Pediatric Infective Pericarditis Treatment & Management

Management of pediatric infective pericarditis is influenced by the cause of the pericarditis. It may involve supportive care, pain control, and antibiotic therapy if necessary, as well as pericardiocentesis (indicated when the etiology is in doubt and essential in suspected tamponade), open pericardial drainage, or pericardiectomy as required.

2015 European Society of Cardiology (ESC) recommendations

The 2015 ESC update of their 2004 guidelines on the diagnosis and management of pericardial diseases recommends the following for treatment of pediatric acute and recurrent pericarditis (all level C evidence) ^[23] :

• Administer high-dose NSAIDs as first-line therapy for acute pericarditis until complete symptom resolution (class I).
• Consider colchicine as an adjunct to anti-inflammatory therapy for acute recurrent pericarditis (< 5 years: 0.5 mg/day; >5 years, 1.0-1.5 mg/day in two or three divided doses) (class IIa).
• Consider anti-interleukin 1 agents in the setting of recurrent pericarditis, particularly in corticosteroid-dependent children (class IIb).
• Avoid aspirin (because of the associated risk of Reye syndrome and hepatotoxicity), as well as corticosteroids (due to severity of side effects in this population) unless there are specific indications (eg, autoimmune disease) (both class III).

See Infective Endocarditis and Antibiotic Prophylactic Regimens for Endocarditis for more information on these topics.

Viral pericarditis

In general, management of viral pericarditis is conservative (expectant) and symptom specific. Bed rest and the use of anti-inflammatory agents (eg, nonsteroidal anti-inflammatory drugs [NSAIDs]) are mainstays of initial therapy. Aggressive pain control may be necessary in some patients, although most cases respond to salicylates or NSAIDs.

Corticosteroid therapy is rarely indicated. Consider this option only when NSAIDs are unsuccessful and a bacterial or fungal etiology has clearly been excluded by culture of the pericardial fluid. Although corticosteroid therapy might dramatically reduce symptoms, no convincing evidence of any long-term benefits has been reported. Moreover, corticosteroid therapy may increase the risk of recurrence.

A prospective randomized trial reported a significant reduction in the rate of recurrence with colchicine therapy in patients with a first episode of acute pericarditis. ^[24] However, this study involved mainly adult patients with a wide spectrum of etiologies, and diarrhea necessitated discontinuation of colchicine in numerous patients.

Resolution of effusion may occur within several days to weeks after initiating anti-inflammatory drugs; however, patients should be closely observed for the development of pericardial tamponade as a part of their initial care.

Therapy for cardiac tamponade consists of removing the pericardial fluid by means of pericardiocentesis, pericardiotomy, or pericardiectomy. A pericardial drainage catheter may be indicated. (See the Pericardiocentesis and Surgical Pericardial Drainage sections.)

Caution: Do not confuse tamponade with congestive heart fialure (CHF). Medications used to treat heart failure (eg, digoxin) may slow the heart rate. Because tachycardia represents the only effective compensatory mechanism available to the patient for maintaining cardiac output, slowing the rate may cause acute cardiovascular collapse. Administration of diuretics, certain anesthetic agents, or afterload-reducing agents can also lead to cardiovascular collapse.

Occasionally, intravenous immunoglobulin has been used to treat patients who develop chronic pericarditis with satisfactory results.

Viral pericarditis requires no special diet. The patient’s activity should be reduced to the level that he or she can tolerate.

Bacterial pericarditis

Proper treatment of life-threatening illness requires proper antimicrobial therapy, pericardial decompression and drainage, and intensive supportive care.

Until a definitive agent is identified, empiric therapy includes antibiotics to treat both S aureus and gram-negative bacilli. Initial antibiotics should include a combination of penicillinase-resistant penicillin and third-generation cephalosporin. In areas of high antibiotic resistance, consider the use of vancomycin and a third-generation cephalosporin. Include an aminoglycoside if the patient is postoperative from cardiac surgery, is immunocompromised, or has a genitourinary coinfection. Relatively recently, tigecycline has been used to treat methicillin-resistant S aureus pericarditis, where vancomycin is ineffective. ^[9]

Duration of antibiotic therapy is empiric but generally continues for 3-4 weeks with an antibiotic specific to the organism isolated.

