Infectious DiseasesTier 2Topic

Basic imaging - ultrasound scan, including echocardiography for the evaluation of endocarditis

Role

Ultrasound uses no ionising radiation and provides real-time imaging, making it a first-line, repeatable modality for abdominal/pelvic collections, soft tissue abscess characterisation, and - as echocardiography - direct visualisation of cardiac valves and structures for suspected endocarditis
Extremely widely used given portability (point-of-care ultrasound), safety, and repeatability without cumulative radiation exposure concerns

TTE vs TOE

Transthoracic echocardiography (TTE) is first-line for suspected endocarditis but has limited sensitivity, particularly for prosthetic valves and small vegetations - transoesophageal echocardiography (TOE) offers substantially higher sensitivity and should be pursued when TTE is negative but clinical suspicion for endocarditis remains high (e.g. persistent bacteraemia, new murmur, prosthetic valve)

Point-of-care and guided procedures

Point-of-care ultrasound rapidly identifies free fluid, superficial abscess, or a dilated biliary tree at the bedside, guiding immediate management and further imaging needs
Ultrasound-guided aspiration/drainage of abscesses combines diagnostic sampling with therapeutic source control in a single procedure

Acting on findings

Negative TTE with ongoing high suspicion for endocarditis -> proceed to TOE rather than concluding endocarditis is excluded
Identified abscess accessible to ultrasound guidance -> image-guided aspiration/drainage, sent for culture to direct antimicrobial therapy

Common indications

Infective endocarditis (TTE vs TOE sensitivity distinction), superficial and deep abscess, biliary sepsis (cholangitis/cholecystitis source identification)

Limitations

A negative transthoracic echocardiogram does not exclude endocarditis, particularly with a prosthetic valve or small vegetation - transoesophageal echocardiography should follow when clinical suspicion remains high, since treating a negative TTE as definitively excluding the diagnosis is a recognised diagnostic pitfall

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