Makindo Medical Notes

🩺 The presence of an Endocarditis Team is crucial in IE. This multidisciplinary approach has been shown to significantly reduce 1-year mortality. ⚠️ Do not start antibiotics before taking at least 3 blood cultures over 12+ hrs, using strict aseptic technique.

📖 About

• Infective Endocarditis (IE) = infection of the endocardium and heart valves, usually bacterial.
• Vegetations consist of organisms + fibrin + platelets, may embolise.
• Causes valve destruction, regurgitation, abscesses, and embolic/immune complications.

🧬 Aetiology & Pathophysiology

• Infection of native or prosthetic valves, congenital defects (VSD, bicuspid aortic valve).
• Often seeded by bacteraemia in patients with prior endothelial damage.
• Immune complex deposition → vasculitis, glomerulonephritis, skin signs.
• Emboli may affect brain 🧠, spleen, kidneys, or lungs.

📊 Epidemiology

• Commoner in men
• Increasingly older patients
• IV drug use → right-sided IE (tricuspid valve)
• Underlying rheumatic or congenital heart disease

🦠 Common Organisms

⚠️ High Risk Groups

• Prosthetic valve patients (including TAVI)
• Previous IE
• Uncorrected cyanotic congenital heart disease, or within 6 months post-repair

🩺 Clinical Features

• Constitutional: malaise, fever, sweats, weight loss
• Cardiac: new murmur, AF, HF, conduction block
• Embolic: stroke, splenic infarct, lung abscess
• Peripheral stigmata: Roth spots 👁, splinter haemorrhages, Osler nodes (tender), Janeway lesions (painless)
• Right-sided IE → septic lung emboli, cavitating pneumonia

Clinical signs or Stigmata of Endocarditis

Vegetations

Roth's spots

Vegetations

🔎 Diagnosis

• Blood cultures: 3 sets before antibiotics
• Echocardiography: TEE > TTE for vegetations, abscess, prosthetic dehiscence
• Duke criteria: Major + minor clinical/micro/echo findings

🧪 Investigations

• Bloods: normocytic anaemia, raised ESR/CRP
• Urine: microscopic haematuria (GN)
• ECG: arrhythmia, AV block (aortic root abscess)
• CXR: pulmonary oedema, septic emboli
• CT/MRI brain: embolic infarcts (often haemorrhagic if anticoagulated)

💊 Medical Management

• Source control: treat dental/skin sepsis
• Culture-guided IV antibiotics (see table below)
• Duration: 4–6 weeks (≥6 weeks if prosthetic valve)
• Prosthetic valve IE: triple therapy (vancomycin + gentamicin + rifampicin)
• Close liaison with Endocarditis MDT

📊 Endocarditis – Antibiotic Management Summary

💡 Exam Tip: Always take 3 sets of blood cultures before starting antibiotics (unless the patient is critically unwell). Surgical referral is urgent if there is heart failure, peri-valvular abscess, uncontrolled sepsis, or large vegetations.

🪡 Surgical Management

• Indications: refractory infection, emboli despite therapy, HF from valve destruction, abscess
• Procedures: valve replacement (mechanical, bioprosthetic, homograft), repair where feasible, abscess drainage, device removal
• Timing: urgent if severe HF/emboli; elective if stabilised after antibiotics

📚 Reference

• ESC 2015 Guidelines for the Management of Infective Endocarditis