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Table of contents
1. Prevention of infective endocarditis in the pediatric congenital heart population......................................... 1

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Document 1 of 1

Prevention of infective endocarditis in the pediatric congenital heart population

Author: Estlow, Margaret M
ProQuest document link
Abstract (Abstract): In 1997, the American Heart Association updated recommendations for the prevention of
sub-acute bacterial endocarditis (SBE) or infective endocarditis (IE) occuring in the pediatric population with
congenital heart disease.
Abstract: In 1997, the American Heart Association updated recommendations for the prevention of sub-acute
bacterial endocarditis (SBE) or infective endocarditis (IE) occurring in the pediatric population with congenital
heart disease (Dajani, et al., 1997). Although uncommon, endocarditis remains an important cause of morbidity
and mortality in children with cardiovascular disease, which constitutes the primary population at risk. Through
comprehensive discharge planning and teaching, the advanced practice nurse (APN) and the pediatric
cardiovascular nurse may contribute significantly toward preventing IE in this population. Nursing's role and
responsibility is to convey the appropriate information to patients, families, and the staff who care for children
with heart disease.
Links: FullText?
Full text: Headnote
In 1997, the American Heart Association updated recommendations for the prevention of sub-acute bacterial
endocarditis (SBE) or infective endocarditis (IE) occurring in the pediatric population with congenital heart
disease (Dajani, et al., 1997). Although uncommon, endocarditis remains an important cause of morbidity and
mortality in children with cardiovascular disease, which constitutes the primary population at risk. Through
comprehensive discharge planning and teaching, the advanced practice nurse (APN) and the pediatric
cardiovascular nurse may contribute significantly toward preventing IE in this population. Nursing's role and
responsibility is to convey the appropriate information to patients, families, and the staff who care for children
with heart disease.
nfective endocarditis (IE) or subacute bacterial endocarditis (SBE) is a major area of concern for the child with a
congenital heart defect (CHD). IE constitutes less than 0.2% to 0.5% of all pediatric admissions, yet it remains
an important cause of morbidity and mortality (about 10%) in children with cardiac malformation (Curran,
Moulton, &Mavroudis, 1994; Dajani, 1993; Newberger, 1992). Although a relatively rare problem considering the
number of patients at risk, IE continues to have a disproportionate influence on clinical practice and is one of the
most feared complications of structural heart disease (Kaplan Shulman, 1989).
Nurses working with the pediatric congenital heart population need to remain diligent by giving high priority to
infective endocarditis discharge teaching in both the pre and post repair congenital heart patient. Knowing the
information children and families need and understanding the updated recommendations from the American
Heart Association (Dajani et al., 1997) can enable nurses to improve quality of patient education in children
requiring endocarditis prophylaxis.
Definition
Infective endocarditis (IE) is an inflammatory process of valve, endocardium, or endothelium, resulting from
infection from a bacterial or fungal agent, occurring almost exclusively in individuals with pre-existing anatomic
abnormalities of the cardiovascular system (Curran et al., 1994; Dajani, 1993; Hazinski, 1992; Newberger,
1992). At one time, convention dictated that IE be classified as acute or subacute. Although many clinicians
continue to use this terminology, classifying the disease based upon the microorganisms involved is more
meaningful. For example, Ahemolytic streptococci almost always causes a prolonged subacute form of the
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illness; staphylococcus aureus, streptococcus pneumoniae, or BHemolytic streptococci are usually associated
with a more virulent or "acute" clinical illness (Kaplan Shulman, 1989). Because the newer classification is
based on microbiologic etiology rather than description, a general term of IE is the more widely accepted term
today (Friedman Stark, 1990).
Epidemiology
The incidence of IE in children ranges from 0.22 to 0.78 cases per 1000/year hospital admissions and appears
to be rising (Dajani, 1993). Over the past two decades, the incidence of IE has gradually increased principally
due to improvements in congenital heart surgery, the patient population at greatest risk for developing the
disease (Curran et al., 1994; Dajani, 1993; Kaplan &Shulman, 1989; Newberger, 1992). However, it must also
be noted that the use of indwelling catheters, immunosuppression medications, improved care of critically ill
neonates, and widespread IV drug abuse among older children have led to an increase in the incidence of IE in
structurally normal hearts (Curran et al., 1994; Wells, 1989).
