Lecture 7 Part 1: Endocarditis

Question 1

In what layer of the heart are the valves and vessels located?

Answer 1

Endocardium

Question 2

For infective endocarditis to occur and actually affect a valve, what conditions generally need to be present?

Answer 2

• Valvular damage/abnormality
• OR
• Turbulent blood flow

Question 3

What is the MC route for IE to occur?

Answer 3

Oral

• Dental extraction/surgery
• Chewing candy
• Tooth brushing

Question 4

Where does IE tend to occur in hearts? What is the exception?

Answer 4

• Mainly on the left-side.
• Exception: IV drug users (IVDU)

Direct injection goes straight to the right side first. TV is also the most common among IVDU as a result.

Question 5

What is a kissing valve infection?

Answer 5

Both valves infected, i.e. mitral valve and aortic valve.

Question 6

What is the MC causative organism in native valve IE?

Answer 6

Staph Aureus

2nd is streptococcus

MC bacteria in the mouth and skin as well.

Question 7

For a prosthetic valve, what are the most common causative organisms?

Answer 7

• If prior to 2 months, staph is MC.
• If post 2 months, strep is MC.

A is before R, so STA before STR

Question 8

For IVDU, what is the MC causative organism for IE?

Answer 8

Staph, specifically affecting the TV.

Followed by strep (viridans) and enterococci.

Question 9

For nosocomial IE, what is the MC causative organism?

Answer 9

Staph aureus

Question 10

In what demographic is fungal IE MC in?

Answer 10

IVDU or ICU patients receiving broad-spectrum abx.

Question 11

What is the MCC of death for patients with IE?

Answer 11

Heart failure

Question 12

What is the common clinical presentation of IE?

Answer 12

• Fever (90%)
• Chills
• Weakness
• SOB
• Night sweats

AKA all constitutional symptoms.

Question 13

What are the most common conditions present in someone with IE?

Answer 13

1. Heart murmurs (unless IVDU)
2. CHF
3. Septic emboli

Question 14

What are the common physical exam findings for IE?

Answer 14

• Murmurs
• Petechiae
• Splinter hemorrhages
• Janeway lesions
• Osler nodes
• Roth spots

Question 15

What is a Janeway lesion vs an Osler node?

Answer 15

Janeway lesion: PAINLESS patches on palms or soles, caused by staph.

Osler node: PAINFUL nodules on pads of fingers/toes, caused by vasculitis. MC: strep.

Probably know that jane is a painless staph.

Question 16

What are Roth spots?

Answer 16

• Oval, pale, retinal lesions surrounded by hemorrhage caused by vasculitis.
• Usually chronic
• MC: Strep

Question 17

What is the MC neurologic manifestation that may occur due to IE?

Answer 17

CVA

Question 18

For bacteremia, what is the procedure for blood cultures?

Answer 18

1. 3 sets of cultures from different sites
2. First and last samples must be drawn at least 1 hr apart.

Need prior to initiation of ABX

Only need to get 1 set before starting ABX.

Question 19

When might a TEE be preferred over TTE?

Answer 19

TEE would be preferred if the vegetation is small and/or large body habitus.

Question 20

What are the major Duke Criteria?

Answer 20

• Blood culture positive
• Endocardial involvement on echo (including new murmur)

Question 21

What are the minor Duke criteria?

Answer 21

• Fever > 38C
• Immunologic phenomena
• Vascular phenomena
• Echocardiography minor criteria ELIMINATED
• Predisposition
• Microbiologic evidence

FIVE PM

Question 22

What is the Duke criteria mnemonic?

Answer 22

• Blood culture positive
• Endocardial involvement
• Fever > 38C
• Immunologic phenomena
• Vascular phenomena
• Echocardiography minor criteria ELIMINATED
• Predisposition
• Microbiologic evidence

BE FIVE PM

Question 23

What is required for a definitive diagnosis of IE via Duke criteria?

Answer 23

• 2 major
• 1 major + 3 minor
• 5 minor

Question 24

What is required for a possible diagnosis of IE via Duke criteria?

Answer 24

• 1 major + 1 minor
• 3 minor

Question 25

For native valve IE, what is the first-line abx?

Answer 25

* Pen G + gent, but Vanco for the big boys | penguins gentleman

Question 26

For IVDU IE, what are the first-line abx?

Answer 26

* Nafcillin * Gent * Vanco

Question 27

For prosthetic valve IE, what are the first-line abx?

Answer 27

* Vanco * Gent * Rifampin

Question 28

For Fungal IE, what is the first-line abx?

Answer 28

Amphotericin B | Still need sx!

Question 29

What surgery is used for IE management?

Answer 29

Open sternotomy valve replacement, repair, or debridement.

Question 30

When is surgery indicated for IE?

Answer 30

* Refractory CHF (MCC for early sx) * Fungal IE * Sepsis post 72 hrs of abx * Recurrent septic emboli after 2 wks of abx * Rupture of aneurysm of sinus of Valsalva * Conduction disturbances 2/2 septal abscess * Kissing infection of anterior mitral leaflet and aortic valve.

Question 31

What is a common evaluation we should consider to help prevent people who are at risk of IE?

Answer 31

Dental evals!

Question 32

What oral disease is the MCC of spontaneous bacteremia?

Answer 32

Gingivitis

Question 33

What kind of patients are at high risk for IE and should be prophylaxed?

Answer 33

* Prosthetic valves * Prior endocarditis * Cyanotic CHD * Cardiac transplantation patients with valvulopathy

Question 34

What procedures need endocarditis prophylaxis?

Answer 34

* Dental procedures * Respiratory tract procedures * Procedures on infected skin or MSK tissue. | NO MORE GI/GU prophylaxis

Question 35

What are the preferred abx for endocarditis prophylaxis?

Answer 35

1. Axoxicillin 2. Clinda/keflex/azithro/claritho (for PCN allergy) 3. Ampicillin IM 4. Cefazolin/rocephin IM | Usually about 1 hour prior to the procedure. ## Footnote Example: 4 tabs of amoxicillin 500mg 1 hour prior to dental procedure

Question 36

How do we diagnose IE and how long is tx?

Answer 36

* Duke's criteria for diagnosis * 6 week treatment!