Infective Endocarditis Flashcards
1
Q
Define: Rheumatic fever
A
Systemic immune response after beta-hemolytic strep infection
2
Q
Features of RF
A
- Uncommon in US
- Peak: 5-15 yrs
- Self-limited carditis & valvulitis or progressive valvular deformity (MC = mitral)
3
Q
RF: Minor criteria
A
“CAFE P”
- CRP elevated
- Arthralgia
- Fever
- ESR elevated
- Prolonged PR
4
Q
RF: Major criteria
A
“CANCER”
- Carditis
- Arthritis
- Nodules
- Chorea
- Erythema margination
- Rheumatic fever
5
Q
RF: What is the DDx?
A
- Rheumatoid arthritis
- Osteomyelitis
- Endocarditis
- SLE
- Lyme disease
- Sickle cell anemia
6
Q
RF: Dx tests
A
- Echo
- ECG
- CRP/ESR
- CBC
- ASO
7
Q
RF: Jones Criteria
A
- 2 major criteria OR
- 1 major & 2 minor OR
- 3 minor (if recurrent)
8
Q
Tx of RF
A
- Supportive care
- Salicylates
- Penicillin
- Corticosteroids
- Education
- Prevention of recurrences
9
Q
RF: Px
A
- Wks to mos in children
- Mortality 1-2%
- 30% of children die within 10 yrs
- Persistent carditis = poor px
10
Q
RF: Complications
A
- Rheumatic valve disease
- HF
- Arrhythmias
- Pericarditis w/ effusion
- Rheumatic pneumonitis
11
Q
RF: Referrals
A
- Pediatric ID
- Pediatric rheumatologist
- Pediatric cardio
12
Q
Define: Rheumatic heart disease
A
Permanent heart valve damage, subsequent to ARF
13
Q
What is the major cause of CV disease in developing nations?
A
RHD
14
Q
What does RHD cause?
A
Symptomatic valvular heart disease
15
Q
RHD: Dx
A
TTE
16
Q
RHD: Tx
A
- Restrict activity
- Tx complications
- Prevent IE
- Referrals as needed
17
Q
Define: infective endocarditis
A
Microbial infection of valvular or endocardial surface of heart
18
Q
IE: Classification
A
- Native valve endocarditis
- Prosthetic valve endocarditis
- Injection drug users
19
Q
Features of IE
A
- Men > women
- Pts over 60
- Mortality 16-37%
- Prosthetic valve endocarditis accounts for 10-30%
20
Q
IE: Patho
A
- Thrombus formation on endothelial surface
- Bacteria circulates in bloodstream, infects site
- Bacterial proliferation –> vegetations on endothelial surface
- Valves involved
21
Q
What valve is involved in native endocarditis?
A
Mitral, followed by aortic
22
Q
What valve is involved in IDUs?
A
Tricuspid, followed by aortic
23
Q
What organism is most common in native valve endocarditis?
A
S. aureus
24
Q
What organisms are most common in prosthetic valve endocarditis?
A
- S. aureus
- Coagulase- negative staphylococci
25
What organisms are most common in intermediate-late endocarditis?
- Streptococci
| - S. aureus
26
What organisms are most common in IDUs?
- S. aureus (most frequent)
- Streptococci
- Enterococci (least frequent)
27
IE: Cardiac involvement
- More likely to have right-sided IE
| - Tricuspid valve involved in 30-70%
28
What are risk factors for IE?
- Age > 60
- Male
- IDU
- Poor dentition
- Valvular disease
- Congenital heart disease
- Prosthetic heart valve
- Hx of IE
- Chronic hemodialysis
- HIV
29
What are sx of IE?
- Fever
- Cough
- Dyspnea
- Arthralgias/arthritis
- Diarrhea
- Abd/flank/back pain
30
IE: What is seen on PE?