Reported mortality rates for IE have decreased significantly from the pre-antibiotic era rate of virtually 100% to
the 20% rate today (Curran et al., 1994; Dajani, 1993). But the ultimate consequences, including morbidity and
mortality, which are principally related to the complications of the infection (Curran et al., 1994), and the
expenses associated with prolonged and often intense medical and surgical therapy, remain formidable (Kaplan
&Shulman, 1989).
Although the incidence of IE varies with specific cardiac lesions, virtually any congenital heart defect may
predispose a child to develop IE (Dajani, 1993; Friedman &Stark, 1990; Newberger, 1992). The children at
highest risk are those with cyanotic heart disease (e.g., tetralogy of Fallot, pulmonary atresia [PA], tricuspid
atresia [TA]), ventricular septal defect [VSD] with aortic regurgitation or obstruction, aortic stenosis [AS], patent
ductus arteriosus [PDA], and coarctation, as well as children with prosthetic heart valves, systemic-pulmonary
shunts, and those who have recently undergone cardiac surgery (Kaplan &Shulman, 1989; Curran et al., 1994;
Newberger, 1992).
Clinicians recognize that endocarditis can affect children of all ages with underlying cardiovascular disease.
Although relatively uncommon, IE can occur in infants and young children, but most cases appear to occur
among older children. An extensive review of the literature in the pediatric age group revealed that almost half
of the children with endocarditis were 10 years of age or older (Curran et al., 1994; Kaplan &Shulman, 1989).
Reports in the literature indicate a wide disparity regarding IE in children. Most large studies are retrospective
and do not report the total number of admissions to institutions during study periods. Studies conducted from
1952-1982 by various children's hospitals in North America found large discrepancies in the numbers of children
admitted for IE (Friedman Stark, 1990). Much has been written about the epidemiology of IE, yet documentation
of epidemiologic trends has been somewhat imprecise. This has been related to two deficiencies:
(a) the lack of adequate data about the size and specific characteristics of the population at risk, and (b) the lack
of conclusive documentation of the diagnosis. Furthermore, because relatively few cases are seen in any one
institution, many authors have combined their clinical experience over several decades. This frequently has
resulted in obscuring epidemiologic trends (Kaplan &Shulman, 1989).
In reviewing the following studies, the reported overall risk in the congenital heart population for developing IE
ranges from 0.9%-9.7%. Shah, Singh, Rose, and Keith (1966) determined the lifetime risk of developing IE in an
unrepaired simple VSD was 12%-13%. Steeg, Marmer, Varmer, and Blumenthal (1970) found the risk was 3.2%
over the first decade of life. In a large cooperative study on the natural history of unoperated VSD, AS, and
pulmonary stenosis (PS), Gersony and Hayes (1977) reported a risk of 9.7% of patients developing IE by the
age of 30. However, if the patient underwent surgical repair, the incidence was much lower, except in patients
with AS in which the risk slightly increased to 1.4% (Friedman &Stark, 1990).

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In a study of 266 children, tetralogy of Fallot accounted for the largest percentage of patients with CHD who
developed IE (Kaplan, 1977). Similar findings are reported in studies from South Africa (Rose, 1978), New York
City (Blumenthal, Griffiths, &Morgan, 1960), and France (Bayer, 1982). VSD was the second most common
lesion, accounting for 16% of the group, followed by AS (8%), PDA (7%), and TGA (4%) ((Friedman &Stark,
1990). However, other studies reported that VSD (Yokochi, Sakamoto, Mikajima, &Ichinose, 1986; Johnson
&Rhodes, 1982) and aortic valve disease (Auger, Marquis, Dyrda, &Martineau,1981) were more common predisposing factors. The most common lesions found in patients with CHD who developed IE after surgery were
tetralogy of Fallot and transposition of the great arteries (TGA) with PS (repaired with a systemic-pulmonary
shunt) (Curran et al., 1994; Friedman &Stark, 1990).
