Flashcards in Clinical Endocarditis Deck (40):
What is infective endocarditis?
disease caused by microbial infection of the endothelial lining of intracardiac structures.
What makes up the vegetation of IE?
mass of platelets, fibrin, mircro colonies of microorganisms, and inflammatory cells.
Even though IE most commonly involves the heart valves, where else can it infect?
low pressure side of a VSD, on mural endocardium, or on intracardiac devices
What is infective endarteritis?
process involving arteriovenous shunts, arterioarterial shunts (PDA), or coarctation of the aorta.
How do we classify IE?
1. Site of infection (left or right heart, or nonvalvular)
2. Temporal evolution
3. Cause of infection (bacteria, fungal, HACEK organism, or culture negative).
4. Predisposing risk factors (native valve, prosthetic valve, or IVDU).
What is acute temporal evolution IE?
hectic febrile illness that rapidly damages cardiac structures, seeds extra cardiac sites, and progresses to death in days to 6 weeks if untreated.
What is subacute/chronic temporal evolution IE?
indolent course, causes structural cardiac damage only slowly if at all, rarely metastasizes, death in 6 weeks to 3 months, and gradually progressive unless complicated by a major embolic event or ruptured mycotic aneurysm.
What is the median age age of a pt with IE?
How does community acquired IE compare to healthcare associated IE of NATIVE valves?
community acquired= strep viridans, or sometimes staph
healthcare associated= staph
Is prothetic valve IE arising within 2 months of valve surgery generally nosocomial (hospital acquired)?
YES and surgery is often required.
Is the risk higher or lower for IE in pts with intracardiac defibrillators vs pacemakers?
higher in pts with intracardiac defibrillators (mostly staph aureus).
What complications are common with pts who get IE with an implantable device?
septic pulmonary emboli (bilateral)
Is the DUKE criteria sensitive for IE of pts with implantable devices?
How can you easily recognize IE in IVDU?
track marks at injection site
Is incidence of mortality higher or lower in IVDU IE?
lower due to right side of heart being effected (staph aureus is culprit).
What pathogen is associated with tap water?
**How does acute left sided IE present?
- sepsis, fever, chills (40%), and tachycardia
- they can also present with CHF (dyspnea, frothy sputum, chest pain).
- murmur of aortic or mitral regurgitation (85%).
- mental status change (similar to stroke symptoms).
**How does subacute left sided IE present?
- recurrent intermittent fever (but not as high as acute)
- malaise, anorexia, weight loss
murmur of aortic or mitral regurgitation
**How does right sided IE present?
- usually acute
- 60% IVDU
- fever, cough, chest pain, hemoptysis, dyspnea
- pulmonary effusions
What should we look for when approaching a pt we suspect has IE?
- new murmur or CHF
- clubbing (not specific of EI)
- neurologic symptoms due to brain aneurysm.
- mucosal or conjunctival petechia, splinter hemorrhages, or palpable purpuric skin rashes.
- Janeway lesions (palms and soles)
- Osler nodes (fingers and painful)
- Roth spots on the retina.
What murmur is most associated with IVDU?
tricuspid regurgitation (right side; increases with INSPIRATION, holosystolic) and JVD.
What will you hear with mitral regurgitation?
holosystolic murmur best heard at the apex, may be associated with an S3 gallop.
What will you hear with aortic regurgitation?
blowing diastolic murmur associated with austin-flint rumbling murmur.
What are the symptoms of CHF?
dyspnea, orthopnea, PND, edema, JVD, S3 gallop
Are Janeway lesions, Osler nodes, and Roth spots more common in acute or subacute IE?
What is the primary route of entry for strep viridans, staph and HACEK IE organisms?
oral cavity, skin, and upper respiratory tract
What is the primary route of entry for strep bovis in IE?
What is the primary route of entry for enterococci in IE?
Why would a pt be culture negative?
due to prior antibiotic exposure, nutritionally variant, or HACEK organisms.
*** What are the 3 MAJOR DUKE criteria for IE blood cultures?
1. at least 2 separate positive blood cultures for typical IE mircoorganisms.
2. persistently postive BCs (2 sets drawn 12 hours apart or 3 BCs with the first and last separated by more than 1 hr).
3. single positive culture for Coxiella burnetii or anti-phase 1 antibody titer greater than 1:800.
*** What are the 4 MAJOR DUKE criteria for echocardial imaging?
1. new valve regurgitation
2. oscillating intracardiac mass on the valve or supporting structure.
4. dehiscence of prosthetic valve.
*** What are the MINOR DUKE criteria for IE?
- predisposing cardiac condition or IVDU
- fever (>100.4)
- positive blood cultures, but not meeting major criteria.
- vascular phenomena (emboli, mycotic aneurysms, petechia, Janeway lesions).
- immunologic phenomena (glomerulonephritis, Osler nodes, Roth spots, or rheumatoid factor).
*** Using the Duke criteria, what is a DEFINITE diagnosis?
- pathology or bacteriology of vegetations
- 2 major criteria
- 1 major and 3 minor
- 5 minor
*** Using the Duke criteria, what is a POSSIBLE diagnosis?
- 1 major and 1 minor
- 3 minor
Can you draw blood cultures from a vascular catheter?
NO due to high incidence of false positives.
How do we treat?
deliver antibiotics via central venous catheter
What are the indications for surgery with IE?
- acute IE with valve stenosis or regurgitation resulting in CHF.
- fungal or other highly resistant organism.
- heart block, annular or aortic abscess or destructive lesions.
- prothetic valve IE with CHF or failed antibiotic therapy.
What is the prognosis for native valve IE with step viridans, HACEK, or enterococci?
survival rate= 85-90% :)
Are the survival rates good for IVDU right sided IE?