Infective Endocarditis Case Studies Flashcards Preview

CV Quiz 2 > Infective Endocarditis Case Studies > Flashcards

Flashcards in Infective Endocarditis Case Studies Deck (44):
1

What are key risk factors for infective endocarditis?

abnormal heart valves and risk of bacteremia
Aberrant flow results in platelet-fibrin thrombus on injured
Bacteria enter bloodstream through skin or mucosal surfaces and adhere to thrombus

2

What predisposing heart conditions can increase chance of getting IE?

prosthetic valves
mitral prolapse w/ regurg or thickened leaflets
Rheumatic heart disease
Complex congential heart
mitral regurg/ AS/ aortic regurg/ ventricular septal defect

3

What procedures can predispose you to IE?

Dental work or poor hygiene- especially associated w/ bleeding
Hemodialysis
IV drug use (Right sided especially)
Focal infection with typical organism

4

What are common clinical presentations for IE?

Almost always fever, and heart murmur. Often have chills and sweats with occasional anorexia/malaise
Lab abnormalities and non-cardiac manifestations 5-50%

5

What noncardiace manifestations appear with IE?

Emolic events 25-50% time... often to CNS (extremeties/spleen or kidneys)
Splenomegaly, clubbing, petechiae less common

6

What peripheral manifestations are seen with IE?

Splinters hemorrhages in the finger nails
Oslers
Janeways
Roths

7

When are Splinter hemorrhages more concerning for IE?

when they are proximal or mid nail and more if they are red/purple (opposed to brown)

8

tender violaceious subQ nodes in the fingers or toes. D/t inflammation and immune complexes

Osler nodes

9

nontender erythematous or hemorrhagic macules or papules in fingertips, palms or soles dt septic emboli

Janeway lesions seen in IE

10

What are roth spots?

retinal lesions--hemorrhagic with white central spot, immunologic process seen in IE

11

What key lab anormalities do we see in IE

anemia 70-90% time
leukocytosis 20-30% time
microscopic hematuria 30-50%
and elevated sed rate and CRP

12

Most common organisms in IE in acute cases:

Staphylococcus aureus

13

Most common organisms in IE in prosthetic valves :

coagulase-negative Staph

14

Most common organisms in IE in elderly:

Enterococcus sp.

15

Most common organism in IE in a native valve

streptococci

16

Most common organism in IE in early prosthetic valve replacement:

Coag-Neg staph or possibly staph aureus, but not steptoccocci in early valve replacement (more common for a native valve)

17

Most common organism in IE in late prosthetic valve replacement:

streptococci (almost same as it would be for native)

18

Your patient has IE and you identify the causitive agent as strep bovis, what else should you be concerned about?

assoc. with colonic lesions

19

Are gram - rods or fungi associated with IE?

not usually but if they are more likely due to prosthetic valve or IV drug users

20

S. aureus, Candida parapsilosis and pseudomonas are causitive IE agents seen in which patients?

IV drug users

21

Your patient has an elevated fever, chills and weight loss. You hear a murmur and strongly suspect IE after you see evidence in the echo. You take cultures but the cultures are negative... what would you change your DDx to?

don't necessarily... some IE can be 'culture-negative'

22

What are our common 'culture negative' causitive agents of endocarditis

Haemophilus
Actinobacillus
Cardiobacterium
Eikenella
Kingella
HACEK

23

which is more sensitive for evaluating prosthetic valves, perivalvlar exctension, myocardial abcesses, fistulas and valve perfs?
Transthoracic or transesophageal

Transesophageal echo or TEE

24

echo that is rapid and noninvasive but sensitivity is less then 70%

Transthoracic echo or TTE

25

Echo that is sensitive up to 95%

transesophageal or TEE

26

How do you make a diagnosis of IE?

based on clinical, lab and echo criteria; Modified Duke criteria of 2 major or one major plus 3 minor

27

Major Duke criteria to Dx IE

Microorganism from 2 seperate blood cultures
--if its an unusual IE organism has to be persistantly positive
-or positieve serology C.burnetti
Evidence of endocardial involvement; new vavlular regurg or positive echocardiogram

28

Minor Duke criteria to Dx IE

Predisposition: heart abnormalities or IV use
Fever
Vascular phenomena: excluding petechiae or splinter
Immunologic phenomenoa; RH factor, Oslers or Roths

29

Because bacteria are in vegitative configuration in IE, what do we need to do in therapy to overcome that?

must have PROLONGED and bacteriaCIDAL therapy
(bc they are metabolically inactive and inaccessible to host)
***MUST KILL EVERY BACTERIUM

30

Rx for penicillin susceptible IE caused by streptococcis

Penicillin or Ceftriaxone x4-6wks
with Vanco x 5-6 weeks

31

Rx for intermediate penicillin susceptible IE caused by streptococcis

Pen or Ceph x 4-6 wks with Gent x 2-6 wks
– Vancomycin x 4-6 wks

32

Rx for IE caused by enterococci

Pen or Amp x 4-6 wks with Gent x 2-6 wks
– Vanco with Gent x 6 wks

33

Pt has a native heart valve and IE caused by staph... Rx?

Nafcillin or Oxacillin (+/-Gentamicin x 3-5
days)
– Cefazolin (+/- Gentamicin x 3-5 days)
– Vancomycin

34

PT has a prosthetic heart vavle and IE d/t Staph... Rx?

– Nafcillin or Oxacillin + Rifampin (+/- Gent x 2
wks)
– Vancomycin + Rifampin (+/- Gent x 2 wks)

35

What Rx do we give patient for IE caused by HACEK?

Ceftriaxone x 4-6 wks
• Amp/sulbactam x 4-6 wks
• Ciprofloxacin x 4-6 wks

36

What are some possible indications for surgery in patient with IE?

congestive HF, prosthetic valve endocarditis, valve perforation or rupture, new heart block, mult embolic events, uncontrolled infection on appropriate rx

37

When do we expect to see fever dissipate in pts with IE?

half within 3 days of
starting treatment, 75% within one week

38

Pt has prolounged fever, a week after they started tx for IE, what are my most likley causitive agents?

more likely associated with S.aurues, GNR, fungi
--see this associated with other complications

39

What cardiac complications arise as a result of IE?

congestive heart failure, heart block, valve failure, abscess or fistula

40

What neurologic and systemic complications arise dt IE?

embolic stroke, mycotic aneurysm and menigits
systemically: septic emboli and abcesses

41

Most common peripheral MCA, usually at bifurcations and more common with virdians step... can be caused by direct emboli or infection of wall or immune complex

Mycotic aneurysms

42

A patient that has IE asks about prophylaxis so she doesn't get IE again in the future... how would you educate her?

inform her bacterimia is more likely doing to result from daily activities such as not brushing teeth then from a procedure and that prophylaxis antiB prevent few, if any IE cases thus risk of taking vs not need to be weighed.
MAITAIN ORAL HYGIENE!!!!!

43

Pt has several surgeries scheduled for the next few months. He has a scaling and root planing appointment with his hygenist and then an endoscopy. Which appts does he need to premedicate with if he had previous IE?

for the scaling and planing
not for GI or GU

44

Recommended pre-med for dental appointments that involve gingiva or perforation or oral mucosa

Dental—single dose, 30-60 min before
– Amoxicillin 2 grams PO
– Clindamycin 600 mg
– Ampicillin 2 grams IV
– Ceftriaxone 1 gram IV