Abstract
SUMMARY Five patients with neonatal infective endocarditis were reviewed, two of whom survived. Infection was caused by Staphylococcus aureus in four and by Candida albicans in one. All cases of bacterial endocarditis had clinical signs of septicaemia, positive blood cultures, thrombocytopenia, microscopic haematuria, and heart murmurs. Three developed skin abscesses early in their illnesses. Three patients had two dimensional echocardiographic studies that showed bacterial vegetations. One of these studies was done before the heart murmur could be heard. We suggest that echocardiography in conjunction with the clinical picture described may help in making an early diagnosis of endocarditis in neonates.

Bacterial endocarditis in neonates is a rare and usually fatal disease; the first survivor was reported in 1983. 1 2We became interested in the disease after two patients in our neonatal unit survived. We therefore reviewed all five cases of neonatal infective endocarditis seen at this hospital over the past 10 years to see if we could find similarities that could lead to earlier diagnosis and treatment; this is the largest published series that we know of.
Case reports CASE 1
A boy weighing 1000 g was born by spontaneous vaginal delivery at 28 weeks' gestation. He required resuscitation after birth with endotracheal ventilation. Sodium bicarbonate and dextrose were given through a catheter in the umbilical vein. His Apgar scores were 1 at one minute and 3 at five minutes. He was transferred to this hospital.
Case reports CASE 1
Initial management included mechanical ventilation, intravenous fluid replacement, and treatment with penicillin and gentamicin. Vascular access catheters were inserted in the radial artery and a central vein. At 7 days of age a patent ductus arteriosus was confirmed by two dimensional echocardiography. The heart was structurally normal and the baby was successfully treated with indomethacin. At At 21 days he developed a fever, a generalised rash, and malaise. Cultures of blood, swabs of the skin lesions, and a specimen of urine aspirated suprapubically grew S aureus that was sensitive to gentamicin. A full blood examination showed a platelet count of 10 000x 109/l. Despite initial treatment with penicillin and gentamicin he failed to respond. At 27 days of age a swab from a skin pustule grew methicillin resistant S aureus; treatment with vancomycin and rifampicin was started.
Case reports CASE 1
At 28 days a pansystolic murmur was heard and two dimensional echocardiography showed a mobile vegetation attached to the papillary muscle of the mitral valve (fig 1) . Fundoscopy showed four chorioretinal atrophic areas and computed tomography of the brain showed several embolic areas.
Case reports CASE 1
Antibiotic treatment was continued for six weeks, and echocardiography at 7 weeks of age showed no evidence of vegetations. At discharge he had completely recovered with no obvious sequelae. CASE 4 A boy weighing 800 g was born at 26 weeks' gestation and transferred to this hospital shortly after delivery. The mother's membranes had been ruptured for four days before delivery and there had been a small antepartum haemorrhage. Apgar scores at birth were 6 at one minute and 9 at five minutes. Previous studies have reported that the dermatological lesions of endocarditis such as Janeway's spots, Osler's nodes, and Roth's spots are seen in less than 5% of paediatric patients. In our patients skin abscesses or pustules that were thought to be seedlings of infection from the cardiac vegetations appeared in three of the four patients with bacterial endocarditis. Two of the five developed petechia during their illnesses.
Case reports CASE 1
The first echocardiographic diagnosis of bacterial endocarditis was in 1977 by an M mode scan.7 In 1983 Kavey et al found that 82% of the children with infective endocarditis that they examined had echocardiographic findings compatible with the diagnosis.9 Vegetations as small as 1-3 mm could be seen. 10
Case reports CASE 1
Murmurs or changing murmurs were present in all four patients later in their illnesses. Thrombocytopenia and microscopic haematuria were present in all babies at an early stage. In two cases the development of a murmur led to two dimensional echocardiographic examination that showed a vegetation. In one case, with the clinical signs of septicaemia, skin pustules, haematuria, and thrombocytopenia, two dimensional echocardiography showed a vegetation in the left atrial appendage before a murmur could be detected. Fourteen days earlier a patient with similar signs was treated with vancomycin for 10 days after methicillin resistant S aureus had been isolated from cultures. Echocardiography at that stage might have shown a vegetation and resulted in a prolonged course of antibiotics with the hope of preventing further damage. Interestingly in older children the mean duration of symptoms before the diagnosis of bacterial endocarditis is 35 days.
Case reports CASE 1
With the increasing availability of two dimensional echocardiography neonates with septicaemia, especially if it is prolonged or recurrent, and skin pustules, haematuria, and thrombocytopenia, may warrant a cardiac scan to search for vegetations before a heart murmur has developed.
Case reports CASE 1
Non-bacterial endocarditis is an important predisposing factor to the development of bacterial endocarditis because it may form a nidus for bacterial superinfection and increase the possibility of embolisation. In one study of neonates who died 10% had evidence of thrombotic james00@example.com Eighty per cent of them had had an intracardial central venous catheter inserted. The initial event in the development in thrombi is thought to be endocardial damage, presumably traumatic in these cases.3 8 11 Congenital heart disease is also an important predisposing factor, and it was present in one of our patients. In addition, one report suggested an association between persistent fetal circulation and non-bacterial endocardial thrombosis in neonates. '2 In bacterial endocarditis the bacteraemia is usually low grade and constant, and detectable in 77-96% of the first blood cultures. This is increased to nearly 100% if three blood cultures are taken.'3 S aureus has become an increasingly common cause of endocarditis since antibiotics have been used, and it is more virulent than other bacterial causes of endocarditis. The 

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