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Infective endocarditis (Risk factors (Immunosuppression e.g. post…
Infective endocarditis
Definition
Cardiovascular disorder of
an infected heart valve
Risk factors
Immunosuppression
e.g. post transplant, DM)
Post-op wounds
Renal failure
Dermatitis
IVDU
Abnormal heart structure
(valve disease, prosthetic valves,
coarctation, PDA, VSD)
Poor dentition
Pathophysiology
Process
Infection of heart valves, colonisation, invasion
and formation of bulky friable 'vegetations'
Seeding of blood with microbes (bacteraemia) via dental/surgical procedure, dirty needles, trivial injury
Consequences
Heart
Valve destruction and regurgitation or obstruction
Aortic root abscess - impinges AVN, slows P-R or AV block
Kidneys
Glomerulonephritis and renal failure
Systemic
Vasculitis
Emboli and abscesses (brain, kidney, liver, gut, skin [Janeway])
Infacts (gut, limbs, digits [Osler's])
Organism
Streps
Commonest
Uusally abnormal valves
S aureus
High virulence
Ususally infects normal valves
IVDU
S epidermidis
Prosthetic valves
Fungi
Rarer e.g. Candida, aspergillus
Onset
Acute
Normal valves, prosthetics (immed after surgery)
Acute HF and emboli (stroke, ischemic limb)
Subacute
Abnormal valves, prosthetics (haem spread)
Clinical
presentation
Fever
Rigors
Nigh sweats
Malaise
Weight loss
Diagnosis
Examination
Cardio - pallor, splinter haemorrhages, Osler's/Janeway, clubbing, track marks, new/changing murmur, digital infarcts
Abdo - track marks, signs of liver disease if IVDU
Fundoscopy - Roth spots (retinal haemorrhages)
Investigations
Bloods
FBC (normochromic normocytic anaemia),
CRP/ESR (high),U+E, LFTs, blood cultures
Imaging
CXR -cardiomegaly
ECHO - vegetations
Bedside
Obs - fever, tachycardic
ECG - may have arrhythmia e.g. AF,
prolonged PR
Urine
Dipstick - microscopic haematuria
History
HPC - acute/subacute
PMH - structural heart disease,
valve replacements, immunosuppression
SH - IVDU, smoking, alcohol
Diagnostic criteria (Duke's)
2 major, 1 major 3 minor,
or all 5 minor
Minor
Predisposition
Fever >38C
Vascular/immunology signs
+ve blood culture not meeting major
Positive ECHO not meeting major
Major
+ve blood culture on 2+ occasions
Endocardium involvement
(+ve ECHO, new regurgitation)
Management
Definitive
Medical
Abx
Indication: all patients
E.g. per local guidance, likely
different for native v prosthetics
Surgical
Indication: HF, obstruction, emboli,
fungal, persisting bacteremia, myocardial abscess
MOA: repair or replacement
Conservative
Monitoring
Identify source
Liase micro and cardio
Initial ABCDE
Prevention
Dental hygeine
Avoid risk (IVDU, tattoos, piercing)
Prognosis
30% risk of death if staph,
15% enteric org, 5% streps
Types
Cause
Bacterial
Commonest
Fungal
Onset
Acute
Acute, high virulence
Often normal valves
Necrotic, ulcerative, invasive
High mortality
Subacute
Slower onset, less virulent
Typically abnormal valves
Less destructive lesions
Lower mortality
Location
Mitral
Commonest, organism from lung
Tricuspid
Often IVDU (veins draining limbs to R heart)
Aortic
Common
Complications
Systemic emboli
(R heart to lung, L heart to body)
Distant abscesses
Valve rupture/perforation
Myocardial abscess
Non-infectious
endocarditis
Pathophysiology
Usually normal valves
Minimal destruction
Non infective thrombosis of valves
with potential for emboli
Aetiology
Autoimmune
SLE (Libman-Sachs endocarditis)
Neoplastic
Malignant infiltration