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CLINICAL REVIEW: Rhys P Beynon, V K Bahl, and Bernard D Prendergast Infective endocarditis BMJ 2006; 333: 334-339 [Full text]

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Infective Endocarditis Review: General Practitioner's role understated.

Sam W Mhlongo, Patrick Maduna, Acquira J. Mbokazi   (17 August 2006)

Surgeons perspective

Sujay K Shad   (18 August 2006)

Infective Endocarditis: View from Developing Countries

Vinay K Bahl, Bernard Prendergast   (25 August 2006)

Infective Endocarditis Review: General Practitioner's role understated. 17 August 2006
Sam W Mhlongo, Professor of Family Medicine & Head of Department Department of Family Medicine, University of Limpopo, Medunsa Campus, Medunsa 0204, South Africa, Patrick Maduna, Acquira J. Mbokazi Send response to journal: Re: Infective Endocarditis Review: General Practitioner's role understated.	As family physicians (general practitioners) in a developing country, we find the clinical review article 'Infective Endocarditis' by Rhys P Beynon and colleagues timely and of major importance -(BMJ, Vol 333: 334 - 339). We are however dissaponted that the review is largely biomedical, high-tech with a mere cursory comment on prevention and prophylaxis. In our setting, we see a significant number of patients with mitral valve disease secondary to rheumatic fever and it is our view that rheumatic fever, like TB is the archetypical disease of poverty. Beynon and colleagues are right when they say 'Classic textbook signs may still be seen in the developing world,....".(1) Our undergraduate medical students have no difficulties identifying Osler's nodes. What our students rarely see are intravenous drug users. In order to prevent or reduce cases of infective endocarditis, it is therefore impotant to understand its context. In the box dealing with 'What do general practitioners need to consider', we note that the suggestions are purely biomedical - their job is to diagnose and help to fix things by referring to tertiary care - there is not a single sentence or phrase on prevention and health promotion.(2) Beynon and his colleagues limit the role of general practitioners to venesection (for blood cultures), identification of risk factors for endocarditis and discovery of new cardiac murmurs. W e find this unacceptable not only in our setting in the developing world but anywhere in the world. In our preventive approach, we seek to understand the context of all illnesses. In our setting this is not an easy task. In the review, the authors state 'A history of prolonged unexplained fever, sweats, chills, weight loss, or anaemia should prompt consideration of further investigation, including blood cultures and echocardiography.' In the developing world, the vast majority of patients presenting this way would be diagnosed as immunocompromised (AIDS) patients using the Bangui criteria. An integration of good clinical diagnostic skills and an understanding of the context of the illness is what we consider useful in the management and care of patients in the community. In conclusion, our view is that family physicians (general practitioners) have a mjor role to play in the prevention of infective endocarditis through educating their patients and collaborating with public health physicians in putting pressure on governments to improve living conditions. We do not think the development of anti-bacterial vaccines, though welcome, and the preoccupation with biomedicine ( the engineering model of medicine) will serve as major factors in our endeavour to eradicate infective endocarditis. References: 1.Rhys P. Beynon et al: Infective endocarditis: BMJ Vol.333 12 Aug. 2006 2.Ian R. McWhinney: A Textbook of Family Medicine (OUP,1989) Competing interests: None declared
Surgeons perspective 18 August 2006
Sujay K Shad, Consultant Cardiac Surgeon Sir Ganga Ram Hospital, New Delhi India Send response to journal: Re: Surgeons perspective	It is possible that dental disease is less important in the UK;however this might not hold true for our setting. Poor dental hygiene with significant periodontal disease and dental caries is frequently observed here. When these patients are treated for regurgitant valvular lesions, it is common for treating physicians to often rightly consider them rheumatic. At surgery however one often finds leaflet disruption, perforation and other telltale signs of healed endocarditis. Without proof however, I assume them to be of dental origin. Returning to history after the op (oops!), one can often elicit a history of high grade temperature with prostration that was treated by multiple physicians with multiple antibiotics a few months or years ago. I wish to putforth what surgeons consider absolute indications for surgery during acute endocarditis- uncontrollable infection (after 4-5 days anitbiotics), uncontrollable heart failure, fungal infection, repeated systemic embolisation, aortic root abscess (conduction defects), prosthetic valve endocarditis and possibly also Staph aureus endocarditis (much more destructive). Competing interests: None declared
Infective Endocarditis: View from Developing Countries 25 August 2006
Vinay K Bahl, Professor of Cardiology All India Institute of Medical Sciences, New Delhi-110029, Bernard Prendergast Send response to journal: Re: Infective Endocarditis: View from Developing Countries	We agree with Professor Mhlongo that valvular rheumatic heart disease is the most common underlying lesion for infective endocarditis in developing countries. The prevention is of paramount importance in this regard. Well-established guidelines are available for prophylaxis of both rheumatic fever and infective endocarditis. However, their proper implementation is lacking in developing countries for various reasons and need to be improved and emphasized to general practioners. It is equally important to be aware of management guidelines for established cases of infective endocarditis as it is a fatal disease if not treated properly. It is only with a multi-directional approach including public health education, improvement in living standard, awareness and implementation of prophylaxis guidelines by family physicians, development of newer and better modalities of diagnosis ( not forgetting improved clinical skills !) and treatment (including !vaccines), one can hope to eliminate the problem of rheumatic fever and infective endocarditis, We also agree with Dr Shad that poor dental hygiene is important factor in developing countries in context of infective endocarditis . The timely surgical intervention in these patients can be life saving. Competing interests: None declared