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Cardiovascular: infections > Infective Endocarditis > Flashcards

Infective Endocarditis Flashcards

1
Q

what is it?

A

This is an endovascular infection of cardiovascular structures, including cardiac valves, atrial and ventricular endocardium, large intrathoracic vessels and intracardiac foreign bodies e.g. prosthetic valves, pace-maker leads and surgical conduits.

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2
Q

when someone has a fever and a new murmur=

A

IE until proven otherwise

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3
Q

Any fever lasting >1 week in those known to be at risk must prompt ______ ____.

A

Any fever lasting >1 week in those known to be at risk must prompt blood cultures.

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4
Q

acute IE presents as _______ and _______

A

s overwhelming sepsis and cardiac failure

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5
Q

acute IE normally affect ____ valves

A

normal valves

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6
Q

what are the risk factors for acute IE? 6

A

dermatitis, IV injections, renal failure, organ transplantation, DM, post op wounds

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7
Q

subacute IE normally affect ____ valves

A

abnormal

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8
Q

what are the risk factors for subacute IE?

A

aortic or mitral valve disease, tricuspid valves in IV drug users, coarctation, patent ductus arteriosus, VSD, prosthetic valves

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9
Q

what are the symptoms of subacute IE? 5

A

fever, malaise, weight loss, tiredness and breathlessness

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10
Q

what are the signs of subacute IE? 6

A
  • fever, new or changing heart - murmur
  • finger clubbing
  • splinter haemorrhages
  • splenomegaly
  • roth spots, janeway lesions osler nodes
  • microscopic haematuria
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11
Q

what is the pathogenic process of IE?

A
  1. heart valve damaged
  2. turbulent flow over roughened endothelium
  3. platelets/fibrin deposited
  4. bacteraemia
  5. organisms settle in fibrin/platelets
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12
Q

which side of the heart is normally affected?

A

left side

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13
Q

Infected vegetations are friable and break off, becoming lodged in the next _____ ____ they encounter causing ____ or _____ - may be fatal

A

Infected vegetations are friable and break off, becoming lodged in the next capillary bed they encounter causing abscesses or haemorrhages - may be fatal

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14
Q

which organisms cause early endocarditis on native valves?

A
  • staph aureus (38%)
  • Viridans streptococci (31%)
  • enterococcus (8%)
  • staphylococcus epidermidis (6%) - pretty unusual
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15
Q

which organisms cause late (more than 60 days after valve surgery ) endocarditis on native valves?

A 
strep viridans (50-70%) 
staph aureus (25%)
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16
Q

what are some unusual organisms causing IE?

A

bartonella, coxiella burnetii, chlamydia, legionella, mycoplasma, brucells

gram -ve

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17
Q

culture negative endocardities tends to be?

A

coxiella burnetii, chlamydia, bartonella and legionella

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18
Q

which fungi can cause IE?

A

candida, aspergillus, histoplasma

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19
Q

what are the other causes of IE/

A
  • SLE (Libman- Sacks endocarditis)

- Malignancy

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20
Q

what are the septic signs of IE? 8

A

fever, rigors, night sweats, malaise, weght loss, anaemia, splenomegaly and clubbing

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21
Q

Any new _____ or a changing pre-existing _____, should raise the suspiscion of endocarditis

A

Any new murmur or a changing pre-existing murmur, should raise the suspiscion of endocarditis

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22
Q

vegetations may cause valve ______ and severe ______ or valve ______

A

vegetations may cause valve destruction and severe regurgitation or valve obstruction

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23
Q

an ______ ___ _____ causes prolongation of the PR interval

A

an aortic root abscess causes prolongation of the PR interval

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24
Q

____ is a common cause of death

A

LVF

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25
Q

why do you get splinter haemorrhages?

A

this is because the immune complexes circulate around the body and when they get to the capillaries they cause them to become leaky

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26
Q

_________ and acute renal failure may occur

A

glomerulonephritis and acute renal failure may occur

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27
Q

what are roth spots?

A

retinal haemorrhages

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28
Q

Emboli may cause abscesses in the relevant organ eg brain, heart, kidney, spleen, gut (or lung if right sided IE) or skin (______ ______ - these are painless palmar or plantar macules)

A

Emboli may cause abscesses in the relevant organ eg brain, heart, kidney, spleen, gut (or lung if right sided IE) or skin (janeway lesions - these are painless palmar or plantar macules)

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29
Q

eary - usually infected at time of valve insertion and usually due to ________ or _________§

A

usually infected at time of valve insertion and usually due to Staph epidermidis or staphylococcus aureus

30
Q

IE in IV drug users causes?

A

right sided endocarditis

31
Q

which valve is normally affected in IE for drugs users?

A

tricuspid

32
Q

which organism causes IE for drugs users?

