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Infective Endocarditis

Clinical features o Subconjucntival haemorrhages o Cerebral emboli o Roth spots in funi o Petechial haemorrhages of mucous membranes and fundi o Poor dentition o Splenomegaly o Systemic emboli- nail fold infart o Digital clubbing- long standing emboli only o Oslers nodes- painful o Janeway lesions- non-painful. o Splinter haemorrhages o Petechial rash o Loss of pulses o Varying murmurs- new onset. o Conduction disorder o Cardiac failure Subacute bacterial endocarditis- SBE o Often due to streptococci, mild to modrate illness, with progresses over weeks and months and has low propensity to seed to extracardiac sites Acute bacterial endocarditis- ABE

o RF

Fulminant illness over days to weeks and is more likely due to Staph aureus and frequently causes metastic infection.

o IVDU o Dermatitis o Renal failure o Organ transplantation o DM o Post-op wounds o Valve replacement o Entry usually via skin. Diagnosis

o Duke criteria Major criteria Positive blood culture o Typical organism in 2 separate cultures or o Persistently +ve blood cultures eg 3 >12 hrs apart Endocardium involved o Positive Echo- vegetation, abscess, dehiscence of prosthetic valve o New valvular regurgitiation Minor criteria Predisposition- IVDU, cardiac lesion Fever > 38 Degrees Vascular/immunological signs o Evidence of emboli, janelway lesions etc o Immunological problems- GN, Oslers nodes

Positive blood culture that does not meet major crtierai Positive Echocardiogram that does not meet major criteria. Diagnosis 2 major 1 major + 3 minor 5 minor

Treatment- Ab o Empirical therapy Benzylpencillin 1.2g/4H IV + Gentamicin 1mg/kg/8h for 4 weeks If acute- add flucloxacillin 2g/6h IV to cover staph o Enterococci Amoxicllin 1g/6h iv + Gentamicin 1mg/kg/8h o Streptococcoci Benzypencillin + Amoxicillin for 2 weeks, then add Gentamicin o Staph Flucloxacillin + Gentamicin If MRSA. Vancomycin + Rifampicin o Coxiella Doxycycline 100mg/12h PO indefintied + co-trimoxazole, rifampicin or ciprofloxacin o Fungi Flucytosine 50mg/kg/6h IV followed by fluconazole. Amphotericin if fluctosine resistant or Aspergillus. Miconazole if renal function poor.