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Infectious disease > Infective endocarditis > Flashcards

Infective endocarditis Flashcards

1
Q

How is IE diagnosed

A

Dukes criteria - pathologicla or clinical

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2
Q

What is endocarditis

A

Infection and inflammation of endothelial surface of heart by microorganism

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3
Q

Pathogenesis of endocarditis

A

Tubulent blood flow -> dmaage smooth surfaces - accumulation of platelets/fibrin/leucocytes -> infected by any circulating microorganisms and form vegetation

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4
Q

What is vegetation

A

Infected mass attached to endocardial structure or on implanted intracardiac material

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5
Q

Vegetation on ECHO

A

Oscillating or non oscillating Intracardiac mass or other endocardial structures

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6
Q

Abscess appearance on ECHO

A

Thickened, non homogenous pervalvular area w echodense or echolucent appearance

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7
Q

What is a pseudoaneurysm and how does it look on ECHO

A

Perivalvular cavity communicating within cardiovascular lumen
Pulsatile perivalvular echo-free space with colour doppler flow detected

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8
Q

What is a perforation and how does it look on ECHO

A

Interruption of endocardial tissue continuity traversed by colour doppler flow
Can create a fistula

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9
Q

Valve aneurysm what is

A

Saccular outpuching (bulging on ECHO) of valvular tissue

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10
Q

How does dehiscence of prosthesis appear on ECHO

A

Paravalvular regugitation identified by TTE/TOE with or without rocking motion of prosthesis

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11
Q

Risk factors for IE

A

Any type of structural HD
RHD, mitral valve
Prosthetic valves, cardiac devices
Congenital HD
IVDUs
HIV
Extensive health care system contacts eg hospital interventions and time spent in hosptial

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12
Q

Bacterial causes of IE most common

A

Staoh ir strep 80% time
S.aureus, coagulase engative staph - rising due to hospital related infection
Enterococci - 3rd highest cause, related to healthcare contact
Gram negative and fungal pathogens rare but v severe and poor outcomes

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13
Q

Why cant always trust blood cultures in IE

A

10% patients have negative blood culture - either given antibiotics before or fastridious microorgansisms difficulty to isolate

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14
Q

List of causes of IE negative blood culture

A

Coxiella burnetti (livestocl, Q fever cause)
Bartonella spp (alcohol, homeless)
Brucella spp (livestock or abbattoirs)
Tropheryma whipplei
Brucella spp (middle east, unpasteurised diary)
Bartonella henseale (cats)
Aspergillus spp (healthcare contact w prosthetic valve)

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15
Q

Clinical history of IE why varies

A

Dependent on causative oraganism, cardiac disease etc -> varying presentation

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16
Q

Most common features of IE

A

Malaise, fever, cardiac murumurs

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16
Q

Symptoms that can signify endocarditis

A

Malaise, fever, new murmurs
Haematuria, Splenomegaly,
HF, petechiae ,arthralgia, cerbral emboli, mycotic aneurysm, clubbinng, oslers nodes, splinter haemorrhages, janeway lesions, Roth spots, conjunctival haemorrhages,

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16
Q

What does L sided IE cause

A

Infected emboli travelling through arteries systemically except lungs

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17
Q

What does R sided IE cause

A

Infected emboli -> lungs

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18
Q

Immunological manifestations of IE

A

Oslers nodes
Immune complex deposition glomerulonephitis
Systemic - Rf raised

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19
Q

What are oslers nodes

A

Arteriolar intimal proliferation w extension to venules and capillaries and may be accompanied by thrombosis and necrosis
Immune complexes within lesions

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20
Q

Investigation for IE

A

Bloods - inflam markers - CRP, ESR, WCC, Plts, U+Es, LFTs
Blood cultures
ECHO - TTE or TOE (more sensitive, can ick up emboli <5mm)

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21
Q

Blood cultures required for IE

A

3 sets within a period of time each 1-6 hrs apart
2 sets within 1 hr if septic patient from different sites

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22
Q

Why dont wait for temperature spike in IE

A

Bactaraemia is constant in IE

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23
Q

Treating endocarditis

A

National guidelines
4-6 weeks (L side longer) in hosptial - Outpatient when available
2 weeks if v sensitive
IV fo duration

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24
Q

Indicaitons for surgery with IE

A

Heart failure
Uncontrolled infection
Prevention of embolism

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25
Q

What is counted as uncontrolled infection in IE?

