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1st Year Systems > Infective Endocarditis > Flashcards

Infective Endocarditis Flashcards

1
Q

Learning outcomes

A

So basically how you get it, and what the presentation, investigation and treatment is

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2
Q

What is infective endocarditis?

A

Infective endocarditis is a form of endocarditis. It is an inflammation of the inner tissues of the heart, the endocardium, usually of the valves. Can involve the interventricular septum, chordae tendinae and intra cardiac devices.

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3
Q

How does infective endocardiits affect men and women?

A

Affects men more than women with a ratio of 2:1

Women have a worse prognosis

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4
Q

What percentage of IE patients have underlying structural heart disease?

A

Around 25%

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5
Q

What are the cardiac risk factors for infective endocarditis?

A
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6
Q

What are the predisposing valvular lesions in patients with IE?

A
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7
Q

What are the non-cardiac risk factors for patients with IE?

A
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8
Q

How does infective endocarditis arise?

A

Valvular surface is damaged as a result of turbulent blood flow. As a result, platelets and fibrin adhere to the underlying collagen surface and create a sterile fibrin-platelet vegetation. Bacteraemia leads to colonisation of the thrombus and perpetuates further fibrin deposition and platelet aggregation, which develops into a mature infected vegetation.

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9
Q

What are the ways bacteraemia can arise?

A
  • Extra-cardiac infections
  • Invasive procedures (e.g. oral, abdominal, genitourinary surgery

intravascular catheters)

  • Gingival disease – easy access for bugs to enter blood stream
  • Activities of daily living (brushing teeth and bowel movements)
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10
Q

What are the different modes of acquisition?

A

Health care related - (nosocomial - occuring within the hospital - if over 48 hours after hospitilisation)

Non - nosocomial (if the signs and symptoms appear less than 48 hours after admission - usually as a result of home based nursing, IV therapy, haemodialysis if less than 30 days before onset, acute care facility if 90 days before onset, resident in nursing home)

Community - acquired

IVDA (intravenous drug abuse)

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11
Q

What are the symptoms of infective endocarditis?

A
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12
Q

What is this sign of infective endocarditis?

A

Splinter haemorrhages

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13
Q

What is this sign of infective endocarditis?

A

Vasculitic rash

Petechial (a small red or purple spot caused by bleeding into the skin)

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14
Q

What is this sign of infective endocarditis?

A

Roth spots

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15
Q

What is this sign of infective endocarditis?

A

Osler’s nodes

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16
Q

What is this sign of infective endocarditis?

A

Janeway lesions (Pathognomonic) (specifically characteristic or indicative of a particular disease or condition)

macular means spots

Ecchymotic means: the escape of blood into the tissues from ruptured blood vessels marked by a livid black-and-blue or purple spot or area - differs from petechiae only because the spots are greater than 3 mm

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17
Q

What are the signs of infective endocarditis?

A

Congestive cardiac failure

Immune complex deposition:

splinter haemorrhages

vasculitic rash

Roth Spots

Osler’s nodes

Janeway lesions

nephritis

Embolic Phenomena (vegetation embolises - absess forms in the place it lands)

Focal neurological signs (Focal neurologic signs also known as focal neurological deficits or focal CNSsigns are impairments of nerve, spinal cord, or brain function that affects a specific region of the body, e.g. weakness in the left arm, the right leg, paresis, or plegia.)

Peripheral embolus :

­renal

­cerebral

­splanchnic

­vertebral

Pulmonary Embolus

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18
Q

When is there a high index of suspicion?

A

When there is

FEVER

NEW MURMUR
KNOWN IE CAUSATIVE ORGANISM
PROSTHETIC MATERIAL

PREVIOUS INFECTIVE ENDOCARDITIS

CONGENITAL HEART DISEASE

NEW CONDUCTION DISORDER

IMMUNOCOMPROMISED

IVDA

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19
Q

When are signs asbsent for IE?

A
  • elderly
  • after antibiotic treatment
  • immunocompromised
  • IE involving less virulent / atypical organisms
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20
Q

What are the relevant investigations for IE?

A

Markers for infection for inflammation / infection (Full blood count, neutrophilia, CRP ESR)

Urinary and electrolyte tests - searching for nephritis, infection and sepsis

Blood Cultures (before starting antibiotics)

Urinalysis - looking for blood - if so - nephritis

ECG - looking for conduction delay

CXR - looking for heart failure and pulmonary abscess - sign of embolisation

Echocardiogram - transthoracic or transoesophageal

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21
Q

When would you need a transoesophageal echo?

A

When the TTE is normal and the clinical suspicion is high

OR

When the TTE/TOE is normal but the suspicion of IE remains high - repeat echo at 7/10 days as initial vegetation may have been too small to see.

OR

TTE is positive and you need to assess complications, abscesses and measure the size of the vegetation.

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22
Q

When is repeat TTE and TOE needed?

A

If there is a new complication e.g

new murmur

persisting fever

embolism

heart failure

abscess

atrioventricular block

OR

To assess ongoing treatment (silent complications and vegetation size) / treatment success on completion (valve morphology and cardiac function)

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23
Q

What are the possible ways you get negative blood cultures even when IE is positive?

A

If there has been prior antibiotic use

If there are fastidious organisms present

If there are intracellular bacteria

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24
Q

What are the common bacteria responsible for IE?

A

85% of all IE:

streptococci

enterococci

staphylococcus

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25
Q

How does streptococci viridians enter the blood?

A

Orally

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26
Q

What are the health care associated microbiological causes of IE?

A

Staph aureus

Coagulase negative staph (staph epidermis)

27
Q

Which bacterial cause of IE is most common among intravenous drug users?

