Prevention of infective endocarditis in developing countries

Infective endocarditis (IE) causes substantial morbidity and mortality despite modern antimicrobial chemotherapy and advances in the ability to diagnose and treat complications. Prevention of IE is, therefore, very important. Infective endo-carditis usually develops following a bacteraemia in individuals with underlying structural cardiac defects. Bacteraemia may occur spontaneously, follow everyday procedures or complicate certain interventions, such as dental extraction. 3,4 In developing countries, IE occurs most frequently in patients with rheumatic heart disease (RHD). The first step in the prevention of IE would be to reduce the pool of patients who are susceptible to this infection. This requires the effective implementation of programmes to prevent rheumatic fever and, therefore, RHD. 5,6 Regrettably, this has not happened in developing countries. 5 Furthermore, prophylaxis against IE has been neglected or seen as a separate issue. The prevention of both IE and rheumatic fever recurrences should be viewed as part and parcel of the care of a patient with RHD in order to reduce unnecessary morbidity and mortality in patients with RHD in developing countries. RHD should be prioritised in developing countries and a greater emphasis needs to be placed on the simple and cost-effective measures that are currently available to combat RHD in the developing world. 5-8 Many patients with RHD are unaware of the presence of their underlying heart disease and are, therefore, unable to request prophylaxis against IE. It has been proposed that in developing countries, registered nurses be trained to detect children with cardiac abnormalities, refer them to doctors organising the screening programme for assessment, and thereafter maintain follow up of these patients. 9 The nurses would be responsible for ensuring secondary prophylaxis against rheumatic fever and prophylaxis against IE. The doctor in such a nurse-orientated primary healthcare service would be responsible for the organisation, monitoring and continuity of such programmes. Dodu and Bothig stated that in many countries, nurses are trained to recognise certain criteria such as heart murmurs for referral and have proved to be both reliable and efficient in identifying children who need medical examination. 13 School-based surveys could be made more effective if performed as part of a general-purpose health survey of school children. The ultimate aim should be to incorporate screening surveys into a routine school examination system conducted on a regular basis or to establish such services where they do not exist. Such school-based surveys can only reach children who attend school. Children who …