CHICAGO – In screening children with suspected endocarditis, clinicians should first apply Duke’s Criteria to assess risk and guide the decision of whether to order an echocardiogram.
Nancy Hua, DO, a first-year pediatric cardiology fellow at Doernbecher Children’s Hospital/ Oregon Health & Science University in Portland, and fellow researchers evaluated the appropriateness and effectiveness of 300 echocardiograms ordered at their institution over 10 years for suspected infective endocarditis in pediatric patients. Patients were younger than 21 years and all had structurally normal hearts. “We did notice there have been a lot of people ordering echocardiograms because of a concern about infective endocarditis,” Dr. Hua said. “But echocardiograms are expensive and require the patients to lay still for half an hour to an hour with a probe on their chest to obtain the images.”Duke’s Criteria, when there is a negative echo, it’s less likely to be infective endocarditis,” said Dr. Hua. In fact, a positive Duke’s Criteria carried the highest positive predictive value for a positive echocardiogram in the study, 0.8, compared to zero for one positive blood culture, and 0.3 for two positive blood cultures.
A total of 10, or 3%, of echocardiograms were positive for a mass, abscess, thrombus, or new valve regurgitation consistent with infective endocarditis. Eight of the 300 patients screened with echocardiography were diagnosed with infective endocarditis. Of the two remaining patients, one had negative blood cultures, so clinicians did not administer antibiotics or diagnose infective endocarditis. The other patient presented with a new, mild mitral valve regurgitation; however, the echocardiography results appeared within normal limits, according to a cardiology consultation. This patient was ultimately treated for bacteremia.
“If the patient doesn’t really have the appropriate risk factors [for infective endocarditis], do they really need to go for this echo?” Dr. Hua asked here at the annual meeting of the American Academy of Pediatrics. The researchers suggest considering an echocardiogram when a patient has two or more persistent positive blood cultures, persistent fever on antibiotic therapy, and/or a new pathologic murmur.
Dr. Hua and her colleagues plan to launch a quality improvement project to target more appropriate echocardiogram use. Specifically, they are developing an elecronic health record order set to remind clinicians about appropriate criteria for ordering the imaging when they suspect infective endocarditis. “Does the patient fulfill the criteria? If the answer is no, they can reconsider if they want to order the echo at that point. Or if they are still worried for any reason at all, they can consult pediatric cardiology.” She added, “If we think it’s still warranted, we’ll order the echo ourselves.”
Dr. Hua reported having no financial disclosures.