see:
- [Dunn - Endocarditis](x-devonthink-item://99DB9DE3-A0CD-458D-B2F9-4752D2EDCC26)
- ==[Hayes' sonography of infective endocarditis](x-devonthink-item://42E3767A-6BCB-4DFA-BA96-EFC03696E32F)==
- [Hayes' Bacterial endocarditis](x-devonthink-item://72B54FF8-8825-422C-9F77-B25D24752EC3)
- [Rosen - infective endocarditis and valvular heart disease](x-devonthink-item://5774E353-C5F3-499E-950B-57CED9C97125)
- [Tintinalli - Endocarditis](x-devonthink-item://1776C440-59D8-4BE3-A07E-2BE4E2A8F894?page=46)
> [!Key Points]
> **Bacterial endocarditis is a _commonly missed_ diagnosis as symptoms and signs are very non-specific, and so called “classical” signs are frequently absent.**
>
> most commonly presents as pyrexia of unknown origin
# Risk factors
- **Prosthetic valve** endocarditis accounts for up to 30 % of cases.
- In developing countries, **rheumatic fever** remains the commonest risk factor for infective endocarditis.
- IV drug use a risk factor in australia
- any structural valvular lesion
- Mitral valve prolapse
- proesthetic valves
- congenital disease
- cardiomyopathies
- previous endocarditis
- immunosuppression
- diabetes
- foreign bodies
- central lines
- PPMs
# Pathophysiology
## organisms
3 principle causative organisms are:
1. Staph aureus
2. Streptococcus species
3. enterococcus
### Staph aureus
- commonest cause
- seen in IVDU
- accounts for majority of tricuspid vegitations
### Streptococcus
- including viridans in cases of bad dental hygeine
### Enterococcus
- older age groups >60
- ?from colonoscopies
# presentation phenotypes
1. old people: subacute, fatigue, anaemia
2. acute: high fever, mmurmurs, flu-like illness, younger
## prosthetic valve endocarditis
**Ring abscess** - hallmark of mechanical valve endocarditis
Can cause:
- valve dehissance
- Myocardial abscess and [[Heart Block|AV Block]]
- Perivalvular leak
- Valve stenosis
- Purulent pericarditis
# Duke Criteria
> can diagnoise IE with:
> 2 major criteria
> 1 major and 3 minor
> 5 minor criteria
## major criteria
1. positive blood culture for IE from 2 separate cultures
2. evidence of endocardial involvement (positive ECHO)
## minor criteria
1. predisposing factors (IVDU, cardiac condition)
2. Fever
3. Vascular phenomena
1. janeway lesions
2. systemic arterial thrombus (septic emboli)
3. conjunctival haemorrhages
4. immunologic phenomena
1. glomerulonephritis
2. osloer's nodes
3. roth spots (retina)
4. rheumatoid factor
5. mycrobacterial evidence
1. positive but doesn't meet criterion
6. ECHO findings
1. that don't meet above criterion
# ECHO features of endocarditis
#pocus
- valvular vegetations
- irregular masses attached to upstream side of valves. ==atrial side of mitral and tricuspid, and ventricular side of aortic and pulm valves==
- oscillating and chaotic movements independent of valve motion, often extruding out with systole and prolapsing inward with diastole
- older vegetations can be fibrotic and calcified
- valvular regurgitation
- inadequate leaflet coaption
- valve perforation
- chordal involvement
- other, eg:
- paravalvular abscesses
- tissue destruction
- prosthetic valve dehiscence
- fistulae
- effusions due to pancarditis
- intracardiac thrombi
![[Pasted image 20240915224659.png]]
mitral valve IE. vegetations located on inflow side (LA) of the valve. free-floating into the LA during systole and prolapse into LV in diastole
![[Pasted image 20240915224754.png]]
aortic valve IE. vegetations attached on ventricular side. in diastole they prolapse into the LV, and in systole protrude into the aorta.
![[Pasted image 20240915224859.png]]
Tricuspid valve IE. specific (but infrequent) for IVDU. also can see from PPM lead or immunocompromised. *don't need TOE to dx tricuspid IE*. vegetations can be *large*, and are attached to atrial side, prolpasing into the RA in systole and into RV in diastole. tricuspid IE embolize into pulm circulation
![[Pasted image 20240915225040.png]]
Tricuspid IE in subcostal view
# Treatment
emperic treatment, give all:
- flucloxacillin 2 g 4 hourly
- ampicillin 2 g IV 4/ 24 (or benzyl penicillin)
- gentamicin 4-5 mg/kg IV daily
if proesthetic valve:
- vanc
- ceftriaxone
- gent
s aureus endocarditis has high rate of ICH; ∴ weigh pros/cons of anticoagulation
## indications for urgent surgery
- refractory heart failure related to valvular dysfunction
- abscess or fistula formation
- ongoing sepsis or ↑ vegetations despite abx
- unstable prosthesis
- multiple embolic episodes
# Related Questions
## endocarditis
- [ ] 10Q: [Endocarditis](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=36) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=38)
## infective endocarditis
- [ ] 17Q: [Fever and Malaise](x-devonthink-item://F3284DF7-780A-48C2-B18F-86C7C6B2AC27?page=5) -- [Answer](x-devonthink-item://2088AEED-9FCF-4CF0-B58D-E4279D4BCC76?page=47) -- [prop](x-devonthink-item://5F365535-E019-4C8D-8402-2E764B328988?page=8)
## murmurs
- [ ] 18Q: [Missed Murmur](x-devonthink-item://B9C99BB4-DAF8-4D15-BBD3-40E82B279902?page=4) -- [Answer](x-devonthink-item://DF848F67-27AB-450A-988B-159784B72957?page=4)
## rheumatic fever
- [ ] 20Q: [Rheumatic Fever](x-devonthink-item://4AD9F692-A113-4718-94B0-7292F2273B1F?page=5) -- [Answer](x-devonthink-item://A10DE51E-92FA-42D1-8AA0-7AE68C2FA743?page=21)