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2438407316470Risk Factors00Risk Factors15557507316470Valvular heart disease: mitral valve regurgitation most common in developed world; calcific aortic stenosisOther structural heart disease: 75% children have pre-existing heart abnormality; bicuspid aortic valve most commonIVDU: 20% admissions with fever are endocarditis; 30x general population; 2-5% risk per year; mean age 30yrs; especially cocaine; 40% recurrent; usually normal valve; R>L embolise to lungs therefore cause respiratory symptoms; tricuspid 45%, mitral 30%, aortic 20%; lower mortality than other causes; poor prognosis if large vegetation size, fungal)Other: Poor dental hygiene, dialysis, diabetes, HIV, male, rheumatic heart disease (leading risk factor in developing countries); <20% occur following prophylaxis-requiring procedure; hypercoagulable state (eg. SLE, malignancy)00Valvular heart disease: mitral valve regurgitation most common in developed world; calcific aortic stenosisOther structural heart disease: 75% children have pre-existing heart abnormality; bicuspid aortic valve most commonIVDU: 20% admissions with fever are endocarditis; 30x general population; 2-5% risk per year; mean age 30yrs; especially cocaine; 40% recurrent; usually normal valve; R>L embolise to lungs therefore cause respiratory symptoms; tricuspid 45%, mitral 30%, aortic 20%; lower mortality than other causes; poor prognosis if large vegetation size, fungal)Other: Poor dental hygiene, dialysis, diabetes, HIV, male, rheumatic heart disease (leading risk factor in developing countries); <20% occur following prophylaxis-requiring procedure; hypercoagulable state (eg. SLE, malignancy)2438403425190Aetiology00Aetiology154939934258250022834606809105Staph aureus, strep, candida, aspergillus00Staph aureus, strep, candida, aspergillus15557506809105Paed-iatrics00Paed-iatrics15487655927725Pros-thetic00Pros-thetic22879055927725Early (<2/12) = peri-operative contamination = 25% staph epidermidis; 20% staph aureus; 20% G-ives; 10% fungi; 10% strep; 10% diptherioids Late (>2/12) = usual mechanism = 30% strep viridans; 30% staph epidermidis; 10% staph aureus; 10% G-ives; 10% Grp D strep; 5% fungi; 5% diptherioids00Early (<2/12) = peri-operative contamination = 25% staph epidermidis; 20% staph aureus; 20% G-ives; 10% fungi; 10% strep; 10% diptherioids Late (>2/12) = usual mechanism = 30% strep viridans; 30% staph epidermidis; 10% staph aureus; 10% G-ives; 10% Grp D strep; 5% fungi; 5% diptherioids15487654598670Adults00Adults22879054598670>30% staph overall, 28% staph aureus: poor prognosis with rapid destruction of valves21% strep viridans (less severe); 14% other strep (Strep sanguis / bovis (elderly) / mutans)10% enterococcus: usually have risk factors10% coag neg staph: epidermis / lugdunensis; high risk of valve destructionHACEK 2% (G-ives: haemophilus / aeromonas / cardiobacterium hominis / eikenella / kinginella), fungi 1%5-10% culture –ive: usually HACEK; 30-50% culture –ive if prior antibiotics00>30% staph overall, 28% staph aureus: poor prognosis with rapid destruction of valves21% strep viridans (less severe); 14% other strep (Strep sanguis / bovis (elderly) / mutans)10% enterococcus: usually have risk factors10% coag neg staph: epidermis / lugdunensis; high risk of valve destructionHACEK 2% (G-ives: haemophilus / aeromonas / cardiobacterium hominis / eikenella / kinginella), fungi 1%5-10% culture –ive: usually HACEK; 30-50% culture –ive if prior antibiotics2287905342455566% staph aureus – infects normal valves, high virility, especially tricuspid valve10% strep viridans – poorer prognosis4% enterococcus – infect previously abnormal mitral and aortic valve, low virility3% coag neg strep, 3% other strep – pathophysiology as per enterococcus1% fungi3% culture negative0066% staph aureus – infects normal valves, high virility, especially tricuspid valve10% strep viridans – poorer prognosis4% enterococcus – infect previously abnormal mitral and aortic valve, low virility3% coag neg strep, 3% other strep – pathophysiology as per enterococcus1% fungi3% culture