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Bacterial Endocarditis in Neonates
and Lactating Infants

Robredo, Alberto; Wayar, Florencia;
Fuentes, Analia; Licudis, Carolina;
Le Favi, Jose; Lapasset, Maria; Pietronave, Mirian

Instituto de Enfermedades Cardiovasculares, Cordis, Salta, Argentina

SUMMARY
Introduction: The Bacterial Endocarditic (BE) is uncommon pathology in Neonates and Lactating Infants (NL), has problem with the diagnosis suspicion, with the bacteriology and with the differents treatments.
Objective: To analyze the characteristics of BE in NL.
Materials and Methods: All the BE in NL of the last 3 years were included. The diagnosis was made using Duke's criteria. The cardiac post surgery EB's were excluded.
Results: Six cases of BE were diagnosed in five NL. The average age of the diagnosis was 65,5 days (2 days to 8 months). Male sex: 3 (60 %). Five were pre-term new born. The tricuspid valve was affected in five cases and the mitral valve in one. None presented structural cardiac pathology. In five cases the BE was related to the presence of intracardiac catheters. The control Echocardiogram for child that was gravely ill produced the diagnosis in all cases. Positive hemocultures were obtained in five BE cases: 4 Klebsiella and 1 Candida. All received antibiotic treatment and the catheters were removed (in one case by cardiotomy). There was one death (BE on the mitral valve).
Conclusions:
1- BE in NL is an affection with scarce clinical suspect, with bacterial and predisposesing factors of its own.
2- The routine Echocardiogram of children suspected to have infection and that have intravenous catheters, is of great value for the diagnosis.
3- Antibiotic treatment with removal of the catheter is very effective in tricuspid BE.

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INTRODUCTION
   The Bacterial Endocarditic (BE) is uncommon pathology in Neonates and Lactating Infants (NL), has problem with the diagnosis suspicion, with the bacteriology and with the different treatments.

OBJECTIVE
   To analyze the characteristics of BE in NL. Different presentation, diagnostics way and treatments.

MATERIALS AND METHODS
   All the BE in NL of the last 3 years were included. The diagnosis was made using Duke's criteria. The cardiac post surgery BE's were excluded.

RESULTS
   Six cases of BE were diagnosed in five NL. The average age of the diagnosis was 65,5 days (2 days to 8 months). Male sex: 3 (60 %). Five were pre-term new born. The tricuspid valve was affected in five cases and the mitral valve in one. None presented structural cardiac pathology. In five cases the BE was related to the presence of intracardiac catheters. The control Echocardiogram for child that was gravely ill produced the diagnosis in all cases. Positive hemocultures were obtained in five BE cases: 4 Klebsiella and 1 Candida. All received antibiotic treatment and the catheters were removed (in one case by cardiotomy). There was one death (BE on the mitral valve).

DISCUSSION
   BE is a disease difficult to diagnose when it affects the N L. This is because it does not have clinical symptoms of its own and which therefore requires trained professional and adequate technology (Echocardiogram with Doppler colour, an advanced bacteriological laboratory, etc.) Which in a methodic and serial manner find the diagnostic criteria of the BE in a gravely ill child.

   From our experience and from the literature the very scarce frequency of cardiac malformations in the BE of the NL is clearly evident. The traumatic lesions of the vascular endothelium caused by intracardiac catheters is found in up to 80 % of the cases, being the most important etiopathogenic mechanism for the development of this type of BE, a figure which is in agreement whit our results. However, in our casuistic the tricuspid valve was the most frequently affected, followed by the mitral, valvular affections reported by the literature to occur infrequently. In five of our six cases the valvular trauma caused by the catheter were without doubt shown by the Echocardiogram including the BE on the mitral valve.

   The most frequent causative germs mentioned by the literature are Staphylococcus Aureus or Epidermis, followed by Candida Albicans and with less frequency by Enterococcus, Streptococcus sanguis and Streptococcus group B. In our bacteriology, with 83 % positive hemocultures, Klebsiella (four cases) predominated and one case of Candida. This variation can be to the types of germs that affect our intensive care units.

   The diagnosis of a neonate o lactate with probable or confirmed infections syndrome should be based on hemocultures or positive cultures of the catheter tips, with Echocardiograms that show the vegetations. In our experience this last method was crucial in the diagnosis as it showed the vegetation adhered to the cardiac valves. We must remember that differential diagnosis of the intracardiac masses and that the resolution of the method is 2 mm. The Echocardiogram should be made in a serial way so as to increase diagnostic sensibility, in our case indicated by finding that in two NL we had to repeat the study five times to reach the diagnosis. In all cases serial Echocardiograms should be made (one a week) until the clinical picture has been resolved.

   Adequate antibiotic treatment and catheter extraction were highly effective in our tricuspid BE's. When the antibiotic treatment is not able to control the infection and the catheter remains in place, all possible means of extraction should be studied (hemodynamic or surgical).

   The way to proceed with intravenous catheters that could not be removed from the NL after their use in and a symptomatic child, is an unresolved topic.

CONCLUSIONS

1- BE in NL is an affection with scarce clinical suspect, with bacterial and predispose sing factors of its own.
2- the routine Echocardiogram of children suspected to have infection and that have intravenous catheters, is of great value for the diagnosis.
3- Antibiotic treatment with removal of the catheter is very effective in tricuspid BE.
The way to proceed with intravenous catheters that could not be removed from the NL after their use in an a symptomatic child, is an unresolved topic.

 

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2nd Virtual Congress of Cardiology

Dr. Florencio Garófalo
Steering Committee
President
Dr. Raúl Bretal
Scientific Committee
President
Dr. Armando Pacher
Technical Committee - CETIFAC
President
fgaro@fac.org.ar
fgaro@satlink.com
rbretal@fac.org.ar
rbretal@netverk.com.ar
apacher@fac.org.ar
apacher@satlink.com

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