1. Infective Endocarditis A Disease in Disguise
Optimizing Recognition &Response Ann Krinks Trainee Advanced Nurse Practitioner

2. Raise Awareness of Infective Endocarditis by Launching an Educational Awareness Campaign
Promote awareness of infective endocarditis throughout the health care setting
Alert health care professionals to the seriousness of the disease challenging them to recognise and act upon presenting signs & symptoms
To be aware of high risk patients who may be susceptible to developing infective endocarditis
To get health care professional to think past initial diagnosis and consider IE as the primary cause of underlying conditions

3. Impact on Practice Raise the bar on quality of care
Improve patient safety
Early recognition of signs & symptoms
Early diagnosis
Early treatment
Improved prognosis and patient outcome

4. INFECTIVE ENDOCARDITIS

5. A deadly disease, high mortality nearly 100% if not recognised or left untreated & % when treated.
Historically associated with heart valve damage from rheumatic fever (now un- common in the developed world).
Perceived to be uncommon & diagnosis is often missed or diagnosed late when the disease is advanced
Despite evolution in antibiotic therapy & sepsis prevention , incidence not declined in last 30 years ?
Changes in nature of disease & emergence of new causes – degenerative heart disease in the growing elderly population has replaced rheumatic fever as the major cause of valveular disease

6. Why?
Difficult to diagnose – no single clinical sign or symptom & no single diagnostic front line test
Many cases missed or diagnosed late when disease is advanced
Antibiotic resistance ( makes treatment challenging)
Disease in disguise- can manifest with varied clinical presentations
Symptoms can be non specific – viral symptoms, lethargy, low grade fever (25% of patients take over 1/12 to be admitted after onset of initial symptoms)

7. Microbial infection of the endothelial surface of the heart & heart valves
Caused by micro-organisms , usually bacteria, also fungi causing inflammation within the endocardium (inner lining of the heart)
Micro-organisms can adhere & multiply on the heart valves leading to vegetation growth (clumps of bacteria red & white blood cells, fibrin)
Vegetation can break off & cause emboli to occlude blood vessels within the body ( a serious complication of IE)

9. Bacteria enter the bloodstream causing bacteraemia
Bacteria can settle on normal or abnormal heart valves
This can damage or destroy the heart valves ( leading to valve perforation)

10. Staphylococcus aureus (nose, skin, respiratory tract)
Staphylococcus epidermidis
(normal skin flora, immunocompromised. …patients, hospital acquired)

11. Streptococci viridans
(mouth)
Enterococci
(normal intestinal flora)

12. Fungal Endocarditis On mitral valve Candida Albicans
( oral & genital infections)

13. Who's at Risk? Prosthetic valves Degenerative heart valve disease
Congenital heart defects (patent ductus arteriosus, VSD)
Implanted cardiac devices Pacemaker, ICD
Long term indwelling vascular catheters Hickman lines, PICC lines
Immunocompromised
Injection drug users
Risky social behaviour eg Body piercings, Tattoos
Previous endocarditis

14. Presentation
Initially symptoms may be vague & put down to viral illness
Low grade fever
Chills
Night sweats
Fatigue
Arthralgia
Weight loss
85% patients present with a new or worsening existing murmur

15. Cardiac signs- resulting from damaged valves
New heart murmur
Change in existing murmur
↓ Cardiac output (valve perforation)
Heart Failure
Conduction disorders (mainly) AV blocks
Myocardial infarction (coronary embolism)

16. Oslers nodes (painful nodules on fingers & toes)
Dermatological signs – result of small emboli travelling to peripheral vessels
Splinter haemorrhage
Oslers nodes (painful nodules on fingers & toes)

17. Janeway lesions
(Painless lesions on palms & soles …of feet)
Nail fold infarct
( Systemic emboli)

18. Petechiae
Inside eyelids
Oral mucosa

19. Petechial rash (non –blanching )
Roth spots (retinal haemorrhage seen on fundoscopy)

20. Complications of embolization
Symptoms will depend on where the emboli dislodge and where they go RIGHT SIDE - Tricuspid PULMONARY CIRCULATION PE LUNG ABCESS LEFT SIDE- Mitral BRAIN (stroke) KIDNEY SPLEEN (infarct) MI

21. Management Early recognition
Early blood cultures ( ideally pre antibiotic) to avoid false negative results
Early echo TTE (inadequate views in up to 20%) /TOE (>90% sensitivity detects small emboli <5mm)
Team approach involve Cardiologist, ID, Microbiologist
Treatment is with lengthy IV antibiotic therapy +/- surgery

22. Key Message
Infective endocarditis is a diverse disease and can masquerade as other illnesses
Vigilance & suspicion are key
Suspect IE in fever of unknown origin
FEVER + MURMUR INFECTIVE ENDOCARDITIS (until proven otherwise) ENDOCARDITIS
THINK?

23. THANKYOU for listening