negative15487653424555IVDU00IVDU2438402103120Patho-physiology00Patho-physiology15557502102485Mitral > aortic > tricuspid > pulmonary (tricuspid most common in IVDU)Staph aureus is most common cause overallNon bacterial thrombotic endocarditis (sterile vegetations) forms in areas of turbulent flow (or where damage from particular matter in blood stream in IVDU) bacterial infection of thrombus develops following bacteraemic episodes sequestration of bacteria in thrombus that phagocytic cells cannot penetrate intermittent embolisation of infective emboli; prosthetic valve endocarditis hallmark = ring abscesses00Mitral > aortic > tricuspid > pulmonary (tricuspid most common in IVDU)Staph aureus is most common cause overallNon bacterial thrombotic endocarditis (sterile vegetations) forms in areas of turbulent flow (or where damage from particular matter in blood stream in IVDU) bacterial infection of thrombus develops following bacteraemic episodes sequestration of bacteria in thrombus that phagocytic cells cannot penetrate intermittent embolisation of infective emboli; prosthetic valve endocarditis hallmark = ring abscesses243840964565Epidemiology00Epidemiology1551305963296In native valves: Mortality 25% (50% if aortic valve; 56% if HIV); acute has worse prognosis; 100% mortality if untreated; L>RIn prosthetic valves: 3% incidence in prosthetic valves in 1st year; 1%/yr thereafter; 50% mortality overall (75% in early infections due to ? virulence of micro-organism (ie. Staph aureus), 40% in late, 90% if fungal, 85% if staph); no significant difference in risk between biological and mechanical; lower risk if bioprosthetic initially (same risk after 5 years)00In native valves: Mortality 25% (50% if aortic valve; 56% if HIV); acute has worse prognosis; 100% mortality if untreated; L>RIn prosthetic valves: 3% incidence in prosthetic valves in 1st year; 1%/yr thereafter; 50% mortality overall (75% in early infections due to ? virulence of micro-organism (ie. Staph aureus), 40% in late, 90% if fungal, 85% if staph); no significant difference in risk between biological and mechanical; lower risk if bioprosthetic initially (same risk after 5 years)246380330200Infective Endocarditis00Infective Endocarditis2463808133080Investigations00Investigations15506708133080Bloods: normal/? WBC (? in 50% prosthetic), ? ESR (>90%), haemolytic anaemia (70-90%; especially if prosthetic), +ive RF; persistently +ive blood cultures (always do before antibiotics; 70% risk if all 4 +ive; 90% positive; 95% positive if prosthetic; false –ive due to antibiotics / unusual micro-organism)Urine: haematuria (in 50%)ECG: RBBB, LBBB, HB, PR depression; cardiac monitor if new conduction defectCXR: pneumonia (25%), septic emboli findings (25%), acute pulmonary oedema (15%); normal in 35%Echo: transthoracic sensitivity 65% (88-98% in TinTin); transoesophageal sensitivity 85%, specificity 95% (recommended if prosthetic valves, fat / COPD etc…, high risk)00Bloods: normal/? WBC (? in 50% prosthetic), ? ESR (>90%), haemolytic anaemia (70-90%; especially if prosthetic), +ive RF; persistently +ive blood cultures (always do before antibiotics; 70% risk if all 4 +ive; 90% positive; 95% positive if prosthetic; false –ive due to antibiotics / unusual micro-organism)Urine: haematuria (in 50%)ECG: RBBB, LBBB, HB, PR depression; cardiac monitor if new conduction defectCXR: pneumonia (25%), septic emboli findings (25%), acute pulmonary oedema (15%); normal in 35%Echo: transthoracic sensitivity 65% (88-98% in TinTin); transoesophageal sensitivity 85%, specificity 95% (recommended if prosthetic valves, fat / COPD etc…, high risk)2463804166870Assessment00Assessment15506704166870Fever: most common symptom; high fever of short duration (in 80% IVDU; in 95% prosthetic valves); usually within 2/52; may be absent in elderly, previous antibiotics, severe CCF, ARF, immunosuppressionHeart murmur (85%): in 70% IVDU; in 30% when R side, in 70% when L side; in 50% prosthetic valves; usually regurgitationRespiratory symptoms: in 75% when tricuspid valveVascular symptoms: organ emboli (20-50%; especially if fungal eg. Focal neurological deficit; MCA CVA most common