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Published on: January 27, 2023
Transthoracic echocardiography in children with Staphylococcus aureus bacteraemia: a multi-centre retrospective
Kirsty Gray1,2, Farhana Ahad1, Aubrey Cunnington3,2
1Department of Paediatric Infectious Disease, West London Children's Healthcare, London, UK.
Insights
A risk-stratified approach to transthoracic echocardiography (TTE) is recommended for children with Staphylococcus aureus bacteraemia (SAB). TTE may be omitted in low-risk children, reserving it for those with specific clinical indicators of infective endocarditis (IE).
Area of Science:
- Pediatric Cardiology
- Infectious Diseases
- Medical Imaging
Background:
- Staphylococcus aureus bacteraemia (SAB) poses a risk for infective endocarditis (IE), a rare condition in children without known risk factors.
- Routine transthoracic echocardiography (TTE) is frequently used in pediatric SAB cases, despite limited evidence supporting its universal application.
Purpose of the Study:
- To evaluate the utility of TTE in diagnosing infective endocarditis (IE) in children with Staphylococcus aureus bacteraemia (SAB).
- To determine criteria for a risk-stratified approach to TTE in pediatric SAB.
Main Methods:
- A multi-center retrospective cohort study involving 101 children (≤18 years) with SAB across six London hospitals (2018-2023).
- Data were collected from electronic patient records, comparing outcomes between children who underwent TTE and those who did not.
Main Results:
- Infective endocarditis (IE) was confirmed in 5.6% of children who underwent TTE, all with pre-existing risk factors.
- Children undergoing TTE had significantly longer hospital stays (median 17 vs 4 days).
- Features associated with IE in the TTE group included embolic phenomena, persistent bacteraemia, and polymicrobial blood cultures.
Conclusions:
- A universal TTE approach in pediatric SAB is not supported; a risk-stratified strategy is recommended.
- TTE can be omitted in children without cardiac risk factors or suggestive clinical signs.
- TTE should be considered for children with embolic phenomena, persistent bacteraemia, polymicrobial growth, murmurs, or known IE risk factors.
Background:
Staphylococcus aureus bacteraemia (SAB) is associated with risk of infective endocarditis (IE). IE is rare in children in the absence of known risk factors such as congenital heart disease. Routine transthoracic echocardiography (TTE) is often performed in children with SAB despite limited age-specific evidence.
Methods:
This multi-centre retrospective cohort study included 101 children (aged ≤18 years) with SAB across six North West London hospitals (2018-2023). Data were collected from electronic patient records.
Results:
71 children (70%) underwent TTE and 30 (30%) did not. IE was confirmed in four (5.6%) of those undergoing TTE. All four IE cases were right-sided and occurred in children with established risk factors: congenital heart disease (2/4), intravenous drug use (1/4) or central venous catheters (2/4). The TTE group had longer hospital stays than the no-TTE group (median 17 vs 4 days, p=0.0020). Acute in-hospital mortality occurred in 1/71 of the TTE group vs 0/30 of the no-TTE group (p=1.0). Among children undergoing TTE, features associated with IE included embolic phenomena (75% vs 1.5%, p<0.001), higher CRP (median 237 vs 124 mg/L, p=0.083), persistent bacteraemia at >72 hours (67% vs 4.9%, p=0.018) and polymicrobial growth on blood culture (50% vs 6%, p=0.033).
Conclusion:
Our findings support a risk-stratified rather than universal approach to TTE in paediatric SAB. TTE could reasonably be omitted in children with a structurally normal heart, no established IE risk factor and no clinical feature suggestive of IE, but should be performed when embolic phenomena, persistent bacteraemia, polymicrobial growth, a pre-existing murmur or an established IE risk factor is present. Prospective multi-centre validation is needed before such an approach can be adopted in routine practice.
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