Antimicrobial prophylaxis against infective endocarditis
د. حسين محمد جمعةاختصاصي الامراض الباطنة
البورد العربي
كلية طب الموصل
2010
Infective endocarditis is an inflammation of the endocardium, particularly affecting the heart valves, caused mainly by bacteria but occasionally by other infectious agents. It is a rare condition, with an annual incidence of fewer than 10 per 100 000 cases in the normal population. Despite advances in diagnosis and treatment, it remains a life threatening disease with significant mortality (approximately 20%) and morbidity.
The National Institute for Health and Clinical Excellence (NICE) has published guidelines on antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures. The guidelines in this module offer practical advice,
but they are not meant to replace clinical judgment.
Adults and children with structural cardiac defects at risk of developing infective endocarditis
• Acquired valvular heart disease with stenosis or regurgitation
• Valve replacement
• Structural congenital heart disease, including surgically corrected or palliated structural conditions, but excluding isolated atrial septal defect, fully repaired ventricular septal defect, or fully repaired patent ductus arteriosus, and closure devices that are judged to be endothelialised
• Previous infective endocarditis
• Hypertrophic cardiomyopathy.
Antibiotic prophylaxis against infective endocarditis is not recommended:
• For people undergoing dental procedures
• For people undergoing non-dental procedures at the following sites:
• Upper and lower gastrointestinal tract
• Genitourinary tract; this includes urological, gynaecological, and obstetric procedures, and childbirth
• Upper and lower respiratory tract; this includes ear, nose, and throat procedures and bronchoscopy.
Any episodes of infection in people at risk of infective endocarditis should be investigated and treated promptly to reduce the risk of endocarditis developing.
If a person at risk of infective endocarditis is receiving antimicrobial therapy because they are undergoing a gastrointestinal or genitourinary procedure at a site where there is a suspected infection, the person should receive an antibiotic that covers organisms that cause infective endocarditis.
Only 12% of patients with endocarditis have splinter haemorrhages.
Antibiotic prophylaxis against infective endocarditis is not recommended for people undergoing dental procedures - even for those who have had a valve replacement.Patient advice
You should offer people at risk of infective endocarditis clear and consistent information about prevention, including:The benefits and risks of antibiotic prophylaxis, and why antibiotic prophylaxis is no longer routinely recommended
The importance of maintaining good oral health
Symptoms that may indicate infective endocarditis and when to seek expert advice
The risks of undergoing invasive procedures, including non-medical procedures such as body piercing or tattooing.
Learning bite
the Duke criteria
Pathologic criteria
Microorganisms demonstrated by culture or histologic examination
Active endocarditis demonstrated by histologic examination
Major criteria
Positive blood culturesTypical microorganisms consistent with endocarditis from two separate blood cultures
Evidence of endocardial involvement
Echocardiography: oscillating structures, abscess formation, new partial dehiscence of prosthetic valve
New valvar regurgitation
Minor criteria
Predisposing heart diseaseFever >38°C
Vascular phenomena
Immunological phenomena
Microbiological evidence (no major criterion)
Suspect echocardiography (no major criterion)
An 80 year woman needs an emergency operation to drain an abscess at the site of her gastrostomy feeding tube.
She has aortic stenosis. Which one of the following should you do?
Prescribe prophylactic antibiotics covering organisms which cause infective endocarditis
The NICE guidelines recommend that if a person at risk of infective endocarditis is receiving antimicrobial therapy because they are undergoing a gastrointestinal or genitourinary procedure at a site where there is a suspected infection, the person should receive an antibiotic that covers organisms that cause infective endocarditis. This might be amoxicillin plus gentamicin in the case of enterococci for example.
