By ULY CLINIC
Infective endocarditis (IE)
The infective process of endocardial layer of the heart can involve native or prosthetic valve and congenital defects/shunts. Alpha–haemolytic streptococci are the most common causes of native valve endocarditis but Staphylococcus aureus is more likely if the disease is rapidly progressive with high fever, or is related to a prosthetic valve (Staphylococcus epidermidis)
Sign and Symptoms
Modified Dukes Criteria is used. Consult microbiologist where possible. Three sets of blood cultures should be taken before starting treatment.
Modified Dukes Criteria
• Positive blood cultures of typical organism for IE from at least two separate blood cultures
• Evidence of endocardial involvement by echocardiogram (Trans–thoracic Echo/Trans– oesophageal Echo)
• Fever > 38ºC
• Presence of Rheumatic heart disease, congenital heart disease
• Vascular phenomena; Major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial haemorrhage, conjuctival hemorrhage, Janeway lesions
• Immunological phenomena; glomerulonephritis, Osler`s nodes, Roth`s spots,
• Rheumatoid factor.
• Serologic evidence of active infective endocarditis or blood culture not meeting major criterion.
Definitive diagnosis of IE
• Two major criteria or
• One major and three minor criteria or
• Five minor criteria
Possible Diagnosis of IE
• One major and one minor or three minor criteria
Key Note: Positive blood cultures remain the cornerstone of diagnosis and provide live bacteria for both identiﬁcation and susceptibility testing.
To improve yield of culturing bacteria at least three blood sample sets are taken at 30 minutes apart each containing 10mLof blood and should be incubated in both aerobic and anaerobic atmospheres.
Sampling should be obtained from a peripheral vein using a meticulous sterile technique.
- Empirical Treatment Consider for negative blood culture or if risk delaying treatment for blood culture outweigh the befit of starting treatment early .
For treatment please refers to picture number 1 and 2
At any stage, treatment may have to be modified according to:
• Detailed antibiotic sensitivity tests
• Adverse reactions allergy
• Failure of response
Endocarditis leading to significant cardiac failure or failure to respond to antibiotics may well require early cardiac surgery within few days
Patients with complicated IE should be evaluated and managed in high level of care or centre, with immediate surgical facilities and the presence of a multidisciplinary including an Infectious Disease specialist, a microbiologist, cardiologist, imaging specialists, and cardiac surgeons
Infective Endocarditis Prophylaxis
Antibiotic prophylaxis should be considered for patients at highest risk for IE: Patients with any prosthetic valve, including a trans catheter valve, or those in whom any prosthetic material was used for cardiac valve repair.
Patients with a previous episode of IE.
Patients with Congenital Heart Disease (CHD):
(a) Any type of cyanotic CHD.
(b) Any type of CHD repaired with a prosthetic material, whether place surgically or by percutaneous techniques, up to 6 months after the procedure or lifelong if residual shunt or valvular regurgitation remains.
Antibiotic prophylaxis is not recommended in other forms of valvular or CHD.
Prophylaxis of Endocarditis Infective
To reduce the risk of bacterial endocarditis, antibiotic prophylaxis should be given to patients undergoing dental procedures requiring manipulation of the gingival or periapical region of the teeth or perforation of the oral mucosa.
Antibiotic prophylaxis is not recommended for,
• Respiratory tract procedures including bronchoscopy or laryngoscopy, or trans nasal or endotracheal intubation
• Gastrointestinal or urogenital procedures or Trans–oesophageal Echocardiogram, gastroscopy, colonoscopy, cystoscopy, vaginal or caesarean delivery.
• Skin and soft tissue procedures
5 Novemba 2020 11:20:58