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Mr Roger Hall,
Four specific groups with infective endocarditis (IE) were discussed
1. The elderly
IE is more common in older patients peaking in the 70s, is more often device related but less often associated with iv drug abuse. Staph Aureus (SA) is less common, but there is probably more infection from GI and GU tract. Gentamicin should not be used unless essential as it has the potential for harm, particularly in the context of the declining renal function often seen in the elderly. There is a lack of data but what data there is shows that surgery is used less than in younger patients, but may offer advantages for some patients who are currently denied it.
Overall 16% of IE occurs in diabetics, rising to 27% in the USA. Again, there are few data, but what there are show that mortality is increased as much as 2 to 5 fold and particularly marked in patients who are treated with insulin. SA infections are more common and the skin may be an important portal of entry. Surgery is used less often, possibly because of more co-morbidity.
3. Negative blood cultures
70% of cases are due to prior antibiotics therapy and the rest are due to fastidious organisms or intracellular organism. The clinical picture is important and the possibility that the echo findings or vegetations or abscess are false positives must be considered. Close co-operation between cardiologists and microbiologists is essential and the antibiotic regime depends on the clinical scenario e.g. native valve, early and late prosthetic valve. The prognosis of these patients is no worse than in patients with positive culture and the indications for surgery are the same.
4. Cardiac devices (ICD and PPM)
The risk is approx 2/1000 per year and makes up between 6-20% of IE depending on the series. The echo may be normal. It is more common if a temporary wire has been used, if there was fever at the time of implantation or if a system is re-implanted too early after an infected system is removed. IE is reduced by prophylactic antibiotics to cover implantation. Treatment consists of antibiotic therapy with removal of the system. This is done percutaneously in most cases but if vegetations are greater than 25mm in size, surgical removal is favoured.
Management of infective endocarditis in particular subgroups