Predictors of definite and possible infective endocarditis in children with bacteremia: a reginal cohort study

Infective endocarditis (IE) in children is rare but potentially severe. Unlike adults, no pediatric-specific guidelines exist to guide echocardiography in children with bacteremia. We aimed to identify risk factors for IE in pediatric bacteremia and propose a selective, risk-based approach to echocardiographic evaluation. An 8-year prospective surveillance included all children (0-18 years) hospitalized with true bacteremia at Soroka University Medical Center between 2015 and 2022. A bacteremia episode was defined as the growth of a single organism during hospitalization. Episodes in which echocardiography was performed were included in the comparison between definite/possible IE, classified according to modified Duke criteria, and episodes in which IE was rejected. Among 2810 bacteremia episodes, echocardiography was performed in 573 (20%); 569 were analyzed. IE was classified as definite in 3/569 (0.5%) and possible in 228/569 (40.1%), while in 338 (59.4%) episodes, IE was rejected. Only 7/231 (3.0%) definite/possible IE cases had diagnostic echocardiographic findings. Independent predictors of IE included high-risk cardiac anomalies (prosthetic valve or material and cyanotic heart disease), prolonged bacteremia, Staphylococcus aureus bacteremia, and embolic or immunologic phenomena. Antimicrobial resistance, central venous catheters, and prior IE were not associated with an increased risk. Physical examination findings, including murmurs, did not differentiate IE from non-IE episodes.

The rate of definite IE in pediatric bacteremia was extremely low, and echocardiographic yield was limited. Echocardiography should be reserved for children with high-risk cardiac conditions, embolic or immunologic phenomena, or additional risk factors as persistent bacteremia particularly Staphylococcus aureus.

• Pediatric infective endocarditis (IE) is rare, particularly in children without high-risk cardiac anomalies. • Unlike in adults, there are no specific guidelines on when to perform echocardiography in children with bacteremia.

• Definite IE was very uncommon among children with bacteremia, and only 3% of definite/possible IE episodes had diagnostic echocardiographic findings. • IE was independently associated with high-risk cardiac anomalies, persistent and S. aureus bacteremia, but not with central venous catheters, antimicrobial resistance or prior IE.