A

Abscess, aneurysms, fistula, enlarging vegetation despite antibiotics (risk of infected emboli high)
Persisting + blood cultures despite appropriate antibiotic
PVE caused by staph or non-HACEK gram - bacteria
Infection caused by fungi or multiresistant organisms

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26
Q

What surgical criteria for preventing embolism in IE

A

Aortic or mitral valve NVR or PVE w persitent vegetations >10mm after one or more embolic episode despite antibioticsn
Aortic or mitral NVE w vegetations >10mm ass w severe valve stenosis or regurg and low operative risk
Aortic or mitral NVE or PVE w isolated large vegetations >15mm
Aortic or mitral NVE or PVE w isolated v large vegetations >30mm

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27
Q

HF signs in IE

A

Aortic or mitral NVE/PVE
Severe acute regurgutatuon, obstruction or situal -> refractory pulmonary oedema or cardiogenic shock OR symptoms of HF, ECHO signs of poor haemodynamic tolerance

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28
Q

Prognosis for IE

A

100% death if no treatment
optimal treamtnet 20-25% die of IE

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29
Q

Predictors of poor otuomes IE

A

Older, prosthetic valve, diabetes, comorbiditiy
Clinical comps - HF, rneal failure, >moderate area ischaemic stroke, brain haemorrhaege, septic shcok Micororgansism - staph aureus, fungi, non-HCAEK gram negative bacteria
ECHO findings

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30
Q

ECHO findings that suggest poor prognosis

A

Periannular comps, severe L sided valve regurgitiation
Low left ventricular ejection fraction
Pulm HPTN
Large vegetations
Sev prosthetic valve dysfunction
Premature mitral valve closure or other signs of elevated diastolic pressure

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31
Q

Pathological criteria for IE

A

Micororganisms demostrated by culture or histology
Need a biopsy of vegetation

32
Q

Clinical criteria for IE how many need confirmed vs possible

A

Confirmed:
2 major criteria
1 major criteria and 3 minor criteria
5 minor criteria
Possible:
1 major criteria and 1 minor criteria
3 minor criteria

33
Q

Rejected IE diagnosis criteria

A

Alternate diagnosis
Resolution with anitbitoic therapy <4 days
No pathologic evidence of IE at surgery or autopsy w antibiotics <4 days

34
Q

What is the new criteria for IE

A

ESC 2023

35
Q

Major criteria for endocarditis Dukes

A

+ blood culture for IE
Evidence of endocardial involvement

36
Q

Evidence of endocardial involvement DUKES criteria

A

+ ECHO for IE
New valvular regurgitation
Vegetation
abscess
new partial dehiscence of prosthetic valve

37
Q

What need for + blood culture IE major criteria

A

typical microorganism from two separate cultures >12hrs apart OR 3 or 4 cultures of blood - first and last 1 hr apart
Eg separated in time and space
Must be one of:
Viridans strep, strep bovis (ganolyticus - ass bowel cancer) or HACEK group OR CAP S.aureus, enterococci without obvious primary source infection
Single positive culture for C.burnettu or antiphase 1 IgG antibody titre >1:800

38
Q

mINOR dUKES CRITERIA FOR ie

A

Predisposition
Fever >38.0
Vascular phneomena
Immunological phenomena
Microbiological phenomena
PCR - broad range of 165
ECHO findings - consistent w IE but not major criterion

39
Q

What are predispositions in DUKES

A

Predisposing heart condition or IVDU

40
Q

Vascular phenomena counting as minor dukes criteria for IE

A

Major arterial emboli, septic pulmonary infarcts CXR, mycotic aneurysm, IC haemorrhage, conjunctival haemorrhage, janeways lesions

41
Q

Immunological phenomena minor dukes criteria IE

A

Glomerulonephritis, oselers nodes, roth spots, Rf

42
Q

Microbiological phenomena minor dukes criteria IE

A

+ blood culture but doesnt meet major criterion or serologuical evidence of activa=e infection with organism consitent with IE

43
Q

Dukes criteria vs ESC 2023 xriteria

A

Imaging in major criteria
Dukes - ECHO
ESC - Cardiac CTs or nuclear imaging
Removed ECHO findings from minor criteria
Removed broad range PCR from minor criteria

44
Q

What bacteria causing IE blood culture sample only need one for

A

C burnetti

45
Q

What are oslers nodes

A

Red v painful spots on pulps of fingers and toes pale in middle

46
Q

Cardiac risk factors for endocarditis

A

Prev IE
Valvular HD stenosis or regurg
Hypertrophic CM
Prosthetic heart valve
Central venous catheter or arterial catheter
Transvenous cardiac implantable electronicdevice
Congnital HD

47
Q

Non cardiac risk factors for IE

A

Central venous catherer
IVDU
Immunosupression
Recent dental or surgical procedures
Recent hospitalisation
Haemodilaysis

48
Q

What are janeway lesions

A

maculopapular on palms or soles non painful few mms

49
Q

What organisms can mean no blood culture +

A

Fastidious gram negative bascilli - HACEK group eg aggregatibacter aphrophilus
Others - Haemophilus, caerdiobacterium hominis, eikenella corrodens and kingella kingae

50
Q

Why use oral antibiotics instead of IV endocarditis

A

Hospital stay - increased risk of hospital complications
After patient stable rare to get bad again

