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CRITERIA AND INVESTIGATIONS OF

INFECTIVE ENDOCARDITIS
REETOBAAN DATTA (31)
Clinical features (recap)
• Fever: 80-90%
• Chills and sweats: 40-75%
• Anorexia, malaise and weight loss: 25-50%
• Myalgia and arthralgias: 15-30%
• Back pain: 7-15%
• Heart murmur: 80-85%
• New or worsened regurgitant murmur: 20-50%
• Arterial emboli: 20-50%
• Splenomegaly: 15-50%
• Clubbing: 10-20%
• Neurological manifestations: 20-40%
• Peripheral manifestations: 2-15%
• Petechiae: 10-40%
Lab features

• Anemia: 70-90%

• Leukocytosis: 20-30%

• Microscopic hematuria: 30-50%

• Elevated esr: 60-90%

• Elevated crp: >90%

• Rheumatoid factor: 50%

• Circulating immune complexes: 65-100%

• Decreased serum complement: 5-40%


Modified duke’s: major criteria

Positive blood culture Evidence of endo-cardial involvement


• Positive echocardiogram findings of
• Typical organism from two cultures vegetations, abcesses, new partial
OR dehiscence of prosthetic valves
• Persistently positive blood cultures: OR
i. Blood cultures drawn >12 hrs apart • New valvular regurgitation
ii. Three or more positive cultures over
1 hour
OR
• Single positive blood culture for
Coxiella burnetii or phase I IgG Ab
titer of >1800
MODIFIED DUKE’S: MINOR CRITERIA

• Predisposition: Predisposing heart condition or IDU


• Fever > 38 C
• Vascular phenomena: major arterial emboli, septic pulmonary
infarcts, Mycotic aneurysm, intra-cranial hemorrhage,
conjunctival hemorrhage, Janeway lesions
• Immunologic phenomena: glomerulonephritis, Osler’s nodes,
Roth’s spots, Rheumatoid factor
• Microbiologic evidence: Positive blood culture but not meeting
major criteria or serologic evidence of active infection with an
organism consistent with IE
The criteria

Definite endocarditis

• 2 major or 1 major+ 3 minor or 5 minor

Possible endocarditis

• 1 major+1 minor or three minor


INVESTIGATIONS
1. BLOOD CULTURE

• In patients with suspected NVE, PVE or CIED IE (not on antibiotics): 3 two-bottle


blood culture sets, separated from one another by at least 2 hours, from different
venipuncture sites over 24 hours
• Negative after 2-3 days: 2-3 additional blood culture sets
• Sub-Acute conditions: withhold empirical antibiotics
• Hemodynamically unstable acute conditions: Start empirical antibiotics
• Bacteria to look for: Staph aureus, beta-hemolytic strep, pneumococci, HACEK,
viridans strep, enterococci, CoNS
• Exceptional cases: Bartonellla, Coxiella
• T. whipplei: culture negative
investigations
2. Serologic tests

• Useful for organisms difficult to extract on culture: Brucella, Bartonella, Legionella,


Chlamydia, Coxiella
• Use of DFA techniques and PCR: helpful in distinguishing affections due to bacteria
and fungi (16 S and 28 S ribosomal unit respectively)
investigations
3. Echocardiography

• Anatomical confirmation, measurement of vegetation, detection of intra-cardiac


complications and assessment of cardiac function
• Transthoracic Echocardiography (TTE): extremely specific but can’t detect
vegetations <2 mm. 65-80% pts with definite endocarditis detected
• Trans esophageal Echocardiography (TEE): Safe and detects veg. in 90% pts with
definite endocarditis. Optimal method for the diagnosis of PVE, detection of
myocardial abcess, valve perforation, CIED, intracardiac fistulae
• Low risk, low suspicion: TTE then TEE
• High risk, high suspicion: TEE
investigations
4. Other investigations

• CBC
• Creatinine levels
• LFT
• ECG
• ESR
• CRP
• Circulating immune complex titer
• Cardiac catheterisation in pts. who are to undergo surgery

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