A

staph aureus

33
Q

IE for drugs users often presents as a staphylococcus aureus ‘pneumonia’ - opaque spaces in varoius regions of the lungs - if ______

A

often presents as a staphylococcus aureus ‘pneumonia’ - opaque spaces in varoius regions of the lungs - if bacteraemia

34
Q

what investigations are done?

A
  • microbiology : blood cultures and serology
  • FBC, U and E, CRP, Urine
  • ECG
  • Echo
  • CXR
35
Q

Blood culture bottles- any growth in the bottle produces ___ which changes the pH - changing the colour

A

Blood culture bottles- any growth in the bottle produces CO2 which changes the pH - changing the colour

36
Q

how many blood cultures should be done?

A

three sets at different sites

37
Q

__% are culture negative

A

10

38
Q

The presence of bacteria in the _______ is not a diagnosis - it usually indicates that there is a focus of infection somewhere in the body BUT it is easy to contaminate blood cultures with skin organisms by using poor techniques

A

The presence of bacteria in the bloodstream is not a diagnosis - it usually indicates that there is a focus of infection somewhere in the body BUT it is easy to contaminate blood cultures with skin organisms by using poor techniques

39
Q

where is strep pneumonia likely coming from?

A

a pneumonia, meningitis focus of infection

40
Q

where is e.coli, klebsiella, other coliforms likely coming from?

A

UTI, gut

41
Q

where is staph aureus likely coming from?

A

skin, wound infection. Bone/joint infection endocarditis

42
Q

what is the commonest coagulase negative staphylococcus?

A

staph epidermidis

43
Q

staph epidermidis is often a skin contaminant bUT can infect _____ _____e.g. IV line infections, prosthetic heart valves/joints

A

ften a skin contaminant bUT can infect prosthetic material e.g. IV line infections, prosthetic heart valves/joints

44
Q

what are examples of other contaminants?

A

corynebacterium (diptheroids)

45
Q

if blood cultures are negative, what is the next test?

A

echo, then serology

46
Q

serology aids diagnosis of which organisms ?

A

coxiella, bartonella, legionella and chlamydia

47
Q

FBC:: A mild _______ _____ anaemia and _________ leucocytosis are common

A

FBC: A mild normochromis normocytic anaemia and polymorphonuclear leucocytosis are common

48
Q

why check U and E?

A

renal dysfunction is common in sepsis

49
Q

why do inflammatory markers?

A

CRP and erythrocyte sedimentation rate are increased in any infection

50
Q

why do urine tests?

A

proteinuria and haematuria occur frequently

51
Q

what may an ECG show?

A
  • evidence of MI or conduction defects
52
Q

what does new AV block suggests ?

A

abscess formation. Patients should have an ECG on presentation and repeat this

53
Q

is transesophageal more sensitive than transthoracic?

A

yes

54
Q

TTE may show vegetations but only if> _mm

A

2mm

55
Q

TOE is more sensitive and better for visualising ___ ____ and possible development of ____ ____ ___

A

TOE is more sensitive and better for visualising mitral lesions and possible developmentof aortic root abscess

56
Q

what may CXR show?

A

cardiomegaly
- hf
in RSE - multiple PE and/or abscess

57
Q

why is high dose needed?

A

because you need to be treated aggresively to make sure the infection is killed

58
Q

what is the empirical treatment for native valve endocarditis?

A

amoxicillin and gentamicin IV

59
Q

why 2 antibiotics?

A

synergistic effect

60
Q

what is the empirical treatment for prosthetic valve endocarditis?

A

vancomycin and gentamicin IV and rifampicin (very rough trousers) but usually valve replacement is required

61
Q

what is the empirical treatment for drug user endocarditis?

A

iv flucloxaxillin

62
Q

what is the definite treatment for staph aureus?

A

flucloxacillin IV- targeting staph aureus

63
Q

what is the definite treatment for MRSA?

A

vancomycin IV and rifampicin PO

64
Q

what is the definite treatment for viridans streptococci?

A

benzylpenicillin and gentamicin IV

65
Q

what is the definite treatment for enterococcus sp.?

A

amoxicillin/ vancomycin and gentamicin IV

66
Q

what is the definite treatment for staph epidermidis?

A

vancomycin and gentamicin IV and rifampicin PO

67
Q

how long are antibiotics normally given?

A

4-6 weeks

68
Q

what should be monitored whilst on therapy ?

A
  • cardiac function
  • temperature
  • serum C reactive protein
69
Q

what should be done if the patient is failing on antibiotic therapy ?

A

consider referral for surgery early- there comes a point where the vegetation is so big that it can compromise the heart function

70
Q

why is Antibiotic prophylaxis solely to prevent IE is not recommended?

A

there is no proven association between having an interventional procedure (dental or non-dental) and the development of IE

71
Q

which group of patients may require prophylaxis for GI or GU procedures? 3

A

Patients with heart valve lesions, congenital heart defect sor prosthetic heart valves are at risk

Cardiovascular: infections (3 decks)

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