Intended for healthcare professionals

Rapid response to:

Clinical Review

Infective endocarditis

BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7563.334 (Published 10 August 2006) Cite this as: BMJ 2006;333:334

Rapid Response:

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

Competing interests: No competing interests

17 August 2006
Sam W Mhlongo
Professor of Family Medicine & Head of Department
Patrick Maduna, Acquira J. Mbokazi
Department of Family Medicine, University of Limpopo, Medunsa Campus, Medunsa 0204, South Africa