Rheumatic heart disease with mitral regurgitation; 3 weeks of fever, weight loss, new breathlessness; splinter haemorrhages, splenomegaly (or IV drug user with fever and a new tricuspid murmur)
Red flags
Acute heart failure
Heart block
Stroke or limb embolism
Persistent fever and bacteraemia
Differential diagnosis
Rheumatic fever
Other bacteraemia source
Atrial myxoma
SLE (Libman–Sacks)
Marantic endocarditis (cancer)
When to admit, call ICU or discharge
Admit: Every suspected endocarditis
ICU: Heart failure, shock, stroke, heart block
Surgery: Heart failure, uncontrolled infection, large vegetation with embolism — emergency to within days
Key points
In India, rheumatic heart disease is still the commonest substrate; viridans streptococci and S. aureus dominate.
Any S. aureus bacteraemia needs an echo and 2 weeks+ of IV therapy.
Prophylaxis before dental procedures is only for prosthetic valves, previous endocarditis, some congenital heart disease (and many advise it in RHD with high risk).
Never
Start antibiotics before 3 sets of blood cultures in a stable patient
Add gentamicin to MSSA native-valve endocarditis
Anticoagulate or give thrombolysis for embolic stroke in active endocarditis without the team
Discharge without a dental source review
Common mistakes
Single culture set
Missing abscess (no ECG, no TOE)
Gentamicin in MSSA NVE
Late surgical referral
Disposition and follow-up
Ward/CCU under an endocarditis team; cardiac surgery centre for complications.
ICU Decoded — original critical-care and internal-medicine pathways by
Dr Javed Akhtar, each cited to a current guideline. For education and quick
reference; verify every dose against local protocols before prescribing.