3: Endocarditis

Question 1

risk factors for IE

Answer 1

• poor dental hygiene
• **IV drug abuse
• hemodialysis
• indwelling catheters + continued access through skin
• DM
• *prosthetic valves

Question 2

most common causative organisms of IE

Answer 2

S. aureus (slow clearing)
Coag (-) staph (early prosthetic valve IE)
Strep- mutans, sanguis, bovis

Question 3

HACEK IE causes

Answer 3

Hemophilus 
Actinobacillus 
Cardiobacterium hominis 
Eikenella 
Kingella kingae

Other: Enterococci, fungi, coxiella burnetti

Question 4

what is special about coxiella burnetti IE?

Answer 4

difficult to culture, so for this bug, just need one positive blood culture whereas for the rest of the bugs, you need two positive blood cultures

Question 5

what MUST you look for if you have a patient with bovis IE

Answer 5

colonoscopy - colon cancer!!!!!!!

Question 6

IE signs and symptoms

Answer 6

**FEVER AND A MURMUR/FEVER AND A NEW/CHANGED MURMUR

fever
weight loss 
fatigue
heart failure
night sweats
heart murmur
splenomegaly 
skin petechiae 
conjunctival hemorrhages
splinter hemorrhages
septic shock 
Osler nodes
Roth spots 
Janeway lesions

Question 7

janeway vs. osler: location

Answer 7

j: soles, palms, thenar and hypothenar eminences, plantar surfaces of toe
o: finger and toe tips, thenar and hypothenar eminences

Question 8

janeway vs. osler: size and shape

Answer 8

j: macules or variable size and irregular shape
o: nodules of 1mm to > 1cm

Question 9

janeway vs. osler: tender?

Answer 9

j: no
o: yes

Question 10

janeway vs. osler: course

Answer 10

j: days to weeks
o: hours to days

Question 11

janeway vs. osler: type of endocarditis

Answer 11

j: acute endocarditis
o: subacute endocarditis

Question 12

janeway vs. osler: culture

Answer 12

j: usually positive
o: usually negative

Question 13

janeway vs. osler: history

Answer 13

j: septic microemboli
o: vasculitis

Question 14

what is a worse complication of IE?

Answer 14

perivalvular abscess

• valve dysfunction
• heart block (late stage finding)
• stroke

Question 15

diagnosis of IE

Answer 15

Modified Dukes Criteria:

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

Question 16

major dukes criteria for IE

Answer 16

• lab evidence of IE (2 + blood cultures, 1 + coxiella culture)
• endocardial involvement (TTE, TEE)
• new valvular regurgitation

Question 17

minor dukes criteria for IE

Answer 17

• predisposing heart condition (risk factors)
• fever
• vascular phenomenon (emboli (JL), mycotic aneurysm, hemorrhages)
• immunologic phenomenon (GN, osler nodes, Rh factor, Roth spots, Janeway lesions)
• positive blood culture of not a major organism that causes IE

Question 18

IE treatment

Answer 18

empirically start vancomycin + aminoglycoside
then when you know sensitivity, if PCN sensitive - switch to a PCN + aminoglycoside

2-6 weeks IV abx

Question 19

should you use anticoagulation in IE patients?

Answer 19

not indicated - doesn’t prevent embolism and may increase risk of bleeding

Question 20

indications for TEE vs. TTE

Answer 20

TEE: with prosthetic valves
TTE: native valves

Question 21

what is the best first test once you suspect endocarditis?

Answer 21

blood cultures

Question 22

what murmur may present in IE

Answer 22

mitral regurgitation (holosystolic)

Question 23

what is vancomycin red man’s syndrome?

Answer 23

a problem with too fast of infusion rate due to histamine release by mast cells- treat by decreasing infusion rate

Question 24

how do you determine sensitivity of a test?

Answer 24

sensitivity = true (+)/ (true (+) + false (-))

Question 25

how do you determine specificity of a test?

Answer 25

specificity = PPV = positive predictive value = 
number tested (+)/ all (+)

Question 26

what bug is associated with the following presentation:

homeless, alcoholic, flea bitten man with fever and murmur; echo with vegetations

Answer 26

Bartonella

Question 27

indications for IE prophylaxis

Answer 27

(very rare) - if asked a question, just say no! 
-prosthetic valves*
-heart transplant recipient 
-previous case of endocarditis*
-uncorrected cyanotic heart disease 
PLUS: 
-dental work with bleeding* (fillings don't count) 
-tonsillectomy/adenoidectomy

Question 28

what medication do you add when someone with a prosthetic valve has IE

Answer 28

rifampin