Endocarditis

Question 1

A 64 year old female is admitted to hospital with fever and rigors but no other focal symptoms. She had a metallic mitral valve replacement 12 months ago. you are asked to review her on a Saturday afternoon as her blood cultures, 24 hrs post admission, have grown methicillin sensitive staphylococcus aureus in 4/4 bottles. How would you manage this situation?

Answer 1

Impression
MSSA bacteraemia given positive culture results. Concerned about high risk of L sided MSSA endocarditis in the setting of metallic valve replacement. Low-virulence infective endocarditis. Significant complications of L sided endocarditis both cardiac (valve rupture, carditis) and systemic (renal/adrenal infarcts, strokes etc)

Goals
- ensure HD stability
- Targeted Hx/Ex/Ix, utilise Dukes criteria for diagnosis (Echo, blood cultures, clinical signs)
- administer appropriate empirical ABx treatment, consult for?surgical intervention given metallic valve in situ

Question 2

Endocarditis - Assessment

Answer 2

Assessment
- ensure HD stability before proceeding with Hx/Ex/Ix

Question 3

Endocarditis - History

Answer 3

History
- Sx: FROM JANE (fevers, Roth spots, oslers nodes, murmur, laneway lesions, anaemia, nail-bed changes, emboli). chest pain, other focal areas of pain, focal neurology
- cardiac sx: dyspnoea, cough, NPD, chest pain
- PC: onset, timing, progression
- Complications: neurology, septic emboli (lungs, kidneys,)l sepsis
- Medications, allergies, PMHx
- SNAP

Question 4

Endocarditis - Examination

Answer 4

Examination
- General appearance
- Vitals
- Cardioresp examination: murmurs (new onset), oslers, laneways, etc
- Fundoscopy: Roth spots
- signs of infective endocarditis

Question 5

Endocarditis - Investigations

Answer 5

Investigations
Duke’s Criteria (BE FEVER)
Major
B - Blood cultures; positive with typical contaminant
E - Echo findings consistent with IE (vegetations)
Minor
F - Fever >38
E - Immunological phenomenon (oslers = ow)
V - Vascular phenomenon (splinter hb, roth spots)
E - Microbio findings not consistent with Major criteria
R - Risk factors (IVDU, RHD, congenital heart disease, valve replacement)

Bedside: uACR, ECG
Bloods: FBC, UEC, CRP/ESR, Blood Cultures, RF,
Imaging: CXR

Question 6

Endocarditis - Management

Answer 6

Management
Management is different based on causative pathogen and type of valve affected (native vs prosthetic)

Complications
- mycotic aneurysm
- sepsis
- GN
- DIC
- other sites of embolism and

Supportive
- Fluids
- antipyretics
- anticoagulation if embolic event
- close monitoring for evidence of complications

Definitive
- Empirical ABx treatment, consult ID
- +/- anticoagulation
- Cardio consult for ?valve replacement –> mitral valve replacement

Empiric ABx treatment (eTG)
Prosthetic valve;
In methicillin sensitive;
- Fluclox + Vancomycin - 6 weeks of ABx treatment
- Gentamicin
- controversy around addition of rifampicin. Seek expert advice

Native valve
Again depends on underlying organism and sensitivities, refer to eTG.
- Ben pen + fluclox
- gentamicin