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Transcript
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