A

Staph aureus

28
Q

What bacteria is most likely to infect native valve?

A

Strep viridians

29
Q

What bacteria is most likely to infect a prosthetic valve?

A

Staph epidermis

30
Q

Give exmamples of fastidious organisms

A

Nutritionally variant streptococci

Fastidious Gram –ve bacilli – HACEK group

­Haemophilus parainfluenzae, H. aphrophilus, H. paraphrophilus, H. influenzae, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae, K. dentrificans

Brucella

Fungi

31
Q

Give examples of intracellular bacteria

A

5% of all IE

Coxiella burnetii

Bartonella

Chlamydia

32
Q

How do you check for intracellular bacteria?

A

Serology, PCR, Gene amplification, Cell culture

33
Q

What are the major findings of the modified DUKE criteria in the diagnosis of IE?

A

Blood cultures positive for IE

Evidence of endocardial involvement

34
Q

When is blood culture for IE considered positive?

A

Typical organisms consistent with IE from 2 separate blood cultures

Persistently positive blood cultures have organisms consistent with IE

Single positive blood culture for coxiella burnetti

35
Q

What is the modified duke criteria - minor?

A
36
Q

What is diagnosis according to modified duke criteria?

A

Definite: 2 major

1 major and 3 minor or 5 minor

Possible:

1 major and 3 minor

37
Q

What is treatment for IE?

A

Antibiotics and maybe surgery

38
Q

What is the benefit of using aminoglycosides in conjunction with beta lactams and glycopeptides (cell wall inhibitors)?

A

Synergistic

Bacetericidal

Shortern duration of therapy

39
Q

What are the likely infective organisms for native valves and the corresponding treatment?

A

staphylococci

streptococci

HACEK species

Bartonella spp.

40
Q

What is the treatment for native valve infection?

A

Plus potentially IV vancomycin (if penicillin allergic/severe sepsis or MRSA)

41
Q

What is the treatment for native valve infection and sepsis

A

Gentamicin

Vancomycin

42
Q

What is the treatment for infection of prosthetic valves?

A

Rifampicin, gentamicin and vancomycin

43
Q

What are the likely infective organisms for prosthetic valve infections?

A

MSSA

MRSA

non - HACEK - ve pathogens

44
Q

What are the potential side effects of gentamicin?

A

Ototoxic and nephrotoxic

45
Q

What are the continuous investigations that are required?

A

Fullblood count

U and E’s

CRP

ECG (1-2 days)

Echo (weekly)

46
Q

When is a fungal infection likely?

A

Prosthetic valve endocarditis

IVDA
Immunocompromised

47
Q

What are the likely organisms for fungal infections?

A

Candida

Aspergillus

48
Q

What is mortality like for fungal infective endocarditis?

A

Mortality is high (over 50%)

49
Q

What is treatment for fungal IE?

A

Dual anti-fungals

Valve replacement

Often maintained long term

Sometimes for life (on antifungals)

50
Q

What are the potential complications of IE? (also the indications for surgery)

A

Heart Failure

Fistula formation

Leaflet perforation

Uncontrolled infection

Abscess formation

AV heart block

Embolism

Prosthetic valve dysfunction / dehiscence

51
Q

What is the most common indication for surgery?

A

Heart failure - refractory pulmonary oedema

52
Q

What is meant by an uncontrolled infection?

A

Persisting fever, +ve blood cultures >7-10 days

  • inadequate antibiotic treatment
  • resistant organisms
  • infected lines
  • locally uncontrolled infection
  • embolic complications – absess?
  • extracardiac site of infection
  • adverse reaction to antibiotics – can cause fever
53
Q

What are the organisms that produce large vegetations?

A

•staph, strep bovis, candida – cause huge vegetations

54
Q

When would you operate an embolism?

A

If the embolism and the vegetation is greater than 10mm

OR

Isolated vegetation is greater than 15 mm

55
Q

What is the most severe form of IE?

A

Prosthetic valve endocarditis

10-30% of all cases

Poor Prognosis (20-40% in-hospital mortality)

56
Q

What is recommended before removal of an intracardiac device?

A

IV antibiotics for as long as possible before removal

57
Q

What is prophylaxis for IE?

A

Limited to highest risk patients (highest incidence and highest risk of adverse outcomes from IE)

Antibiotic prophylaxis should be reduced

Good oral hygiene & regular dental review are of particular importance

58
Q

What are the cardiac conditions at highest risk of IE?

A

Acquired valvular heart disease:

  • stenosis
  • regurgitation

Valve replacement

Structural congenital heart disease

  • surgically corrected / palliated structural conditions
  • excluding
  • isolated ASD
  • fully repaired VSD or PDA
  • closure devices that are endothelialised

Hypertrophic cardiomyopathy

Previous IE

59
Q

What are risky procedures that may have to be avoided?

A

Body piercing and tattooing

Puts patients at risk of IE

60
Q

DO NOT OFFER

A
61
Q

Look

A
62
Q

Which infective organism is responsible for acute and sub acute IE?

A

Acute: days and weeks (staph aureus)

Subacute: Weeks and months (strptococci)

63
Q

What is treatment for Staph?

A

MSSA:

Native valve: Flucloxacillin - 4 weeks

Prosthetic valve: Flucloxacillin, rifampicin and gentamicin - 4 weeks

MRSA:

Native valve: Flucloxacillin, rifampicin - 4 weeks

Prosthetic valve: Vancomycin, rifampicin - 6 weeks and gentamicin - more than weeks

1st Year Systems (81 decks)

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