neurological manifestation; retinal artery emboli, PE, MI, splenic infarct); mycotic aneurysm in 20% ( SAH); splinter haemorrhages (15%; >4 = abnormal; red for 72hrs brown) Janeway lesions (<10%; acral distributiuon; painless, haemorrhagic, on palms/soles, containing bacteria)Immunological symptoms: glomerulonephritis ( haematuria, proteinuria), Osler’s nodes (10-23%; tender nodules on tips of fingers or thenar eminence, sterile, last only hours-days), Roth’s spots (2-10%; retinal haemorrhage with central clearing; less common in Staph aureus and R sided lesions); rheumatic feverOther: chills, weakness; constitutional symptoms; abdominal / chest / back pain; septic complications in 20%; new onset CCF (70%); valve failure in prosthetic valves; skin manifestations in 18-50% (petechiae 20-40%; not specific for infective endocarditis); hepatomegaly (in 30% IVDU); splenomegaly (20-55%); anaemia (in 40% IVDU); microscopic haematuria (in 50% IVDU); clubbing; subacute has more non- specific symptoms; symptoms usually present for 10-14/7; classical signs often absent if prosthetic valve00Fever: most common symptom; high fever of short duration (in 80% IVDU; in 95% prosthetic valves); usually within 2/52; may be absent in elderly, previous antibiotics, severe CCF, ARF, immunosuppressionHeart murmur (85%): in 70% IVDU; in 30% when R side, in 70% when L side; in 50% prosthetic valves; usually regurgitationRespiratory symptoms: in 75% when tricuspid valveVascular symptoms: organ emboli (20-50%; especially if fungal eg. Focal neurological deficit; MCA CVA most common neurological manifestation; retinal artery emboli, PE, MI, splenic infarct); mycotic aneurysm in 20% ( SAH); splinter haemorrhages (15%; >4 = abnormal; red for 72hrs brown) Janeway lesions (<10%; acral distributiuon; painless, haemorrhagic, on palms/soles, containing bacteria)Immunological symptoms: glomerulonephritis ( haematuria, proteinuria), Osler’s nodes (10-23%; tender nodules on tips of fingers or thenar eminence, sterile, last only hours-days), Roth’s spots (2-10%; retinal haemorrhage with central clearing; less common in Staph aureus and R sided lesions); rheumatic feverOther: chills, weakness; constitutional symptoms; abdominal / chest / back pain; septic complications in 20%; new onset CCF (70%); valve failure in prosthetic valves; skin manifestations in 18-50% (petechiae 20-40%; not specific for infective endocarditis); hepatomegaly (in 30% IVDU); splenomegaly (20-55%); anaemia (in 40% IVDU); microscopic haematuria (in 50% IVDU); clubbing; subacute has more non- specific symptoms; symptoms usually present for 10-14/7; classical signs often absent if prosthetic valve170751541675050058540664166871004050665416750529686254167505002463802854325Complications00Complications15525752854961Myocardial abscesses atrioventricular blockImmune complex diseaseThromboembolism: systemic embolisation (occurs in 50%, usually within 2-4/52) subsequent infarction and infection; 65% brain > lung, spleen, kidney, liver; more common in subacutePericarditis, Mycotic aneurysm, intracranial haemorrhageIn prosthetic valves: valve dehiscence, perivalvular leak, valve stenosis (more common in mechanical valves), leaflet tears / perforations, purulent pericarditis00Myocardial abscesses atrioventricular blockImmune complex diseaseThromboembolism: systemic embolisation (occurs in 50%, usually within 2-4/52) subsequent infarction and infection; 65% brain > lung, spleen, kidney, liver; more common in subacutePericarditis, Mycotic aneurysm, intracranial haemorrhageIn prosthetic valves: valve dehiscence, perivalvular leak, valve stenosis (more common in mechanical valves), leaflet tears / perforations, purulent pericarditis155575049720500246380501650Duke Criteria00Duke Criteria15525751827530Duke Criteria = 2 major or 1 major + 3 minor or 5 minor Sensitivity 90%Possible infective endocarditis = 1 major + 1 minor or 3 minorTypical micro-organism: strep bovis / viridans, HACEK, staph aureus, enterococci; can have single +ive blood culture for Coxiella burnetti00Duke Criteria = 2 major or 1 major + 3 minor or 5 minor Sensitivity 90%Possible infective