A smaller study from Yale-New Haven hospitals found a higher incidence of IE in patients with CHD who had
not undergone surgery than in those who had (Stanton, Baltimore, &Clemens, 1984). Acyanotic lesions were
more common in the nonsurgery group; cyanotic lesions predominated in the postoperative group. Dacron(R)
patches and Gore-Tex(R) were more common sites of infection than prosthetic valves (Friedman &Stark, 1990).
Commenting on the above studies, Friedman and Stark (1990) suggest that the large differences in findings are
due to the complexity of the disease.
Pathophysiology
In most instances of endocarditis, two pre-existing conditions are present: (a) a congenital lesion of the heart or
great vessels, and (b) an infective agent in the blood stream (Dajani, et al., 1990; Kaplan, &Shulman, 1989;
Newberger, 1992). Furthermore, certain cardiac conditions are more often associated with endocarditis than
others (Dajani et al., 1990). For instance, lesions leading to a high velocity of blood flow through a heart valve,
septal defect, or blood vessel are associated with increased susceptibility to endocarditis (Newberger, 1992).
Virtually all vegetations occur in areas where there is a pressure gradient. The pressure gradient causes a
hydrodynamic effect, which leads to turbulence against either the vascular endothelium or endocardium and
results in tissue damage (Kaplan &Shulman, 1989). Vegetation usually forms on the low pressure side of the
defect, where endothelial damage is established by the jet effect of the defect (Friedman &Stark, 1990). The
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turbulent blood flow results in tissue damage with disposition of platelets, fibrin, and thrombus formation.
Circulating bacteria get trapped in this thrombus, becoming the focus of the IE (Curran et al., 1994; Dajani,
1993; Friedman &Stark, 1990; Hazinski, 1992; Newberger, 1992). Growth of the fibrin and platelet deposition
results in the formation of a nonbacterial thrombotic vegetation (NBTV), which is essential in the pathogenesis
of endocarditis. Transient bacteria that occur as a normal part of daily life may cause colonization of the NBTV.
As the NBTV grows, adherence of the bacteria occurs and an infected vegetation develops (Friedman &Stark,
1990).
Transient bacteremias occur frequently in human beings, particularly during surgical or dental procedures and
instrumentation involving mucosal surfaces or contaminated tissues (Dajani, 1993). Blood-borne bacteria may
lodge on damaged or abnormal heart valves, on the endocardium, or on endothelium near congenital anatomic
defects, resulting in IE (Dajani et al., 1990). The ability of microorganisms to adhere to endocardial epithelial
cells or to intravascular fibrin-platelet deposits is the critical first step in the development of IE. Those bacteria
that most frequently cause IE can be shown experimentally to adhere more readily to normal aortic valve
leaflets than do other organisms (Dajani, 1993). Moreover, specific products of these adherent bacteria
enhance their ability to colonize the endocardium and fibrinplatelet deposits (Dajani, 1993). Additionally,
endocarditis producing streptococci and staphylococci are potent stimulators of platelet aggregation, an action
that enhances the formation of vegetation (Dajani, 1993).
Specific dental and surgical procedures are much more likely to initiate a bacteremia that results in IE, with
dental procedures constituting the most frequent antecedent event prior to IE (Dajani et al., 1990; Newberger,
1992; Zales &Wright, 1997). Among the most potentially dangerous inducers of bacteremia is extraction of an
abscessed tooth and dental cleaning, where a subsequent bacteremia may reach 80%. In one study, 155
strains of bacteria were isolated from 100 patients undergoing extraction or cleaning (Kaplan &Shulman, 1989).
In addition to dental procedures, other surgical procedures followed by bacteremia have been associated with
IE. Such procedures include cardiac surgery, tonsillectomy, bronchoscopy, ventriculoatrial shunts for
hydrocephalus, urologic surgery, placement of urinary and dialysis catheters, and a very minute percentage of
cardiac catheterization (Dajani et al, 1990; Newberger, 1992).

