Paeds · cardiology
Infective endocarditis
Also known as Infective endocarditis · Bacterial endocarditis · Subacute bacterial endocarditis · Prosthetic-valve endocarditis · Right-sided endocarditis · Culture-negative endocarditis · Native-valve endocarditis
Fellowship guide to infective endocarditis in children: a microbial infection of the endocardial surface, usually a heart valve, that presents as fever with a new or changing murmur, embolic phenomena or a sepsis-like illness in a child with or without underlying structural heart disease. The page covers the Modified Duke diagnostic criteria, the pivotal roles of blood culture and echocardiography, empirical and targeted antibiotic therapy for four to six weeks, the surgical triggers of heart failure, abscess and large mobile vegetations, and the prophylaxis strategy that now targets only the highest-risk cardiac lesions before dental and respiratory procedures.
On this page
Study tools
Your progress
Saved on this device.
Practise this topic
Target exams
Red flags
- A febrile child with a new or changing heart murmur has infective endocarditis until proven otherwise — take three sets of blood cultures from separate sites before starting antibiotics, and request echocardiography, because delaying cultures is the commonest reason the organism is never identified
- A child with infective endocarditis who develops acute pulmonary oedema, a loud regurgitant murmur or cardiogenic shock has acute valve destruction or a flail leaflet — this is a surgical emergency, because medical therapy alone cannot rescue catastrophic acute regurgitation
- A new prolongation of the PR interval or higher-degree atrioventricular block in a child with endocarditis means an aortic-root abscess has eroded into the conduction tissue — escalate to a cardiac surgery centre immediately, because abscess extension carries a high mortality and needs surgical debridement
- Staphylococcus aureus bacteraemia in a neonate with a central venous catheter, or in a child with an indwelling line, carries a meaningful risk of right-sided infective endocarditis — remove the line and image the heart, because persistent bacteraemia is both the clue and the danger
- A sudden focal neurological deficit or seizure in a febrile child with known structural heart disease is an embolic stroke from a vegetation until excluded — image and culture first, and avoid anticoagulation, because haemorrhagic transformation of a mycotic aneurysm is catastrophic
Life stages
Care settings
Clinical exam formats
Board mappings
- Infective endocarditis
- New murmur with fever in a child with heart disease
- Endocarditis prophylaxis for dental procedures
- Modified Duke criteria for infective endocarditis
- Prosthetic-valve and culture-negative endocarditis
- Surgical indications and complications of endocarditis
- Fever and a new murmur
- Staphylococcus aureus bacteraemia with a central line
- Embolic stroke in a child with congenital heart disease
- Short case: the changing murmur and peripheral stigmata
- Long case: endocarditis prophylaxis and follow-up
- Cardiology: infective endocarditis
- Cardiac emergencies and antimicrobial stewardship
- Acquired heart disease: infective endocarditis
- Modified Duke criteria and endocarditis prophylaxis
- Cardiovascular examination: peripheral stigmata of endocarditis
- Congenital heart disease complications
- Endocarditis prophylaxis
- Patient Care: acquired cardiac infection and antimicrobial therapy
- Medical Expert: infective endocarditis in children
The idea that organises the whole topic is that infective endocarditis is an infection of damaged or prosthetic endocardium, so the child with underlying congenital heart disease or an indwelling prosthesis sits at the centre of the risk pyramid, and the bedside job is to culture before treating and to treat long and hard. A febrile child with structural heart disease and a new murmur is not a viral illness until endocarditis is excluded, and a staphylococcal line infection that will not clear is right-sided endocarditis until the echo proves otherwise. [1] [6]
This page covers the recognition of the febrile child at risk, the Modified Duke diagnostic pathway with its reliance on blood culture and echocardiography, the empirical and targeted antibiotic regimens given for four to six weeks, the surgical triggers that separate salvageable from catastrophic disease, and the prophylaxis strategy that now narrows to the highest-risk cardiac lesions. It links to the congenital heart disease and rheumatic heart disease leaves for the substrate, and to the heart failure leaf for the consequences of acute valve destruction. [1] [7]
Overview & Definition
Infective endocarditis is an infection of the endocardial surface of the heart, most commonly the valve leaflets, by bacteria, fungi or other micro-organisms that settle on a nidus of platelet and fibrin. The American Heart Association childhood statement defines it as a microbial infection producing vegetations composed of platelets, fibrin, microcolonies of organisms and inflammatory cells, which adhere to the endocardium and may destroy underlying tissue or shower emboli into the systemic or pulmonary circulation. [1] [7]
The term replaced the older division into acute and subacute bacterial endocarditis, but the clinical contrast survives because it carries prognostic weight. Acute endocarditis is caused by virulent organisms, classically Staphylococcus aureus, and destroys valve tissue over days, producing acute regurgitation, heart failure and a sepsis-like presentation. Subacute endocarditis, caused by less virulent organisms such as the viridans streptococci, smoulders for weeks with low-grade fever, weight loss and the peripheral stigmata, and usually arises on pre-existing structural disease. [1] [6]
What makes the disease hard is that the early presentation is nonspecific and the child at risk is not always known. A teenager with unrecognised bicuspid aortic valve may present with weeks of fatigue and night sweats, and the cardiac cause is missed because the clinician chases the fever rather than the murmur. The discipline that catches these children is to listen carefully for a new murmur in any febrile child, to know which children carry the high-risk cardiac lesions, and to draw blood cultures before reaching for an antibiotic. [1] [12]
References12ShowHide
- [1]Baltimore RS; Gewitz M; Baddour LM; et al Infective Endocarditis in Childhood: 2015 Update: A Scientific Statement From the American Heart Association. Circulation, 2015.PMID 26373317
- [2]Baddour LM; Wilson WR; Bayer AS; et al Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications. Circulation, 2015.PMID 26373316
- [3]Wilson W; Taubert KA; Gewitz M; et al Prevention of infective endocarditis: guidelines from the American Heart Association. Circulation, 2007.PMID 17446442
- [4]Durack DT; Lukes AS; Bright DK New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service. Am J Med, 1994.PMID 8154507
- [5]Li JS; Sexton DJ; Mick N; et al Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis, 2000.PMID 10770721
- [6]Johnson DH; Rosenthal A; Nadas AS A forty-year review of bacterial endocarditis in infancy and childhood. Circulation, 1975.PMID 1116249
- [7]Habib G; Lancellotti P; Antunes MJ; et al 2015 ESC Guidelines for the management of infective endocarditis. Eur Heart J, 2015.PMID 26320109
- [8]Delgado V; Ajmone Marsan N; de Waha S; et al 2023 ESC Guidelines for the management of endocarditis. Eur Heart J, 2023.PMID 37622656
- [9]Pakotiprapha A; Chungsomprasong P; Vijarnsorn C; et al Risk of Infective Endocarditis in Pediatric Staphylococcal Bacteremia: A 20-Year Cohort Study. Pediatr Infect Dis J, 2026.PMID 42115837
- [10]Pinilla J; Baral B; Rosseto G; et al Infective endocarditis in patients with and without CHD: a meta-analysis of age-specific outcomes. Cardiol Young, 2026.PMID 41891166
- [11]Ondusko DS; Nolt D Staphylococcus aureus. Pediatr Rev, 2018.PMID 29858291
- [12]Habib G; Lancellotti P; Erba PA; et al The ESC-EORP EURO-ENDO (European Infective Endocarditis) registry. Eur Heart J Qual Care Clin Outcomes, 2019.PMID 30957862