endocarditis = 1 major + 1 minor or 3 minorTypical micro-organism: strep bovis / viridans, HACEK, staph aureus, enterococci; can have single +ive blood culture for Coxiella burnetti4345940501650MinorIVDU / congenital heart diseaseT >38°CVascular phenomenaImmunological phenomena+ive blood culture / echo no meeting major criteria00MinorIVDU / congenital heart diseaseT >38°CVascular phenomenaImmunological phenomena+ive blood culture / echo no meeting major criteria1552575501650Major2x +ive blood culture of typical micro-organism >12hrs apartMobile echodense intracardiac mass on echoPeriannular abscess on echoPartial dehiscence of prosthetic valve on echoNew regurgitation on echo00Major2x +ive blood culture of typical micro-organism >12hrs apartMobile echodense intracardiac mass on echoPeriannular abscess on echoPartial dehiscence of prosthetic valve on echoNew regurgitation on echo281305407035Management00Management1555750407036Always admit febrile IVDU / febrile patient with prosthetic valve for assessment; anticoagulation not indicated; start antibiotics before blood culture resultsIV antibiotics for 2-6/52: Acute = ampicillin 2g Q4h (or benzylpenicillin 60mg/kg to max 3g) + flucloxacillin 2g Q4h + gentamicin 5mg/kg OD Subacute = ampicillin (or ceftriaxone or vancomycin) + gentamicin Prosthetic / IVDU = ceftriazone (if >1yr since replacement, to cover HACEK) + vancomycin + gentamicin Valve replacement: if moderate-severe CCF / pseudomonas / brucella / coxsiella burnetti / fungal / new ECG changes / unstable prosthesis / staph aureus in prosthetic valve / persistent bacteraemia despite antibiotics; usually not needed if prosthetic valve >1yr old; delay surgery if recent intracerebral haemorrhage or cerebral embolismIf prosthetic: stop anticoagulation if staph aureus (high risk of intracerebral haemorrhage)Antibiotic prophylaxis: If suitable lesion: prosthetic valve, previous infective endocarditis, unrepaired cyanotic defects, repairs with prosthetic material, residual defects at site of prosthetic material, valvulopathy post-cardiac transplant, RHD) Not suitable lesion: prev ASD / VSD / PDA repair+ suitable procedure: ie. >70% risk of bacteraemia = I+D of abscess, reimplantation tooth, dental abscess drainage, vaginal delivery with prolonged labour)Not needed procedure: IDC placement, ETT, IV access, ICC placement, NGT placement, PEG tube placement, D+C, normal SVDGive PO 1hr before / IV immediately before; use amoxicillin / clindamycin / cephalexin / vancomycin00Always admit febrile IVDU / febrile patient with prosthetic valve for assessment; anticoagulation not indicated; start antibiotics before blood culture resultsIV antibiotics for 2-6/52: Acute = ampicillin 2g Q4h (or benzylpenicillin 60mg/kg to max 3g) + flucloxacillin 2g Q4h + gentamicin 5mg/kg OD Subacute = ampicillin (or ceftriaxone or vancomycin) + gentamicin Prosthetic / IVDU = ceftriazone (if >1yr since replacement, to cover HACEK) + vancomycin + gentamicin Valve replacement: if moderate-severe CCF / pseudomonas / brucella / coxsiella burnetti / fungal / new ECG changes / unstable prosthesis / staph aureus in prosthetic valve / persistent bacteraemia despite antibiotics; usually not needed if prosthetic valve >1yr old; delay surgery if recent intracerebral haemorrhage or cerebral embolismIf prosthetic: stop anticoagulation if staph aureus (high risk of intracerebral haemorrhage)Antibiotic prophylaxis: If suitable lesion: prosthetic valve, previous infective endocarditis, unrepaired cyanotic defects, repairs with prosthetic material, residual defects at site of prosthetic material, valvulopathy post-cardiac transplant, RHD) Not suitable lesion: prev ASD / VSD / PDA repair+ suitable procedure: ie. >70% risk of bacteraemia = I+D of abscess, reimplantation tooth, dental abscess drainage, vaginal delivery with prolonged labour)Not needed procedure: IDC placement, ETT, IV access, ICC placement, NGT placement, PEG tube placement, D+C, normal SVDGive PO 1hr before / IV immediately before; use amoxicillin / clindamycin / cephalexin / vancomycin ................
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