Although needle pericardiocentesis may be life saving in tamponade and may confirm the diagnosis, it rarely provides complete and long-lasting resolution of the effusion. Drainage with a percutaneous pigtail catheter or open surgical drainage is required in most cases of purulent pericarditis to adequately drain the space. (See the Pericardiocentesis and Surgical Pericardial Drainage, sections.)

Almost all patients require intensive supportive care. In patients with tamponade, supportive therapies are of little or no benefit until emergent pericardial drainage is performed.

In patients with tamponade prior to drainage, plasma volume expansion is helpful in maintaining cardiac output. Drugs that depress the heart rate, produce vasodilatation, or decrease intravascular volume are contraindicated because they further compromise cardiac output. Do not administer digoxin to an infant with purulent pericarditis who shows signs of congestive heart failure. Although systolic function of the heart may not be depressed, inotropic agents may be required to treat hypotension that persists after pericardial drainage.

Application of positive pressure mechanical ventilation and positive end-expiratory pressure (PEEP) must be performed carefully because the increased intrathoracic pressure can lead to lethal falls in ventricular preload and worsened shock and /or pulseless electrical activity.

Bacterial pericarditis is often preceded by other severe bacterial infections such as pneumonia with empyema. Proper treatment of those infections prevents some cases of pericarditis. Immunization against H influenzae has led to dramatic decreases in the incidence of invasive H influenzae disease, including pericarditis.

Pericardiocentesis is required for all patients who have clinical evidence of cardiac tamponade or suspected bacterial pericarditis and for some immunocompromised patients. Pericardiocentesis is also used as a diagnostic test in patients with a pericardial effusion of unknown cause. The volume of fluid present should be sufficient to allow for the removal of a reasonable portion for diagnostic purposes.

The procedure is associated with morbidity and should be performed or supervised by an experienced physician. Pericardiocentesis is safest when performed in a controlled environment, such as the catheterization laboratory or intensive care unit (ICU). Electrocardiography (ECG), blood pressure, and oximetry monitoring is necessary.

Place the child in a half-sitting position (roughly 45°), with sedation or anesthesia as needed. Sedation is desirable unless the patient is unconscious or extremely unstable. Pericardiocentesis in a struggling patient is dangerous. If anesthesia is used, avoid agents that precipitously decrease systemic vascular resistance because circulatory collapse and cardiac arrest can ensue.

Echocardiography should be available to monitor the position of the needle. Some operators prefer to use ECG monitoring of needle advancement by clipping the V₁ lead to the needle. This technique is cumbersome and is not often used. If visualization is desired, echocardiography or fluoroscopy guidance is preferred.

Insert a beveled, sharp needle beneath the xiphoid, angling up and left toward the left shoulder. Sometimes, a pop is felt as the needle passes into the pericardium. Attempt to withdraw fluid with each advance of the needle. If fluid is obtained, remove enough to alleviate the tamponade. A small amount (as little as 20 mL in an adult) provides considerable benefit.

During pericardiocentesis, bloody fluid is often obtained that may be blood from a myocardial puncture or bloody pericardial fluid. If the fluid is grossly bloody, consider the possibility that the needle is in a cardiac chamber. Placement of a few drops of the fluid on a towel sometimes immediately proves whether the problem is bloodstained fluid and not pure blood. If the result is debatable, centrifuge the fluid because it may have a hematocrit lower than that of blood.

After the fluid obtained is confirmed to be from the pericardium, drain all easily removable fluid. Patients may report relief from symptoms at this point.

Potential complications of pericardiocentesis include arrhythmias, laceration of coronary arteries with subsequent hemopericardium and tamponade, pneumothorax, and myocardial perforation. Avoid repeated attempts at needle pericardiocentesis because they are associated with increased morbidity rates.

The decision whether to leave a drain in the pericardium depends on the probable diagnosis. If evidence of bacterial infection is found, pass a guidewire into the pericardium and confirm its position with echocardiography or fluoroscopy. Then, pass a catheter using a modified Seldinger technique over the guidewire into the pericardium to serve as a drain. The use of a pigtail catheter reduces the risk of dislodgment and myocardial puncture. Additionally, the pigtail catheter may be left in place to provide continuous and potentially definitive pericardial drainage (see image below).

Left: Chest radiograph in a patient with bacterial pericarditis reveals cardiomegaly and left lower lobe infiltrate with marked increase in pulmonary vascular markings. Right: The same patient after placement of a pigtail pericardial catheter and pulmonary artery catheter.

