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Flashcards in Infectious DIsease Deck (46):
1

Infective Endocarditis

- infection of the endocardium
- commonly affects heart valves, esp mitral valve

2

Risk factors for infective endocarditis

- Rheumatic, Congenital or Valvular Disease
- Prosthetic heart valves
- IV drug use
- Immunosuppression

3

Most common causative agent in infective endocarditis

S. aureus
- responsible for > 80% of acute bacterial endocarditis in pts with hx of IV drug use

4

Main causative agents in infective endocarditis

- S. aureus
- Viridans streptoccocci
- Coagualse negative Staphylococcus
- Streptococcus bovus
- Candida and Aspergillus

5

Viridans strep in infectious endocarditis

- most common pathogen for left-sided subacute bacterial endocarditis and following dental procedurs in native valves

6

Coagulase negative streptococcus in infectious endocarditis

- most common infecting organism in prosthetic valves

7

Streptococus bovis endocarditis

S. bovis endocarditis associated with co-existing GI malignancy

8

Candida and Aspergillus endocarditis

account for most cases of fungal endocarditis
- predisposing factors are: long-term IV catheters, malignancy, AIDS, organ transplant, and IV drug use

9

Pt presents w/ fever and new / change inmurmur. Likely diagnosis?

Endocarditis

10

Complications of endocarditis

JR = NO FAME
Janeway lesions (flat and painless)
Roth spots in eyes
Nail-bed (splinter) hemorrhage
Osler's nodes (raised and painful)
Fever
Anemia
Murmur
Emboli to lung or brain

11

Endocarditis: Hx adnd PE

- Constitutional sx (fever/FUO, weight loss, fatigue)
- exam reveals heart murmur (MV > AV) in non-IV drug users; right sided murmur in IV drug users (tricuspid > MV > AV)
- immune phenomena (e.g. splinter hemorrhages, Roth spots)

12

Diagnosis of Endocarditis

- Duke's criteria
- 2 major, 1 major + 3 minor, 5 minor
- CBC with leukocytosis and left shift; incr ESR and CRP

13

Best initial test for endocarditi

- Blood cultures
- TTE
-

14

Duke's Major Criteria for Endocarditis

1. At least 2 separate positive blood cx for a typical organism, persistent bacteremia w/ any organism or a single culture of Coxiella

2. Evidence of endocardial involvement (via TTE/TEE) or new murmur

15

Duke's Minor Criteria

1. predisposing factors
2. Fever > 38.3
3. Vascular phenomena: septic emboli, septic infarcts, mycotic aneurysm, Janeway lesions
4. Immune phenomena: GN, Osler's nodes, Roth's spts,
5. Microbiological evidence that doesn't meet major criteria

16

Tx of infective endocarditis

Best empiric treatment is vancomycin and gentamycin
- narrow abx course wherever appropriate

17

Tx of Viridans Strep endocarditis

- Ceftriaxone for 4 weeks

18

Tx of S. aureus (MSSA)

Oxacilln, nafcillin, or cefazolin

19

Tx of fungal endocarditis (candida or aspergillus)

Amphotericin and valve replacement

20

Tx of staph epidermidis or resistant Staph endocarditis

Vancomycin

21

Tx of Enterococi endocarditis

Ampicillin and gentamicin

22

Indications for surgery in patient with endocarditis

1. CHF or ruptured valve or chordae tendinae
2. Prosthetic valves
3. Fungal endocarditis
4. Abscess
5. AV block
6. Recurrent emboli while on abx

23

Causative organisms in culture negative endocarditis

HACEK (Haemophlus parainfluenzae, Actinobacillus, Cardiobacterum, Eikenella, Kingella)
Coxiella burnetti
Brucella
Bartonella

24

Most common causes of culture negative endocarditis

Coxiella
Bartonella

25

Tx of HACEK group endocarditis

Ceftriaxone

26

Prophylaxis indications of endocarditis

1. Significant cardiac defect (e.g prostetic

27

HIV

retrovirus that targets and destroys CD4 T cells
- infection characterized by high rate of viral replication that leads to progressive decline in CD4 count

28

CD4 count

- indicates degree of immunosuppression
- guides therapy and prophylaxis and helps determine prognosis

29

Viral load

may predict the rate of disease progression
- provides predictions for treatment and gauges response to ARTs

30

HIV: Hx and PE

- acute HIV, pts are often asymptomatic but patients may also present with mononucleosis-like or flu-like symptoms (e.g. fever, lymphadenitis, maculopapular rash)
- HIV may present later as night sweats, weight loss, thrush, recurrent infxns or opportunic infxns

31

Diagnosis of HIV

ELISA test (detects serum antibodies) then Western blot as confirmatory tests

32

Baseline eval for HIV should incle:

HIV RNA PCR (viral load)
CD4 count
PPD skin tests
Pap smear
Mental status exam
VDRL/RPR
serologies for CMV

33

Treatment for HIV

Initiate ART:
1. symptomatic patients (those with AIDS defining illness no matter CD4 count)
2. Patients with CD4 count < 350
3. Pregnant patients
4. Those with HIV specific conditions (e.g. HIV associated nephropathy, neurocognitive deficits)

34

Initial regimen for HIV

2 nucleoside reverse transcriptase inhibitors (NRTIs) plus 1 nonnucleoside reverse transcriptase inhibitor

-- most import is select multiple meds (usually 3) to achieve durable treatment response and limit resistance

35

Goal of HIV therapy

Limit viral suppression < 50 copies
- after therapy is started CD4 count should be monitored monthly until suppression is achieved and every 3-6 months afterward

36

HIV + with CD4 300 - 500

Baceterial infections
TB
Herpes Simplex
Herpes Zoster
Vaginal candidiasis
Hairy leukoplakia
Kaposi's sarcoma

37

HIV + with 75 - 175

Pneumocytosis
Toxoplasmosis
Cryptococcus
Coccidiomycosis
Cryptosporidoios

38

HIV < 50

Disseminated MAC infection
Histoplasmosis
CMV retinitis
CNS lymphoma

39

Pregnant HIV + patient is not on ARVs at time of delivery, she should be treated with what meds?

Intrapaerum zidovudine
- infants should recieve AZT for 6 weeks after birth

40

Which is only live vaccine that should be given to HIV patients?

MMR

41

P jiroveci pneumonia (PCP pneumonia)

- prophylaxis indicated at CD4 < 200
prior PCP infection
- unexplained fever x 2 weeks
- HIV related candidiasis

42

PCP prophylaxis

- single strength TMP-SMX (Bactrim fo
** discontinue PCP prophylaziz when CD4 > 200 for 3 months

43

Mycobacterium avium complex (MAC)

prophylaxis indicated when CD4 count < 50-100
- treated with weekly azithromycin
- discontinue prophylaxis when CD4 count is > 100 for > 6 months

44

Toxoplasma gondii (HIV +)

prophylaxis indicated < 100 with positive IgG serologies
- prophylaxis with double strength Bactrim

45

M tuberculosis (HIV +)

prophylaxis indicated PPD > 5mm
- treated with isonizaid x 9 months (+ pyridoxine) or rifampin (4 months)
- include pyridoxine with INH-containing regiments
`

46

Candida prophylaxis (HIV +)

prophylaxis indicated at multiple recurrences
esophagitis prophylaxis: fluconazole
oral: nystatin swish and swallow