2. How do we make decisions? In
medicine
• Dogma:” Doctrine/Teaching”
• Tradition: “We’ve always done it that way”
• Convention: “Everyone does it this way”
• Evidence-Based: “Evidence supports this way”
3. Evidence Based Medicine(EBM)
• Conscientious, ^yDoh idÌshg wkql+,&
• Explicit, ^iqmeyeos,s&
• Judicious ^m%{djkA;&
• use of
• “current best evidence in making decisions
about the care of individual patients”
4.
5.
6.
7.
8.
9. • First BSAC guidelines- in 2004- Mostly the
expert opinions
• Latest in 2012 –
– Majority of recommendations are evidence
based,
– Rest are consensus among the working party
members (Expert Opinion)
10. What is included in 2012 BSAC
• Mx of Native valve endocarditis(NVE) &
• Mx of Prosthetic valve endocarditis (PVE).
• PVE includes infections in
– Prosthetic valves of all types,
– Annuloplasty rings,
– Intracardiac patches and
– Shunts.
11. What is excluded from 2012
• Infective Endocarditis related to
– pacemakers,
– defibrillators or
– ventricular-assist devices
• These dealt in a separate BSAC review
12. The aim of these guidelines
• Standardize the initial investigation and
treatment of IE;
• Identify the patients who can develop adverse
drug reactions (Side Effects and Toxicity)
• identify pts fail to respond to initial antimicrobial
therapy and may require a change in therapy or
surgery.
13. Summary
2004 Vs 2012
• 2004 guidelines based on expert opinion
• 2012 – Mostly are evidence based: When
evidence is not available→ Consensus
– A-high-quality randomized controlled trials and
meta-analysis of randomized controlled trials;
– B -observational data and non-randomized trials;
and
– C - expert opinion or Working Party consensus.
16. IE- The clinical presentation is highly
variable,
• Vary according to the causative microorganism,
• Vary according to presence or absence of pre-
existing cardiac disease,
• Presence of co-morbidities
• Risk factors for the development of IE.(IVDU,HD,
etc)
17. IE may present as
• An acute, rapidly progressive infection,
• as a subacute or chronic disease,
• low-grade fever and non-specific symptoms that may
cause confusion in initial assessment.
• Patients present to a variety of specialists/GPs who
may consider a range of alternative diagnoses,
– Any chronic infection,
– Rheumatological disorder
– and autoimmune disease or
– malignancy.
18. Presentation
• The majority (90%) of patients present with fever,
– with systemic symptoms of chills,
– poor appetite
– weight loss.
• Heart murmurs up to 85% (Pre existing heart murmur
should prompt heighten degree of suspicion for look for IE)
• New murmurs reported in 48%.
• New valvular regurgitation is more specific for a diagnosis of
IE
19. • Classic textbook signs( Rare)
• Peripheral stigmata of IE are increasingly
uncommon (patients generally present at an
early stage of the disease)
• Immunological phenomena, such as
– Splinter hemorrhages,
– Roth spots and
– glomerulonephritis, are now less common,
• Emboli to brain, lung or spleen occur in 30% of
patients(Often could be presenting symptom)
20.
21.
22. Six right sided endocarditis patients
were followed up….
Present/Yes Absent/No Total
Embolic
phenomena
3
Pneumonia
3 6
Isolate MRSA (3 out of 3 sets) 3
patients
3 6
Risk factor Present in 3 cases
1. CVP cannulation @
ICU 3/12 before for
MX of DHF
2. Recurrent Blood
transfusion for Thal
3. Criminal Abortion
4. Long Term HD
5. Long Term HD
Risk factors not present in
one case
6
Classical risk factors
such as IVDU
No Not present in all 6 case 6
Outcome with
surgery
3 responded for
vegetectomy
one died and 1 responded
for treatment, one
undergoing treatment
6
23. • Atypical presentations
– e.g. absence of fever is more common in the elderly,
after antibiotic pre-treatment,
– in the immunocompromised patients and
– in IE involving less virulent or atypical organisms.
• The diagnosis of IE should also be considered in
patients who present with
– a stroke or transient ischaemic attack and a fever.
29. The Duke criteria has
clinical,
echocardiographic
and microbiological findings,
Were developed as a research tool- provide high specificity and moderate
sensitivity for the diagnosis of IE.
These criteria an objective tool for evaluating the strength of evidence to support a
diagnosis of IE, particularly in difficult cases.
30.
31.
32.
33.
34. IE is a condition where you get
continuous bacteremia
• Generally all three blood cultures will be
positive
• Single blood culture = No culturing
35.
36.
37.
38.
39. WE have stopped giving sensitivities on the isolates directly to the wards. AST should
be interpreted with the help of CLIN_MICRO TEAM
40.
41.
42.
43.
44.
45.
46.
47. Why monitor only aminoglycosides
(and Vancomycin?)
• Low therapeutic index.
• Bactericidal efficacy ᾀ peak concentrations
• Toxicity is related to total drug exposure
• Nephrotoxicity (usually reversible) and ototoxicity
(often irreversible)
• The desired plasma concentration-time profile for
aminoglycosides differs to most other drugs.
48. Amino glycoside toxicity
• More with divided doses than single once
daily dose
• Body weight is measured according to ideal
body weight (not the actual body weight)
• Ideal body weight ± 20% is allowed
52. Use of Ɓ-Lactams
• Can amphicillin/amoxycillin use fro treatment of IE
• Why only penicillin is used?
• What are the drugs given in pen allergy?
• How do you ascertain a history of pen allergy as a true
immediate type of HS?
• With a history of rash with Amp, can you give pen?
• In the backdrop of anaphylaxis, can you give CRO?
53. 5.3 b-Lactams
• Amoxicillin and ampicillin → microbiologically equivalent and
either can be used.
• Amoxicillin can be used instead of benzylpenicillin for
susceptible isolates (greater risk of Clostridium difficile
infection)
• Need to be given more frequently (due to short t1/2)
• No comparison of continuous with intermittent penicillin
administration for streptococcal endocarditis.
• Dose modifications necessary for renal failure
54. A history of a rash with ampicillin or amoxicillin may not indicate true allergy.
Unless signs of immediate-type hypersensitivity (anaphylaxis, angio-oedema, bronchospasm
and urticaria) were reported, a trial with penicillin may be warranted,(A emergency trolley
need to be kept bear)
A rash occurs after 72 h- unlikely to be an immediate IgE-mediated
reaction (type I hypersensitivity).
In a recent study, 72% of patients with a delayed-type hypersensitivity reaction to
aminopenicillins had no cross-reactivity with penicillin.
The American Heart Association (AHA) advises ceftriaxone for the penicillin-allergic pts,
(for allergy other than immediate-type hypersensitivity, because of the risk of cross-
sensitivity with penicillin)
