absence of clear signs of IE.
Definitive diagnosis of IE is made by pathologic or clinical criteria.
Pathologic diagnosis requires positive histology or microbiology of tissue
obtained at autopsy or cardiac surgery (valve tissue, vegetations, embolic
fragments, or intracardiac abscess content). Without pathologic material,
definitive clinical diagnosis can be difficult. Several sets of diagnostic criteria to evaluate patients for endocarditis have been developed. Studies have
verified that the most recent criteria, the Duke criteria, are superior to older
criteria for diagnosing infective endocarditis in children. The criteria are
based on the microbiology of endocarditis and evidence of endocardial involvement by exam or echocardiography.
Major criteria include:
1. Positive blood culture for IE
a. Two positive blood cultures with organisms that typically cause infectiveendocarditis(Viridansstreptococci,Streptococcusbovis,andHACEK
organisms–Haemophilus species, Actinobacillus actinomycetemcomitans,
Cardiobacterium hominis, Eikenella, corrodens, Kingella kingae)
b. Persistent bacteremia from two blood cultures taken >12 hours apart
or three or more positive blood cultures where the pathogen is less
specific, such as Staphylococcus aureus and Staphylococcus epidermidis
c. Positive serology for Coxiella burnetii, Bartonella species, or Chlamydia
psittaci
d. Positive molecular assays for specific gene targets
2. Positive evidence of endocardial involvement
a. Echocardiograph (transthoracic or transesophageal) showing oscillating mass, abscess formation, new valvular regurgitation, or dehiscence
of prosthetic valves
b. Clinical evidence of new valvular regurgitation
Minor criteria are:
3. Predisposing heart disease or intravenous drug use
4. Fever >38°C
5. Immunological phenomena such as glomerulonephritis, Osler nodes,
Roth spots, or positive rheumatoid factor
6. Microbiological evidence not fitting major criteria
7. Elevated C reactive protein or erythrocyte sedimentation rate
8. Vascularphenomenasuchasmajoremboli,splenomegaly,clubbing,splinter hemorrhages, petechiae, or purpura
By these criteria, a definite case of endocarditis is made when a patient
has positive pathologic criteria, two major criteria, one major and two minor
criteria, or five minor criteria. Possible cases are those with one major and
one minor criteria, or three minor criteria.
In summary, clinicians following patients with Staph A bacteremia must
be vigilant for signs of infective endocarditis, knowledgeable in the Duke
criteria for diagnosis, and aware that more than one fourth of these patients
do not have underlying cardiac or valvular abnormalities.
Suggested Readings
Beynon RP, Bahl VK, Prendergast BD. Infective endocarditis. BMJ. 2006;333(7563):334–339.
Di Filippo S, Delahaye F, Semiond B, et al. Current patterns of infective endocarditis in
congenital heart disease. Heart. 2006;92(10):1490–1495.
Friedland IR. du Plessis J, Cilliers A. Cardiac complications in children with Staphylococcus
aureus bacteremia. J Pediatr. 1995;127(5):746–748.
Hoen B. Epidemiology and antibiotic treatment of infective endocarditis: an update. Heart.
2006;92(11):1694–1700.
Prendergast BD. The changing face of infective endocarditis. Heart. 2006;92(7):879–885.
Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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