51
Q

What is POET

A

Partial oral antibiotic endocarditis therapy
Stabilised endocarditis patietns treated initially with IV antibiotics
Then test continuing w oral or IV

52
Q

Method of POET

A

Stable adults receiving IV antibiotics for L sided endocarditis, native or prosthetuic valves, fulfilled modified Duke critiera, + blood cultures for strep, enterococcus, staph aureus, coag negative staph
Antibiotics w moderate to high bioavailability
Put half on combined PO antibiotic therapy

53
Q

What did POET record (events)

A

All cause mortality, unplanned cardiac surgery, embolic events, relapse of bactaraemia for 6 months A

54
Q

POET study finding

A

No significant statistical differnece between oral and IV antibiotics

55
Q

Side effects from PO

A

Allergy, bone marrow suppression, GI side effects

56
Q

Conclusins of POET study

A

Efficacy and safety of shifting to oral antibiotic treatment was non inferior to continued IV antibitoic treatment
Oral antibiotics may safely be administered during half the recommended antibiotic treatment periods - can be oupatient - reduce hospital stays
May apply to >50% endocarditis patients in future

57
Q

What cardiac conditions are not risk factors for IE

A

Isolated ASD
Fully healed VSD, PDA

58
Q

Management of IE

A

Blood culture and ECHO/imaging -> empirical broad spec IV antibiotics
Adjust anitbiotics according to sensitivities and complications treating -> cardiac surgery or

59
Q

Organisms would match with recent dental extraction IE

A

Viridans strep - mitis group

60
Q

Organisms would match with recurrent UTIs IE

A

Enterococcus faecalis

61
Q

Organisms would match with hickmans line IE

A

Candida albicans
Staph aureus, coag negative staph

62
Q

Organisms would match with IVDU IE

A

Staphg aureus, candida albicans

63
Q

Reasons for blood culture negative IE

A

Intracellular pathogens eg legionella, brusella, bartonella, mycoplasma
Specific culture needed eg mycobacteria
Long incubation periods - routine culture doesnt work
16s RNA PCR for bacteria, 18s RNA PCR for fungi

64
Q

What imaging pathway do for endocarditis first

A

TTE
If +, poor quality or theres a prosthetic valve IC device -> TOE
If negative but high clinical sus -> TOE
Repeat TOE in 7-10 dyas if negative but still high clinical sus

65
Q

What antibiotic can reduce duration of treamtnet for IE

A

Gentamicin increased bactericidal acitivity due to syndergism
When caused by penicllin sensitive strep

66
Q

Why differnet treatment for prosthetic HV

A

Biofilm risk - need penetrating agents
6 weeks antibiotics vs 4 for native valves

67
Q

MRSA IE treat

A

Vancomycin, dactomycin

68
Q

HACEK group what stand for

A

Haemophilus
Aggregabactae
Cardiobacterium
Eikenella
Kingella
Fastidious gram negative

69
Q

First line treatment for HACEK

A

Ceftriaxone
CAnt use amoxicillin as some produce beta lactamases

70
Q

Septic/unstable patients with IE treatmet if risk factors for resistant bacteria

A

Vancomycin, meropenem
If none - vancomycin with gentomycin
Otherwise amoxicillin +/- gentomycin
Pending blood cultures or negative - vancomycin, gentamycin, rifampacin - for biofilm

71
Q

Staph IE treat

A

Fluclox, vancomycin, gentomycin, rifmapacin

72
Q

Strep IE treat

A

Benzylpenicillin, ceftriazone, gentamizin, vancomycin, teicoplanin

73
Q

Enterococcal IE treat

A

Prolonged treat in combo
gentomycin or ceftriazone

Amoxicillin
Penicillina
Vancomycin, teicoplanin

74
Q

Fungal IE treat

A

Low threshold for surgery
Look for complications
Fluconazole, variconazole, amphotericin, itaconazole
Remove lines

75
Q

HACEK manageent IE

A

Cephalosporin or amoxicillin
Gentamicin
Ciprofloxacin

76
Q

Complications of IE

A

Neurological
Infective aneurysms
Splenic complications
Myocarditis, pericarditis
Heart rhythm and conduction distubrances
Osteoarticular infection

77
Q

Follow up for IE

A

Monitor for 1 year
Development HF
end treatment TTE
Recurrence
Rehabilitation, psych support

78
Q

Ideal cultures for IE

A

three sets from peripheral sites >6 hours between them if chronic or subacute
If acute from different sites with as ling between as can leave clinicaly safely

79
Q

When do you start antibiotics with IE

A

Chronic - wait for culture senstivities before commence
Septic/acute - commense broad spectrum while waiting cultures

80
Q

FROM JANE signs/symptoms of IE

A

Fever
Roth spots
Oselers nodes
Murumur
Janeway lesion
Anaemia
Nail haemorrhage
Emboli

Infectious disease (37 decks)

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