Pediatric Endocarditis: Duke Criteria, Antibiotic Doses, Dental Prophylaxis

About this tool

This tool walks a clinician through suspected infective endocarditis in a child. It counts major and minor 2023 Duke-ISCVID criteria, the criteria adopted by the 2026 AHA statement, to classify the case as definite, possible or rejected. It then gives the empiric regimen by setting, blood culture and echo steps, and surgery referral triggers.

When the organism is known, the tool gives the antibiotic regimen and duration for streptococci, staphylococci, enterococci, HACEK, gram-negative bacilli, fungi and culture-negative endocarditis. Pediatric mg/kg doses follow the 2015 AHA pediatric statement. Where the 2026 adult statement changed practice, the tool says so, for example 4 weeks for native-valve MSSA, no gentamicin for susceptible streptococci or prosthetic staphylococcal infection, and ampicillin plus ceftriaxone for E. faecalis. Partial oral therapy is shown only as a specialist option for selected patients.

A separate branch answers the prophylaxis question. It covers who qualifies under the 2021 AHA statement, which dental and other procedures need antibiotics, and single-dose regimens with allergy alternatives now that clindamycin is no longer recommended. Every child with endocarditis should be managed with pediatric cardiology and infectious diseases.

Common questions

Which children need antibiotics before dental work?

Only the highest-risk groups: prosthetic valves or valve repair material, previous endocarditis, unrepaired cyanotic heart disease, repaired defects with prosthetic material in the first 6 months or with a residual defect at the patch or device, pulmonary valve or conduit implants, and heart transplant recipients with valve disease. The work must involve the gums, the root tip area, or perforation of the mucosa.

What is the prophylaxis dose of amoxicillin for a child?

50 mg/kg by mouth, maximum 2 g, as a single dose 30 to 60 minutes before the procedure. If it was missed, it can be given up to 2 hours afterward.

Is clindamycin still used for penicillin-allergic patients?

No. The 2021 AHA statement no longer recommends clindamycin. Use cephalexin 50 mg/kg (max 2 g) if there was no anaphylaxis, angioedema or hives, or azithromycin or clarithromycin 15 mg/kg (max 500 mg), or doxycycline.

How is endocarditis diagnosed with the Duke-ISCVID criteria?

Definite endocarditis needs 2 major criteria, 1 major plus 3 minor, 5 minor, or pathologic proof. Possible endocarditis is 1 major plus 1 minor, or 3 minor criteria.

Does a child need a TEE?

TTE is the first test and detects most pediatric endocarditis. TEE is used for prosthetic valves or material, cardiac devices, poor windows in older or larger children or after chest surgery, suspected aortic root abscess, or a negative TTE with high suspicion.

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