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Infectious foci outside the heart may be the origin of bacteremia leading to IE. Among such lesions are
infections of the skin (boils), pneumonia, acute pyelonephritis, sinusitis, osteomyelitis, sepsis, burns, and those
resulting from IV drug abuse (Newberger, 1992). Although bacteremia is common following many invasive

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procedures, only a limited number of bacterial agents cause IE (Dajani et al., 1990). Approximately 80%-90% of
reported cases of endocarditis are caused by gram-positive bacteria, principally streptococcus viridans and
staphylococcus aureus (Curran et al., 1994; Dajani, 1993; Dajani et al., 1990; Friedman &Stark, 1990; Hazinski,
1992; Kaplan &Shulman, 1989; Newberger, 1992; Zales &Wright, 1997). Although streptococcus is most
commonly responsible for IE (Hazinski, 1992), currently in the pediatric age group, staphylococcus aureus now
accounts for approximately one fifth of all cases, essentially among patients without preexisting heart disease
(Newberger, 1992). However, fungi, chlamydia, rickettsiae, and viruses may also be causative agents of IE in all
patients (Dajani, 1993).
Clinical Manifestations/ Diagnosis

Clinical presentation of patients with IE is highly variable and may simulate many other diseases. The spectrum
of presentation varies from acute sepsis to nonspecific changes. IE should be suspected in any child with an
underlying cardiac condition who presents with either unexplained fever or deterioration in cardiac function
(Dajani, 1993).
Fever is the most common finding (present in about 65%-87% of cases), along with nausea, vomiting, irritability,
malaise, anorexia, abdominal pain, arthritic symptoms, splenomegaly, appearance of a new murmur, petechiae,
and fatigue. Patients with IE may also present with other serious complications such as congestive heart failure,
stroke, or pulmonary or renal infarction (Curran et al., 1994; Dajani, 1993; Friedman &Stark, 1990; Kaplan
&Shulman, 1989; Newberger, 1992; Zales &Wright, 1997).
Clinical presentation may vary with the causative organism. Streptococcus viridans and staphylococcus
epidermis may present with only mild symptoms. Staphylococcus aureus and streptococcus pneumoniae may
be more acute, leading to a virulent picture. The clinical presentation also may vary with the site of infection.
Acute aortic valve IE may lead to severe aortic insufficiency with congestive heart failure, while mitral valve
endocarditis may lead to only mild mitral valve dysfunction but systemic embolization (Zales &Wright, 1997).
The diagnosis of IE requires first that the clinician have a high index of suspicion. Diagnosis of IE includes (a)
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pathologic evidence (CHD, cardiac surgery, echocardiogram), (b) at least two sets of blood cultures obtained by
separate venipuncture positive for the same organism with no source of bacteremia other than the heart, or (c)
or when IE is highly suspected based on presenting symptoms. Any patient with CHD who has a fever without
an obvious cause should be suspected of having IE, and blood cultures should be part of the initial work-up.
Serial blood cultures, two to six specimens obtained over 48 hours, have been shown to confirm the diagnosis
in 95% of cases (Zales &Wright, 1997). Children with CHD are at increased risk for IE; therefore, even when an
obvious source for a prolonged fever (e.g., pneumonia, UTI) has been identified, clinicians should still obtain
blood cultures to exclude the possibility of bacteremia leading to simultaneous IE (Curran et al., 1994).
Treatment
A good prognosis for the child with IE is clearly linked to establishing a prompt diagnosis and initiation of
antibiotic therapy (Zales &Wright, 1997). Empiric antibiotic therapy with penicillin and an aminoglycoside should
be initiated after three blood cultures have been obtained if there is a strong suspicion of IE. If possible,
antibiotic therapy should be based on the cultural sensitivities. The effectiveness of therapy should be confirmed
by tests of serum bactericidal activity (CBC w/diff, ESR) and the demonstration of adequate serum antibiotics.
The duration of therapy depends on the patient's response and the organism involved (Curran et al., 1994).
Selection of the appropriate antimicrobial agent(s) is critical for the successful management of IE.
Several general principles provide a basis for the current recommendations for treatment. Preferred regimens
include (a) parental therapy, especially in infants and children; (b) prolonged course, usually 4-6 weeks or
longer; (c) bactericidal agents; and (d) synergistic combinations, when applicable (Dajani, 1993). The need for
surgery for patients with IE generally indicates a failure of medical therapy. Persistent infection, despite
antibiotic therapy, has been cited as the most common indication for surgery, followed by resulting valvular or
other structural abnormalities after IE eradication (Curran et al., 1994).
