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Infective endocarditis
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Infective endocarditis

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  • 1. Infective Endocarditis
  • 2. Etiology and sources of infection
  • 3. A consequence of 2 factors
    • Presence of organism in blood stream
    • Abnormal cardiac endothelium facilitating adherence and growth.
  • 4.
    • Aortic and mitral valves are most commonly involved in infective endocarditis apart from intravenous drug users in whom right sided lesions are more common .
  • 5. Culture negative Endocarditis
    • Coxiella burnetti
    • Bortenella sp.
    • Chlamydia sp.
    • Legionella
    • Prior antibiotic therapy.
  • 6. Clinical features
  • 7. High clinical suspicion if….
  • 8. Diagnostic criteria (Modified Duke’s Criteria)
    • Major criteria:
    • A positive blood culture for IE. Typical organism growing in 2 cultures in absence of a primary focus.
    • A persistently positive blood culture
    • A positive serological test for Q fever.
    • ECHO evidence-mass, abscess, dehiscence.
    • New valvular regurgitation.
  • 9.
    • Minor criteria:
    • Predisposition: predisposing heart condition or intravenous drug use.
    • Fever: temperature ≥ 38°C (100.4°F).
    • Vascular phenomena : major arterial emboli , septic pulmonary infarcts , mycotic aneurysm, intracranial haemorrhage, conjunctival haemorrhages, Janeway’s Lesion.
    • Immunologic phenomena : glomerulonephritis, Osler’s nodes, Roth’s spots , rheumatoid factor.
    • Microbiological evidence: a positive blood culture but not meeting a major criterion as noted above, or serological evidence of an active infection with an organism that can cause infective endocarditis.
    • Echocardiogram: findings consistent with infective endocarditis but not meeting a major criterion as noted above.
  • 10.
    • The diagnosis of infective endocarditis is definite when:
    • A microorganism is demonstrated by culture of a specimen from a vegetation, an embolism or an intracardiac abscess
    • Active endocarditis is confirmed by histological examination of the vegetation or intracardiac abscess
    • Two major clinical criteria, one major and three minor criteria, or five minor criteria are met.
  • 11. ECHO
    • TTE-high specificity. Sensitivity 60-75%.
    • TOE-high sensitivity >90%.
    • A negative echocardiogram does not exclude a diagnosis of endocarditis.
  • 12.  
  • 13. Treatment
    • Blood cultures should be taken prior to empirical antibiotic therapy.
    • Antibiotic treatment should continue for 4–6 weeks.
    • Serum levels of gentamicin and vancomycin need to be monitored to ensure adequate therapy and prevent toxicity.
  • 14.  
  • 15. Causes of persistent fever
    • Most patients with infective endocarditis should respond within 48 hours of initiation of appropriate antibiotic therapy.
    • If persistent fever consider:
    • perivalvular extension of infection and possible abscess formation.
    • Drug reaction (the fever should promptly resolve after drug withdrawal)
    • Nosocomial infection (i.e. venous access site, urinary tract infection)
    • Pulmonary embolism (secondary right-sided endocarditis or prolonged hospitalization).
  • 16. Antibiotic prophylaxis
  • 17. Possible questions.
    • Name the organisms associated with the following locations/situations causing IE:
    • Dental disease or procedures.
    • Prolonged indwelling vascular catheters.
    • Gut and perineum
    • Bowel malignancy
    • Native and prosthetic valve endocarditis-early and late.
    • Soft tissue infection
  • 18.
    • IE in IVDU-name the organism, site, Rx.
    • Name the organisms with negative culture for IE.
    • The following are high clinical suspicion for IE except?
    • The following are major criterion for IE except?
  • 19.
    • Treatment choices for the following clinical situation:
    • Clinical endocarditis, culture results awaited, no suspicion of staphylococci.
    • Suspected staphylococcal endocarditis (IVDU, recent intravascular devices or cardiac surgery, acute infection)
    • Streptococcal endocarditis
    • Enterococcal endocarditis
    • Staphylococcal endocarditis
  • 20.
    • A person treated for IE has persistent fever after 48 hours of treatment. What are the possible explanation for this?