- Fever
- Regurgitant murmur
- Peripheral lesions (petechiae, hemorrhages, osler nodes, janeway lesions, roth spots)
31
What is the DDx of IE?
Bacteremia
32
IE: Dx tests
- Blood cultures
- Echo
- EKG
- CXR
- CT-torso
- Modified Duke Criteria
33
IE: Modified Duke Criteria (Definitive Dx)
- 2 major criteria OR
- 1 major & 3 minor OR
- 5 minor
34
IE: Modified Duke Criteria (Possible Dx)
- 1 major + 1 minor
| - 3 minor
35
Features of bacterial endocarditis ("BE FIVE PM")
- Blood culture +
- Endocardial involvement
- Fever
- Immunologic
- Vascular
- Echo findings
- Predisposition
- Microbial evidence
36
What is the overall general tx for bacterial endocarditis?
- Admit to hospital
- Empiric tx covering staphylococci, streptococci, enterococci
- Antimicrobial therapy (2-6 wks), monitor toxicity
- Consult ID
- +/- consult cardiac surgeon
37
What meds are given to those w/ native endocarditis?
Vancomycin + Ceftriaxone
38
What meds are given to those w/ prosthetic valve endocarditis?
Vancomycin + Rifampin + Gentamicin
39
What meds are used to tx viridans streptococci?
- Penicillin G IV x 4wks OR
- Ceftriaxone IV x 4wks OR
- 1 of the above + gentamicin IV x 2wks (Uncomplicated IE, rapid response to therapy, no underlying kidney disease)
40
What meds are used for other forms of streptococci?
- Penicillin IV x 4wks OR
- Cefazolin IV x 4wks OR
- Ceftriaxone IV x4wks
41
What meds are used for enterococci?
Combo therapy, PCN + gentamicin
- Ampicillin IV or penicillin G IV x 4-6wks
+
- Gentamicin IV x 4-6wks OR ceftriaxone IV 4-6wks (CrCl < 50 or gentamicin restsitance)
42
What meds do you use for staphylococci-methicillin- SUSCEPTIBLE S. aureus?
- Nafcillin or oxacillin IV x 6wks OR
| - Cefazolin IV x 6wks
43
What meds do you use for staphylococci-methicillin- RESISTANT S. aureus?
- Vancomycin IV x 6wks OR
| - Daptomycin IV x 6wks
44
What meds do you add to the tx of Staphylococci – methicillin- susceptible or resistant S. aureus if pt has prosthetic valve endocarditis?
Add rifampin x 6wks
| Add gentamicin x 2wks
45
What meds do you use to tx against HACEK organisms?
Ceftriaxone IV x 4wks
46
What does HACEK stand for?
- Haemophilus
- Actinobacillus
- Cardiobacterium
- Eikenella
- Kingella
47
What is the general response to tx of endocarditis?
- Improves in 3-4 days
- Repeat blood cultures
- Monitor relapse
48
What does the f/u include for endocarditis?
- Baseline eval
- Dental eval
- Drug rehab
49
What are surgical indications of endocarditis?
- Worsening CHF
- Abscess
- Infection w/ fungi
- Staphylococci on prosthetic valve
- Failure of antibiotic therapy
- 2 major emboli or 1 major embolus w/ mobile vegetation
50
When is prophylaxis of IE indicated, according to AHA?
- Prosthetic valve
- Previous IE
- CHD
- Heart transplant w/ valvulopathy
51
What procedures require prophylaxis of IE, according to AHA?
- All dental procedures, which involve manipulation of gingival tissue or periodical region of teeth or perforation of oral mucosa
- Respiratory tract procedures, that involve incision of mucosa
- Procedures on infected skin, skin structure, or musculoskeletal tissue
52
What procedures DO NOT require prophylaxis?
- Ear/body piercing
- Tattooing
- Vaginal delivery
- Hysterectomy
- Routine dental work
53
What med are used for prophylaxis in dental & respiratory procedures?
Amoxicillin (most commonly)
