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CR - Cardiovascular Infections (ii) endocarditis continued (Dx (signs…
CR - Cardiovascular Infections (ii) endocarditis continued
Dx
suspected in ALL patients with fever + murmur
suspected in ALL patients with unexplained emboli
suspected in ALL patients with unusual heart dysfunction (even when fever absent)
signs
cardiomegaly
splenomegaly
splinter haemorrhages
clubbing
3 sets of blood cultures @ least 1 hr apart before starting antibiotics
ECHO
best = TOE (if normal usually excludes endocarditis) - a normal transthoracic ECHO doesn't exclude endocarditis
do 5 days after tx - if done too early bacteria won't be seen
serology
PCR
FBC
ESR/CRP
urinalysis
culture/PCR of excised valves post surgery (in France)
Duke Criteria
major
+ve blood cultures
persistent BSI
more than 1 set > 12hrs apart with 1 focus
evidence of endocardial involvement - vegetation, abscess, dehiscence (rupture)
minor
predisposing heart condition
IVDU
fever > 38
vasc phenomena (embolism, pul infarct, intracranial haemorrhage)
immunological phenomena (e.g. glomerulonephritis)
+ve serology
for Dx: 2 major OR 1 major + 3 minor OR 5 minor
Management
unless v ill, 1st confirm aetiology before starting antibiotics (repeat blood cultures)
liaise with microbiology/infectious disease
antibiotic combo (synergy) for 4-6 wks
consult with cardiac surgeon if there's complications (e.g. recurrent emboli) or failure to respond to Tx (up to 40% need surgery)
MIC
avoid toxicity by monitoring trough level (lowest conc of drug before nest dose is administered)
right-sided endocarditis
minority (5-10% of cases)
associated with IVDU, cardiac device infection, central venous catheters, congenital heart disease
tricuspid often affected
signs of sepsis, resp symptoms, lung abscesses
good outcome except in IVDUs - poor compliance :cry:
culture -ve endocarditis
often from prior antibiotic Tx
fastidious organisms (special growth requirements)
nutritionally variant strep
HACEK
bartonella
chlamydia
coxiella burnetti (Q fever)
brucella abortus
legionella
tropheryma whippelii
non-candida fungi
empiric Tx
IV vancomycin + gentamicin if gram +ve suspected (staph/strep)
add PO rifampicin if coag -ve strep suspected
failure to respond to Tx
valve rupture
perforation
abscess
emboli
urgent valve replacement often needed
risk of superinfection (e.g. C diff)
can be due to drug reactions
prognosis
100% mortality if untxed
20% if txed in a native valve (decreasing)
40% if txed in a prosthetic valve
poorer in elderly, delayed Tx, >1 valve involved, valve destruction, CHF, gram -ve bacilli (e.g. E Coli), fungi, Q fever
prophylaxis
for @ risk groups
prosthetic valve
previous endocarditis
for procedures
dental extractions
periodontal surgery
surgery of GIT, GUT, upper resp tract
amoxicillin (if allergic give clindamycin/azithromycin)