International Journal for Doctor of Medicine and  Medical Students (IJDMMS)

Abstract

Healthcare-associated infective endocarditis (HAIE) is an increasingly significant pediatric population entity due to advances in medical care that have increased survival rates among children with complex chronic illnesses. The epidemiology, microbiology, and outcomes of infective endocarditis (IE) have changed because there is a greater risk of getting invasive procedures, prosthetic cardiac equipment, and long-term intravascular devices. This article reviews emerging trends in pediatric healthcare-associated infective endocarditis (HAIE) encompassing epidemiology, risk factors, microbial patterns, clinical presentation, diagnostic challenges, management, and prevention. Morbidity and mortality associated with HAIE remain high despite advances in further support and antimicrobial regimens. Prevention strategies, early diagnostics, and multidisciplinary management are vital to lower the burden of the disease.

Introduction :

Infective endocarditis (IE) is the life-threatening infection of the endocardial surfaces of the heart, including the cardiac valves and other implanted devices. Although previously associated with rheumatic heart disease and community-acquired bacteremia, pediatric IE epidemiology has changed greatly over the last decades. Improvements in pediatric cardiology, cardiac surgery, oncology, and neonatal intensive care have increased survival of children with congenital heart disease (CHD) and chronic conditions, thereby expanding the population at risk for health care-associated infections.

Healthcare-associated infective endocarditis (HAIE) denotes IE in patients with recent hospitalization, invasive procedures, indwelling vascular catheter use, prosthetic devices, or medical-care related exposure. HAIE accounts for approximately 25-30% of IE cases and is associated with a higher morbidity and mortality compared to a community-acquired disease.

In pediatric populations, the increased use of certain devices such as central venous catheters, prosthetic cardiac materials, and invasive interventions has shifted the etiological microbial agents from streptococci to staphylococci and device-related microbial agents. Emerging trends in pediatric HAIE should be well-studied for appropriate prevention and control measures.

This article aims to review current evidence regarding the epidemiology, risk factors, microbiology, diagnosis, treatment, and prevention of healthcare-associated infective endocarditis among pediatric patients.

Methods :

This study is a narrative literature review performed using medical databases that have been peer-reviewed.

Search Strategy :-

Literature was identified through searching:

Ø  PubMed

Ø  Google scholar

Ø   Pediatric infectious disease and cardiology journals

Keywords included:

Pediatric infective endocarditis, Health care-associated endocarditis, Nosocomial endocarditis, Infection in congenital heart disease, Infection with pediatric cardiac devices

Inclusion Criteria :-

l  Studies involving pediatric patients (<18 years)

l  Articles discussing healthcare-associated IE or hospital-acquired IE Studies describing epidemiological trends, microbiology, diagnosis, and outcomes

Exclusion Criteria :-

l  Adult only studies with no relevance to pediatrics

l   Single cases; no implications for pediatrics;

Risk Factors for Healthcare-Associated IE

Congenital Heart Disease

CHD presents in 60–90% of pediatric IE cases still remains the most significant risk factor. Turbulent blood flow and has surgical interventions make it easier for bacteria to colonize.

Invasive Medical Devices

Major ones include;

l  Central venous catheters

l  Intravenous access devices for prolonged use

l  Prosthetic cardiac valves Pacemakers and implantable cardiac devices

A device-related bacteremia has a major role in HAIE development.

Cardiac surgeries and interventions

Children on:

u  Prosthetic valve implantation

u  Patch repairs

u  Vascular graft procedures; have high chances of developing postoperative endocarditis.

Chronic Illness and Immunosuppression

Children with malignancy, renal disease or immunosuppressive therapy are particularly vulnerable.

Extended Hospital Stay

Intensive care admission and repeated hospital exposure increase colonization of resistant pathogens.

Microbiological Trends

There have been major changes in the microbial profile of pediatric HAIE.

Common pathogens

1.        Staphylococcus aureus (predominantly)

2.         Coagulase-negative staphylococci

3.         Viridans streptococci

4.        Enterococcus species

5.        Gram-negative bacteria are not common.

6.         Fungal pathogens for high-risk or postoperation patients

Healthcare exposure and device use have led to Staphylococcal species replacing streptococci as the dominant organisms.

The antimicrobial resistance, including methicillin-resistant Staphylococcus aureus (MRSA), is increasingly reported’ (Health knowledge, N.d.) in healthcare-associated cases.

Clinical Presentation

Clinical manifestations include;

l  Fever (most common symptom)

l  Heart murmur (new or changed)

l  Fatigue and body weakness

l  Loss of weight

l  Symptoms of heart failure

l   Embolic phenomena;

Right-sided endocarditis occurs more in children with congenital heart diseases than in adults.

Diagnostic Challenges

Diagnosis of HAIE in pediatric patients is difficult due to:

u  Nonspecific symptoms

u  Antibiotics that were given before Cardiac anatomy is complex.

u  Infections involving prosthetic devices

Diagnostic Modalities

Ø  Blood cultures (the gold standard)

Ø  Echocardiography (transthoracic and transesophageal)

Ø   Duke criteria (modified)

Ø  Advanced imaging if/when necessary (CT, MRI)

Prognosis is largely improved by early diagnosis.

Treatment and Outcomes

Medical Management

Standard treatment includes;

a.        Intravenous antibiotics over 4–6 weeks;

b.       Culture-directed therapy

c.        Combination therapy for resistant organisms

Surgical Management

Indications are:

I．Heart failure

II． Bacteremia (Persistent)

III．Large vegetation

IV．Infection of the prosthetic valve

V． Embolic complications.

Discussion:

  Emerging Trends in Healthcare-Associated Disease

Pediatric endocarditis used to be linked to rheumatic heart disease.. Now it is increasingly linked to healthcare exposure and surgeries.

Changing Microbiology

There is a rise in infective endocarditis cases. These cases involve:

* infections

* Multidrug-resistant organisms

* Fungal infections in kids with immune systems

More High-Risk Kids Surviving

Advances in medicine have helped more kids with complex diseases survive.. This also means they are more exposed to healthcare-related risks like hospital-acquired infections.

Better Diagnostic Tools

Improved imaging and microbiological techniques have helped doctors detect endocarditis more easily.

Challenges in Prevention

Doctors are now more careful with recommendations. They focus on heart conditions that can lead to infective endocarditis.

Ways to Prevent Infective Endocarditis

Important steps to prevent endocarditis include:

* Using techniques during catheter insertion and maintenance

* Removing devices early

* Following infection control protocols

* Implementing programs to use antibiotics wisely

* Giving antibiotics to selected high-risk heart patients

* Educating caregivers and healthcare staff

Healthcare-associated pediatric infective endocarditis can be partially prevented with infection-control practices.

Future Directions

Future research priorities include:

* Creating models to predict risk

* Developing therapies to fight infections

* Improving tests to diagnose endocarditis

* Technologies to prevent device infections

* Vaccination strategies to prevent endocarditis

Conclusion :

Healthcare-associated pediatric infective endocarditis is a growing challenge in pediatric medicine. Advances in healthcare have helped kids with diseases survive. However this has also increased their exposure to healthcare-related risks like endocarditis.

The types of infections causing endocarditis are shifting toward device-related and hospital-acquired infections. Staphylococci are becoming the cause of pediatric infective endocarditis.

Early diagnosis, targeted treatments, preventive strategies and care from specialists are crucial to reduce illness and death from infective endocarditis. We need to keep watching and researching to address the growing burden of healthcare-associated endocarditis, in kids.Despite advances, pediatric IE’s mortality remains within 5% to 16%, with the mortality rate being higher in the cases of healthcare-associated IE.

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