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Infective Endocarditis in Neonates

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Infective Endocarditis in Neonates Arch Dis Child: first published as 10.1136/adc.63.1.53 on 1 January 1988. Downloaded from Archives of Disease in Childhood, 1988, 63, 53-57 Infective endocarditis in neonates C O'CALLAGHAN AND P MCDOUGALL Department of Neonatology, Royal Children's Hospital, Melbourne, Australia SUMMARY Five patients with neonatal infective endocarditis were reviewed, two of whom survived. Infection was caused by Staphylococcus aureus in four and by Candida albicans in one. All cases of bacterial endocarditis had clinical signs of septicaemia, positive blood cultures, thrombocytopenia, microscopic haematuria, and heart murmurs. Three developed skin abscesses early in their illnesses. Three patients had two dimensional echocardiographic studies that showed bacterial vegetations. One of these studies was done before the heart murmur could be heard. We suggest that echocardiography in conjunction with the clinical picture described may help in making an early diagnosis of endocarditis in neonates. Bacterial endocarditis in neonates is a rare and and tracheal aspirates; he was treated with intra- usually fatal disease; the first survivor was reported venous vancomycin. in 1983.1 2We became interested in the disease after At 26 days of age the baby had not improved and two patients in our neonatal unit survived. We a systolic murmur could be heard. Echocardio- therefore reviewed all five cases of neonatal infec- graphy showed vegetation round the mitral valve. tive endocarditis seen at this hospital over the past Despite the addition of fusidic acid to his treatment 10 years to see if we could find similarities that could he continued to deteriorate and died at 28 days. lead to earlier diagnosis and treatment; this is the The diagnosis of vegetative bacterial endocarditis largest published series that we know of. due to methicillin resistant S aureus was confirmed at necropsy, together with lung changes consistent Case reports with bronchopulmonary dysplasia. There were also http://adc.bmj.com/ periventricular cystic changes and a cerebral CASE 1 haemorrhage. A boy weighing 1000 g was born by spontaneous vaginal delivery at 28 weeks' gestation. He required CASE 2 resuscitation after birth with endotracheal ventila- A girl weighing 2800 g was delivered by elective tion. Sodium bicarbonate and dextrose were given caesarean section at term. She required resusci- through a catheter in the umbilical vein. His Apgar tation with endotracheal ventilation. Sodium bicar- scores were 1 at one minute and 3 at five minutes. bonate and dextrose were administered through a on October 3, 2021 by guest. Protected copyright. He was transferred to this hospital. catheter in the umbilical vein. Her Apgar scores Initial management included mechanical ventila- were 1 at one minute and 9 at five minutes. tion, intravenous fluid replacement, and treatment She was slow to begin breast feeding and despite with penicillin and gentamicin. Vascular access the early passage of normal meconium she devel- catheters were inserted in the radial artery and a oped progressive abdominal distension. At 4 days of central vein. At 7 days of age a patent ductus age she underwent a laparotomy for severe necro- arteriosus was confirmed by two dimensional echo- tising enterocolitis of the entire colon. Treatment cardiography. The heart was structurally normal included penicillin, gentamicin, and metronidazole. and the baby was successfully treated with indo- Vascular access catheters were inserted in the radial methacin. artery and a central vein. No organisms were grown At 15 days of age he had an abscess over the left from cultures. posterior iliac spine; a full blood count showed A systolic murmur accompanied by congestive thrombocytopenia and analysis of the urine showed cardiac failure was heard postoperatively. An atrio- microscopic haematuria. Methicillin resistant ventricular canal was diagnosed by two dimensional Staphylococcus aureus was cultured from pus from echocardiography and she was treated with digoxin the abscess, and from the cerebrospinal fluid, blood, and diuretics. At 23 days of age, having received no 53 Arch Dis Child: first published as 10.1136/adc.63.1.53 on 1 January 1988. Downloaded from 54 Infective endocarditis in neonates antibiotics for seven days, she showed clinical signs respond. At 27 days of age a swab from a skin of septicaemia. S aureus was cultured from her pustule grew methicillin resistant S aureus; treat- blood and she was treated with flucloxacillin and ment with vancomycin and rifampicin was started. gentamicin. At 25 days of age she developed nodal At 28 days a pansystolic murmur was heard and rhythm and multiple supraventricular and ventri- two dimensional echocardiography showed a mobile cular arrhythmias. She died three days later despite vegetation attached to the papillary muscle of the full intensive care. mitral valve (fig 1). Fundoscopy showed four Necropsy showed vegetations on the pulmonary chorioretinal atrophic areas and computed tom- valve with extension into the