Prevention
The American Heart Association (AHA) issued new guidelines for the prevention of IE in 1997 (Dajani et al.,
1997). These recommendations were formulated and prepared by an ad hoc writing group appointed by the
AHA with liaisons representing the American Dental Association, the Infectious Diseases Society of America,
the American Academy of Pediatrics, and the American Academy of GI Endoscopy.
Although the efficacy of currently recommended antibiotic prophylaxis has never been studied in man (Dajani,
1993; Friedman &Stark, 1990; Newberger, 1992), epidemiologic data provide several justifications for
endocarditis prophylaxis (Dajani, 1993; Kaplan &Shulman,1989). The updated AHA recommendations reflect
analyses of relevant literature regarding procedure-related endocarditis, in vitro susceptibility data of pathogens
causing endocarditis, results of prophylactic studies in animal models of endocarditis, and retrospective
analyses of human endocarditis cases in terms of antibiotic prophylaxis usage patterns and apparent
prophylaxis failures (Dajani et al., 1997). Because it is impossible to predict which child will develop IE or which
particular procedure will be responsible, prophylactic antibiotics are recommended for children at risk for
developing IE who are undergoing those procedures most likely to produce bacteremia with organisms that
commonly cause IE (Dajani et al., 1990).
Major changes in the updated recommendations include the following: (a) an emphasis that most cases of IE
are not attributable to an invasive procedure; (b) stratification of cardiac conditions into high, moderate, and
negligible risk categories based on potential outcome if endocarditis develops; (c) clarification regarding
procedures that may cause bacteremia and for which prophylaxis is recommended; (d) development of an
algorithm to more clearly define when prophylaxis is recommended for patients with mitral valve prolapse; (e)
reduction of the initial amoxicillin dose for oral/dental procedures to 2 g, with a follow-up antibiotic dose no
longer recommended; (f) elimination of erythromycin as the recommended antibiotic for penicillin-allergic
individuals, with clindamycin and other alternatives offered; and (g) simplification of the prophylactic regimens
for GI/GU procedures. These changes were instituted to more clearly define when prophylaxis is or is not
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recommended, improve practitioner and patient compliance, reduce cost and potential GI side-effects, and
approach more uniform world-wide recommendations (Dajani et al., 1997). Tables 1-5 provide IE
recommendations and nonrecommendations for cardiac conditions and dental and surgical procedures from
these most recent American Heart Association guidelines. The guidelines are meant to aid practitioners, but are
not intended as the standard of care for all cases or as a substitute for clinical judgment. They serve only to
supplement practitioners in the exercise of their clinical judgment. It is impossible to make recommendations for
all clinical situations in which IE may develop.
Practitioners must exercise their own clinical judgment in determining the choice of antibiotics and number of
doses administered in individual cases or special circumstances (Dajani et al., 1990; Dajani et al., 1997). In
addition to prophylactic regimen for genitourinary procedures, antibiotic therapy should be directed against the
most likely pathogen. In patients who have prosthetic heart valves, a previous history of IE, or surgically
constructed systemic-pulmonary shunts or conduits, physicians may choose to administer prophylactic
antibiotics even for low-risk procedures that involve the lower respiratory, genitourinary, or gastrointestinal tracts
(Dajani et al., 1990).
There are special situations in which the above recommendations may not apply. Surgical procedures through
infected tissues require antimicrobial therapy directed against the most likely pathogen. Children who are
receiving penicillin prophylaxis for prevention of rheumatic fever recurrence may have A-streptococci in their
oral cavities that are relatively resistant to penicillins. In such cases, an agent other than amoxicillin should be
selected for IE prophylaxis. Finally, prophylaxis is recommended for patients who undergo open heart surgery,
but such prophy]axis should be aimed primarily against staphylococcus. A first-generation cephalosporin or
vancomycin is a reasonable choice, but should only be used postoperatively and for a short duration (Dajani,
1993).
