Infective Endocarditis: Difference between revisions

Several diagnostic criteria have been proposed for the diagnosis of IE. In clinical practice, it is the global clinical picture that leads to decision making in the diagnosis and treatment of endocarditis. The modified DUKE criteria for diagnosis is often widely used, with a sensitivity and specificity approaching ~80%<cite>xiv</cite> The DUKE criteria divides into Definite IE, Possible IE, or Rejected IE. It uses Major criteria (microbiology, valvular abnormalities) and Minor criteria (systemic symptoms described below). Using the diagnostic criteria for IE should not override clinical judgment.

===Roth Spots==

According the American Heart Association guidelines published in 2007 the following groups of patients are considered to be high-risk and require prophylaxis :

- Previous infective endocarditis

- Congenital heart disease (CHD)

- Unrepaired cyanotic CHD, including all palliative shunts and conduits

- Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure

- Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)

- Cardiac transplantation recipients who develop cardiac valvulopathy

- Manipulation of gingival tissue, or the periapical region of teeth or perforation of oral mucosa

- Incision or biopsy of the respiratory mucosa, or procedures involving treatment of abscess of empyema

Antibiotic prophylaxis is also recommended for any procedures on infected skin/skin structures or musculoskeletal tissue in high risk patients .

Conduction abnormalities, commonly characterized by heart blocks in endocarditis are associated with infection extension, increased risk of embolization and increased mortality. They are reported to be present in 26%-28% of patients .  

Embolization is a dreaded complication of IE and most commonly affects the spleen, brain, kidneys in cases of left sided endocarditis, and the lung in right sided endocarditis. Studies report a rate of 8.5-25% and are associated with significant mortality risk . Vegetation length, especially >10mm, infection with S. aureus, S. bovis are predictive factors for a higher rate of embolization and increased in mortality . Embolization to the brain can result in mycotic aneurysms which can present with a variety of neurologic manifestations depending on the anatomic location and spread of infection in the surrounding area. Up to 30% of patients with evidence of embolization to the brain are reported to be asymptomatic.  

Prognosis of IE is largely dependent on the patient’s comorbid conditions such as diabetes , hemodialysis, congestive heart failure , complications of endocarditis, prosthetic valve and the microorganism identified. Generally the outcome largely depends on the organism involved. According to recent data it, the over 30 day mortality is ~15% and the 1-year mortality is ~34%. Prosthetic valve endocarditis has a significant in hospital mortality of ~24%, while native valve endocarditis carries a lower in hospital mortality of 12% if treated early and surgically .