main pulmonary ography of the brain showed several embolic areas. artery, which had ruptured. There was an atrio- Antibiotic treatment was continued for six weeks, ventricular canal and patent ductus arteriosus. The and echocardiography at 7 weeks of age showed no bowel showed necrotising enterocolitis and there evidence of vegetations. At discharge he had com- was an abscess in the loops of small bowel. pletely recovered with no obvious sequelae. CASE 3 CASE 4 A boy weighing 3100 g was born at term by A boy weighing 800 g was born at 26 weeks' spontaneous vaginal delivery following an uncom- gestation and transferred to this hospital shortly plicated pregnancy. His condition at delivery was after delivery. The mother's membranes had been good. He started breast feeding and was discharged ruptured for four days before delivery and there had when 5 days old. been a small antepartum haemorrhage. Apgar At 21 days he developed a fever, a generalised scores at birth were 6 at one minute and 9 at five rash, and malaise. Cultures of blood, swabs of the minutes. He was intubated, ventilated at low venti- skin lesions, and a specimen of urine aspirated lator settings, and treatment was started with peni- suprapubically grew S aureus that was sensitive to cillin and gentamicin. Initial cultures showed no gentamicin. A full blood examination showed a evidence of sepsis and his clinical condition was platelet count of 10 000x 109/l. Despite initial treat- consistent with hyaline membrane disease. ment with penicillin and gentamicin he failed to At 2 days of age an echocardiogram was done http://adc.bmj.com/ on October 3, 2021 by guest. Protected copyright. Fig 1 Two dimensional echocardiogram (apicalfour chamber view) showingpedunculated vegetation in left ventricle attached to papillary muscle. RA =right atrium; RV=right ventricle; TV=tricuspid valve; MV=mitral valve; LV=left ventricle; PV=pulmonary valve, and V= vegetation. Arch Dis Child: first published as 10.1136/adc.63.1.53 on 1 January 1988. Downloaded from O'Callaghan and McDougall 55 which showed normal cardiac anatomy and no biotics were continued for seven weeks, at which evidence of a patent ductus arteriosus. Methicillin time cardiac ultrasound scan showed a slight resistant S aureus was cultured from surface swabs. decrease in the size of the vegetation. He was At 8 days he developed persistent metabolic acidosis discharged when 12 weeks of age. When reviewed at and methicillin resistant S aureus was isolated from 12 months of age neurological and developmental blood cultures; he was treated with vancomycin, but examinations yielded normal results. A further on day 10 methicillin resistant S aureus was isolated echocardiogram showed that the vegetation had from a pustule on his chest. At 25 days, nine days disappeared. after the vancomycin had been stopped, he again developed metabolic acidosis, his white cell count CASE 5 was high, platelets were normal and methicillin A girl weighing 1500 g was delivered at 37 weeks' resistant S aureus was again isolated from blood gestation by caesarean section because of falling cultures. Clotting studies were normal and a chest oestriol concentrations in the mother's urine; she x-ray picture showed bronchopulmonary dysplasia. had had an antepartum haemorrhage at 32 weeks. Treatment with vancomycin and rifampicin was The infant's Apgar scores were 2 at one minute and started. A abscess developed on the left wrist and 5 at five minutes and she responded to three minutes another on the upper arm, and methicillin resistant of endotracheal ventilation. At 24 hours of age she S aureus was isolated from the pus. The cranial developed tachypnoea and became unwell. Cultures ultrasound scan was normal. Two dimensional of blood and cerebrospinal fluid grew S aureus and echocardiography, however, showed a peduncu- she was treated with flucloxacillin and gentamicin. lated vegetation in the left atrial appendage (fig 2). Her condition deteriorated and she developed dis- The methicillin resistant S aureus isolated from the seminated intravascular coagulation. An exchange blood cultures was sensitive to vancomycin, rifam- transfusion was carried out but her condition con- picin, and fusidic acid, but because of possible tinued to deteriorate and she required mechanical antagonism between vancomycin and rifampicin, ventilation. She developed severe cholestatic jaun- rifampicin was replaced by fusidic acid. dice, and acute hepatic necrosis was suspected. He was extubated at 7 weeks of age at which time Three further exchange transfusions were carried he became grossly oedematous with a serum albu- out; despite full intensive care she died at 19 days of min concentration of 19 g/l. This resolved after age. infusion of albumin and restriction of fluids. Anti- Necropsy showed peritonitis, pleurisy, peri- http://adc.bmj.com/ on October 3, 2021 by guest. Protected copyright. Fig 2 Echocardiogram ofa vegetation in left atrial appendage (long axis view). PV=pulmonary valve; LA =left atrium; RV=right ventricle; MV=mitral valve, and V=vegetation. Arch Dis Child: first published as 10.1136/adc.63.1.53 on 1 January 1988.
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