Download endocarditis

ENDOCARDITIS
(see also Infective Endocarditis)
Bacterial or fungal infection of a native (usually damaged) or prosthetic heart valve or of a septal defect.
Always fatal if untreated.
Predisposition
 Congenital biscuspid aortic valve
 Ventricular septal defect
 Other congenital heart disease
 Rheumatic valve disease
 Degenerative aortic valvular disease
 Previous valve surgery or prosthesis
Organisms
Native valvular disease
Viridans streptococci
 dental source
 special association Streptococcus mutans & S. sanguis
 often "sub-acute"
Staphylococcus aureus
 very often previously normal valves
 often unknown source
 dramatic with high mortality
 disseminated infection common
enterococci
 gut or urinary tract
 instrumentation or surgery
other
 Streptococcus bovis -- association with colon carcinoma
 group B streptococci
 pneumococci
 salmonellae
 haemophili
 cardiobacterium
 actinobacillus
 coagulase negative staphylococci
 Coxiella burnettii -- Q fever
 Mycoplasma pneumoniae
 Chlamydia psittaci
Prosthetic valve infection- often recurrent
early
 S. aureus
 coagulase negative staphylococci
 fungi etc.
late
as for native valve infection
Features
 Malaise
 weight loss
 fever
 anaemia
 changing murmur
 embolism
 cardiac failure
 splinter haemorrhages
 Osler's nodes
 raised ESR
 microscopic haematuria
Investigations
 Haemoglobin
 ESR
 urinalysis
 echocardiogram
 Blood cultures ( 3 - 6 sets before treatment)
 Serology
Treatment
Always consult a microbiologist
Native- surgery sometimes required
blind
treatment
streptococci
enterococci
S. aureus
IV benzyl penicillin + flucloxacillin +gentamicin*
IV benzyl penicillin + gentamicin* for 2 wks
then high dose oral amoxycillin for 2 wks
IV ampicillin + gentamicin* for 4 wks
IV flucloxacillin for 4 wks + gentamicin (1 week) or oral fusidic acid
* gentamicin should be used very carefully i.e. not more than 80 mg bd with monitoring not less often
than 48 hourly
Prosthetic- surgery nearly always required
blind treatment
IV vancomycin + gentamicin
coagulase negative staphylocci -go by sensitivities, vancomycin usually
S. aureus
- as above
Prevention
Antibiotics given to cover procedures causing bacteraemia in patients with damaged or prosthetic valves
- see British National Formulary
Procedures
 dental scaling or extraction - single dose amoxycillin
 gut or urinary tract instrumentation or surgery - single dose iv ampicillin + gentamicin
Valve replacement surgery must be covered - (vancomycin in Sheffield )
Blood culture
Use chlorhexidine in alcohol
Leave to dry
"Clean" venepuncture
Put blood in blood culture bottles before others
10 mls anaerobic bottle & 10 mls aerobic bottle
Separate venepuncture for each set
Advantages of multiple sets
 larger volume of blood
 easier to sort out contaminants from pathogens
 bacteraemia may be intermittent
Probably not necessary to change needles