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Careful handling of pericardial fluid is required to properly identify etiologic agents for pericardial effusion. Definitive therapy can begin when a precise diagnosis is established, often only after detailed examination of the fluid is completed.

The effusion of purulent pericarditis usually has a high white blood cell (WBC) count with predominately polymorphonuclear cells. Viral pericarditis produces a lymphocytic picture.

Fluid should be cultured for aerobic and anaerobic organisms, fungi, miliary tuberculosis, and viruses. Approximately 50%-60% of patients with purulent pericarditis have positive pericardial fluid cultures. Antigen detection tests can be helpful in patients who have received antibiotics.

In cases of suspected viral pericarditis, attempt to identify the virus using antigen detection techniques, such as immunohistochemistry and indirect immunofluorescence assay (IFA), amplification of viral genomes by nested reverse transcription polymerase chain reaction (RT-PCR), and sequence analysis. ^[25]

If malignancy is suspected, other studies include cell count and differential, Gram stain, and cytology. Protein and lactate dehydrogenase (LDH) levels are often obtained, although both are usually elevated in most types of pericarditis.

If pericardiocentesis is unsuccessful in resolving tamponade, emergent surgical drainage is indicated. Surgical drainage is indicated in patients with fungal or bacterial pericarditis and continued effusion. Purulent pericarditis is rare and may require surgical drainage. ^[26]

Continuous drainage using specialized pericardial catheters and echographic monitoring has had reported success in treating bacterial pericarditis. However, the pericardial fluid may be too thick or loculated to be drained adequately by a catheter. Delay in adequate pericardial drainage is associated with increased mortality rates. Thus, a surgical approach to pericardial drainage may be indicated.

Various surgical procedures have been used to provide adequate pericardial drainage, and the optimal approach is controversial. Techniques for drainage include placement of a large-bore subxiphoid drainage tube (with or without irrigation), creation of a pericardial window and placement of a drain, or pericardiectomy. Proponents of pericardiectomy argue that thick clots and fibrin are not removed through a tube and that it prevents the possibility of late pericardial constriction and recurrent tamponade.

Pericardiectomy is rarely required to manage chronic recurrent cases. Video-assisted thoracoscopic window has been used in adult patients for diagnosis and management of pericardial effusions. Late pericardiectomy may be required in the rare patient who develops constrictive pericarditis as a complication of the infection.

In viral pericarditis, the following consultations are appropriate:

• Pediatric cardiologist

• Radiologist

• Family physician

• Psychologist

• School teacher

• Specialist nurse

• Pharmacist

• Dietitian

In bacterial pericarditis, the following consultations are appropriate:

• Critical care specialist - Most patients with bacterial pericarditis present with severe hemodynamic compromise. Patients should be referred to specialists proficient in the use of vasoactive agents and mechanical ventilation.

• Cardiologist - Patients with cardiomegaly and cardiovascular compromise require cardiology consultation and echocardiography to rule out myocardial or pericardial disease.

• Cardiovascular surgeon - Emergent consultation with a cardiovascular surgeon is warranted in patients who have incomplete resolution of pericardial tamponade despite pericardiocentesis. Consultation should be considered in patients with recurrent effusions or constrictive pericarditis.

Viral pericarditis

Long-term care for viral pericarditis may include the following:

• Reevaluation of recurrent cases

• Pericardial biopsy

• Pericardiectomy

Continue anti-inflammatory therapy, such as aspirin or indomethacin, for at least several months to monitor the patient’s progress.

After therapy is discontinued, 15-30% of patients have a relapse. The optimal method for prevention is not fully established. Accepted modalities include NSAIDs, corticosteroids, immunosuppressive agents, and pericardiectomy. Colchicine has also been tried in some patients, with a good response. ^{[27, 28]}

Bacterial pericarditis

Once the patient has recovered from the acute infection, follow-up with a cardiologist is recommended to monitor for the development of constrictive pericarditis. Once identified, pericardiectomy is indicated.

Critically ill patients with suspected purulent pericarditis require transfer to a tertiary pediatric center with cardiac, cardiac surgical, and critical care medicine expertise. Bacterial pericarditis is a life-threatening disease that requires a full complement of pediatric subspecialty care.

Do not delay treatment of a critically ill infant in shock. Every hospital with echocardiographic capability should have someone who can perform an emergency pericardiocentesis.