Nursing's Role in Patient Education
Patient education has become an integral part of health care delivery and is now considered a necessary
component of the health care experience rather than a luxury (Rosenblum, 1994). Nurses involved in direct
patient care are expected to balance the competing roles of patient/family educator, direct care provider, patient
care planner, and supervisor of professional and non-professional staff (Hamric &Spross, 1989).
Similarly, educational responsibilities are a traditional part of the advanced practice nurse (APN) role, and
commonly is considered to be an element of expert practice. Because the education focus of the staff nurse and
APN is primarily on the child and family, the educator subrole of the APN tends to overlap with the functions of
the staff nurse (Hamric S Spross, 1989). However, one characteristic separates the APN from other educators:
the ability to perform several roles requiring multiple skills and competencies, often teaching children/families,
staff, and students simultaneously. The APN's education role includes formal and informal teaching of staff
nurses and graduate and undergraduate students in nursing and other disciplines. The informal teaching
strategies are sometimes augmented by the development of structured educational resources such as patient
education pamphlets and unit-based classes. This is important in that the APN may act as a consultant to
determine patient teaching needs and then provide the teaching while acting as a role model for staff nurses
and students (Hamric Spross, 1989).
Stafford commented in an account of the APN role that "Every nurse is a teacher; not to teach is not to nurse"
(Hamric S Spross, 1989). Because IE prophylaxis is such an important element of patient education in the
pediatric congenital heart population, both staff nurses and APNs are in advantageous positions to provide a
quality teaching plan to patients and their families.
Discussion of the Teaching Plan
A teaching plan outline is provided in Table 6; an in-depth discussion of the plan follows.
I. Teaching Plan: Incorporate patient education into a plan of care.
Health care accrediting agencies such as the Joint Commission on the Accreditation of Healthcare
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Organizations (JCAHO) have recently mandated that patient education be included in patient care planning
(JCAHO, 1992).
A. Assessment of patient/parent knowledge about IE prophylaxis: Studies have found that a recurring theme of
the child who is hospitalized is a parent's need for information. Specifically, parents express the need to
understand very complex information about treatment plans, the seriousness of their child's illness, expected
length of stay, purpose and nature of procedures their child will experience, expected outcomes, and how they
can participate in their child's care. Research findings indicate that providing information reassures, confirms,
informs, and assists parental coping (Snowdon &Kane, 1995).
Assessment of knowledge level in patient teaching is directly related to compliance. Parents/children's reading
ability must be evaluated: What level of education have parents experienced, and can they read?
Comprehension of the information involves understanding the meaning of what is read, not just recognizing the
words. Listening comprehension is an important aspect of learning: Does the parent understand what is being
read, the verbal instruction? Inherent in comprehension is cultural literacy. Cultural literacy means that an
individual posses the background information and perspective necessary to read and communicate verbally
with understanding. The individual must understand the undertones of a comment or conversation, the
intonation of voice, and terminology. Cultural literacy involves knowing how to communicate. And finally, do
parents/children possess the ability to process information? Process is one's ability to use reading, language,
and comprehension skills to develop a whole picture-being able to use one's external and internal resources
(i.e., life experiences) to derive a logical connection of a concept, situation, or instructions (Fuszard, 1995). B.
Intervention:

1. Give parents printed instructions. Studies of pediatric discharge programs have focused largely on the
structure and context with which information is provided to parents, and the relationship between providing
information and compliance with treatment regimens. One such study suggests that the majority of parents do

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not comply with prescribed regimens when only verbal information is presented to them (Snowdon &Kane,
1995). Discharge instructions frequently consist of preprinted general guidelines for all parents of hospitalized
children. Thus discharge teaching does not account for the family's individual need, but rather focuses on very
general information (Snowdon &Kane, 1995).
2. Negotiate a time for a teaching session after review of instructions by parents/patients. Amount of time
required for patient education should be individualized based on the nurse's assessment of knowledge level,
language barriers, level of comprehension, reading ability, etc.
