Download INFECTIVE ENDOCARDITIS

Infective Endocarditis
A Disease in Disguise
Optimizing Recognition &Response
Ann Krinks
Trainee Advanced Nurse Practitioner
Raise Awareness of Infective Endocarditis by
Launching an Educational Awareness
Campaign
• Promote awareness of infective endocarditis throughout the health care
setting
• Alert health care professionals to the seriousness of the disease challenging
them to recognise and act upon presenting signs & symptoms
• To be aware of high risk patients who may be susceptible to developing
infective endocarditis
• To get health care professional to think past initial diagnosis and consider IE
as the primary cause of underlying conditions
Impact on Practice
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Raise the bar on quality of care
Improve patient safety
Early recognition of signs & symptoms
Early diagnosis
Early treatment
Improved prognosis and patient outcome
INFECTIVE ENDOCARDITIS
 A deadly disease, high mortality nearly 100% if not recognised or left untreated &
20-25% when treated.
 Historically associated with heart valve damage from rheumatic fever (now un-
common in the developed world).
 Perceived to be uncommon & diagnosis is often missed or diagnosed late when the
disease is advanced
 Despite evolution in antibiotic therapy & sepsis prevention , incidence not declined
in last 30 years ?
 Changes in nature of disease & emergence of new causes – degenerative heart
disease in the growing elderly population has replaced rheumatic fever as the major
cause of valveular disease
Why?
• Difficult to diagnose – no single clinical sign or symptom & no single diagnostic
front line test
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Many cases missed or diagnosed late when disease is advanced
Antibiotic resistance ( makes treatment challenging)
Disease in disguise- can manifest with varied clinical presentations
Symptoms can be non specific – viral symptoms, lethargy, low grade fever (25% of
patients take over 1/12 to be admitted after onset of initial symptoms)
Microbial infection of the endothelial surface of the
heart & heart valves
• Caused by micro-organisms , usually
bacteria, also fungi causing
inflammation within the endocardium
(inner lining of the heart)
• Micro-organisms can adhere & multiply
on the heart valves leading to vegetation
growth (clumps of bacteria red & white
blood cells, fibrin)
• Vegetation can break off & cause
emboli to occlude blood vessels within
the body ( a serious complication of IE)
• Bacteria enter the bloodstream causing
bacteraemia
• Bacteria can settle on normal or abnormal
heart valves
• This can damage or destroy the heart
valves ( leading to valve perforation)
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• Staphylococcus aureus
(nose, skin, respiratory tract)
• Staphylococcus epidermidis
(normal skin flora, immunocompromised.
…patients, hospital acquired)
• Streptococci viridans
(mouth)
• Enterococci
(normal intestinal flora)
Fungal Endocarditis
• On mitral valve
• Candida Albicans
• ( oral & genital infections)
Who's at Risk?
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Prosthetic valves
Degenerative heart valve disease
Congenital heart defects (patent ductus arteriosus, VSD)
Implanted cardiac devices Pacemaker, ICD
Long term indwelling vascular catheters Hickman lines, PICC
lines
Immunocompromised
Injection drug users
Risky social behaviour eg Body piercings, Tattoos
Previous endocarditis
Presentation
Initially symptoms may be vague & put down to viral illness
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Low grade fever
Chills
Night sweats
Fatigue
Arthralgia
Weight loss
85% patients present with a new or worsening existing murmur
Cardiac signs- resulting from damaged valves
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New heart murmur
Change in existing murmur
↓ Cardiac output (valve perforation)
Heart Failure
Conduction disorders (mainly) AV blocks
Myocardial infarction (coronary embolism)
Dermatological signs – result of small emboli
travelling to peripheral vessels
• Splinter haemorrhage
• Oslers nodes (painful nodules on
fingers & toes)
• Janeway lesions
(Painless lesions on palms & soles
…of feet)
• Nail fold infarct
( Systemic emboli)
Petechiae
Inside eyelids
Oral mucosa
Petechial rash (non –blanching )
Roth spots (retinal haemorrhage
seen on fundoscopy)
Complications of embolization
Symptoms will depend on where the emboli dislodge and where they go
RIGHT SIDE - Tricuspid
PULMONARY CIRCULATION
PE LUNG ABCESS
LEFT SIDE- Mitral
BRAIN (stroke) KIDNEY SPLEEN (infarct)
MI
Management
• Early recognition
• Early blood cultures ( ideally pre antibiotic) to avoid false negative results
• Early echo TTE (inadequate views in up to 20%) /TOE (>90% sensitivity
detects small emboli <5mm)
• Team approach involve Cardiologist, ID, Microbiologist
• Treatment is with lengthy IV antibiotic therapy +/- surgery
Key Message
• Infective endocarditis is a diverse disease and can masquerade as other
illnesses
• Vigilance & suspicion are key
• Suspect IE in fever of unknown origin
• FEVER + MURMUR
ENDOCARDITIS
(until proven otherwise)
INFECTIVE
ENDOCARDITIS
THANKYOU for listening