3. Review information/answer questions: A comprehensive explanation of the need for good oral hygiene
enables parents to understand and feel involved in their child's care. Explain that individuals who are at risk for
developing IE should establish and maintain the best possible oral health to reduce sources of bacterial seeding
(Dajani et al., 1990). In general, dental or surgical procedures that induce bleeding from the gingiva or from
mucosal surfaces of the oral, respiratory, and GI/GU tracts require IE prophylaxis. Such procedures include
tooth extraction, professional dental cleaning, gum surgery, tonsillectomy/adenoidectomy, bronchoscopy with
rigid scope, esophageal dilatation, and others (Dajani, 1993). Refer to a preprinted booklet or handout for the
updated AHA recommendations. Reinforce the need to communicate to dentists and other physicians of the
child's CHD. Give copies of the printed material to the child's physicians, providing them with a ready resource
to aid in prescribing the appropriate procedure-specific antibiotics and dosages.
C. Evaluation/Outcomes: To evaluate the prevention plan, when parents/children return for follow-up visits, ask
questions about the last dental visit, what was done, and if they are practicing IE prophylaxis. The desired
outcome is that parents/children will comply with the recommended IE prophylaxis for a lifetime, decreasing the
risk of IE.
Conclusion
Because of the high morbidity and mortality associated with IE, any measure that can prevent the disease is
advisable. Prophylactic antibiotics are recommended for children who are at risk to develop IE when undergoing
procedures that may induce bacteremia with organisms likely to cause IE (Dajani, 1993).
Nurses can make a difference in the prevention of IE in the pediatric congenital heart population. By delivering a
comprehensive and thorough teaching plan, pediatric congenital heart patients can move forward on a
continuum of health and well-being.
References
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hospitalized child. Pediatric Nursing, 21(5), 425-428. Stanton, B.F., Baltimore, R.S., &Clemens, J.D. (1984).
Changing spectrum of infective endocarditis in children. American Journal of Disabled Children, 138,720.
Steeg, C.N., Marmer, E.L., Varmer, A.O., &Blumenthal, S. (1970). The risk of infective endocarditis in patients
with ventricular septal defect: A "life table" analysis. Circulation, 3(42), 113.
References
Wells, W.J. (1989). Surgical problems of endocarditis in children. Journal of Cardiac Surgery, 4, 313.
Yokochi, K., Sakamoto, H., Mikajima, T., &Ichinose, E. (1986). Infective endocarditis in children: A current
diagnostic trend and the embolic complications. Japan Circulation Journal, 50, 1294.
Zales, V.R., &Wright, K.L. (February, 1997). Endocarditis, pericarditis, myocarditis. Pediatric Annals: A Journal
of Continuing Pediatric Education, 26(2), 116-121.
AuthorAffiliation
Margaret M. Estlow, MSN, RN, PNP, C, is a Clinical Nurse Level Il, Pediatric Cardiac Med/Surg Unit, Deborah
Heart &Lung Center, Browns Mills, NJ.
Subject: Pediatrics; Heart; Cardiovascular disease;
MeSH: Antibiotic Prophylaxis -- methods, Child, Child, Preschool, Endocarditis, Bacterial -- nursing, Equipment
Contamination -- prevention & control, Humans, Infant, Infant, Newborn, Infection Control -- methods, Nurse
Practitioners, Patient Care Planning, Patient Discharge, Patient Education as Topic -- methods, Risk Factors,
Endocarditis, Bacterial -- etiology (major), Endocarditis, Bacterial -- prevention & control (major), Heart Defects,
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Congenital -- complications (major), Pediatric Nursing -- methods (major)

Publication title: Pediatric Nursing
Volume: 24
Issue: 3
Pages: 205-12, 225
Number of pages: 9
Publication year: 1998
Publication date: May/Jun 1998
Year: 1998
Publisher: Anthony J. Jannetti, Inc.
Place of publication: Pitman
Country of publication: United States
Publication subject: Medical Sciences, Medical Sciences--Nurses And Nursing
ISSN: 00979805
Source type: Scholarly Journals
Language of publication: English
Document type: PERIODICAL
Accession number: 9987418, 03859433
ProQuest document ID: 199514886
Document URL: http://search.proquest.com/docview/199514886?accountid=14205
Copyright: Copyright Jannetti Publications, Inc. May/Jun 1998
Last updated: 2012-06-20
Database: ProQuest Education Journals

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