B4-013 CBCL: Infectious Cardiac Valve Disease Flashcards
- febrile illness that rapidly damages cardiac structures
- seeds extracardiac sites
- progresses to death within a few weeks if untreated
acute endocarditis
caused by high virulence organisms involving a normal valve
acute endocarditis
large vegetations prone to mobilize
acute endocarditis
- high mortality
- less likely to cure with anti-microbial therapy
- higher incidence of surgical treatment
acute endocarditis
S. aureus is most common causative organism
acute endocarditis
indolent, febrile illness developing over weeks or months
subacute endocarditis
- new or changing cardiac murmur
- embolic phenomena on exam
- usually caused by lower virulence organisms
subacute endocarditis
common causative agents:
* s. viridans
* enterococci
* HACEK
subactute endocarditis
smaller vegetations usually formed on abnormal or diseased valves
subacute endocarditis
less likely to cause structural/tissue damage
higher incidence of cure with antimicrobial therapy
subactute endocarditis
partially treated acute endocarditis can clinically appear to be
subacute endocarditis
most common cause of infective endocarditis
s. viridans
most common cause of infective endocarditis in IV drug users
S. aureus
most common cause of acute infectious endocarditis
S. aureus
most common cause of prosthetic valve endocarditis
S. epidermis
cause of endocarditis due to underlying colon polyps or cancer
S. gallolyticus (bovus)
HACEK group
Hemophilus
Actinobacilus
Cardiobacterium
Ekinella
Kingella
commonly associated with negative blood cultures
HACEK group
causative fungi in immunocompromised patients
Candida
if portal of entry is:
oral, skin, upper respiratory
what organisms?
viridans, staph, HACEK
if portal of entry is gastrointestinal
what organism
S. gallolyticus (bovus)
if portal of entry is GU
what organism
enterococci
most common cause of community acquired endocarditis
S. viridans
> 72 hours post admission or with 6-8 weeks after hospital based procedure
nosocomial endocarditis
three fold increased mortality over community acquired
nosocomial endocarditis
common agents of nosocomial endocarditis
- S. aureus
- coag neg Staph
- entercocci
6-25% of [….] results in endocarditis
IV catheter related bacteremia
causative agents of prosthetic valve endocarditis within 2 months of surgery
nosocomial
- S. aureus
- coag neg staph
- fungi
causative agents: pacemaker/ICD associated endocarditis within weeks of procedure
nosocomial
- S. aureus
- coag neg staph
risk factors for infective endocarditis
- previous endocarditis
- rheumatic heart diease
- degenerative mitral valve
- biscuspid aortic valve
- prosthetic valves
- intravascular device
risk factors for bacteremia
- IV drug users
- indwelling venous catheters
- poor dentition
- hemodialysis
- diabetes
common clinical manifestations of infective endocarditis
- fever
- elevated ESR
- chills, sweats
- new or changing heart murmur
- anemia
retinal hemorrhages with white or pale centers
roth spots
IE
painful, red, raised lesions found on the hands and feet
osler’s nodes
IE
brownish, longitudinal lesions in the nailbeds that look like splinters
splinter hemorrhages
IE
non-tender, small erythematous or hemorrhagic macular or nodular lesions on palms and soles
Janeway lesions
IE
- extremely debilitating
- high morbidity/mortality
- presents with constitutional symptoms
- immunocompromised and IV drug users
fungal endocarditis
candida species most commonly isolated
fungal endocarditis
low rate of positive blood cultures
fungal endocarditis
in culture negative endocarditis that fails to respond to anti-bacterial therapy, consider
fungal endocarditis
diagnosis of infective endocarditis requires
- modified Duke criteria
- positive blood cultures
- ECG
major Duke criteria
- positive blood cultures
- ECG findings
- new valvular regurgitation
minor Duke criteria
- predisposing heart lesion of IV drug use
- fever
- vascular lesions
- immunologic phenomena
- ECG findings
how many of the Duke criteria need to be met to diagnose IE?
2 major OR
1 major/3 minor OR
5 minor
blood cultures should be drawn […] minutes apart
30
how many culture bottles should be drawn?
2-3
from different venipuncture sites
common cause of false negative culture results
prior abx use
species that are nearly always culture contaminants
- Coag neg staph
- bacillus
- corynebacterium
- propionibacterium
allows you to see:
* vegetation size
* intracardiac complications
* assessment of cardiac function
ECG
- ECG
- non-invasive
- technically difficult in 20% of patients
- 65% sensitivity, high specificity
TTE
- ECG
- 90% sensitivity
- prosthetic valve endocarditis
- myocardial abscess, valve perforation, intracardiac fistula
TEE
focal dilation of an artery caused by growth of microorganisms within the vascular wall
mycotic aneurysm
complications of IE
- valvular regurgitation
- CHF
- stroke
- peripheral emboli
- mycotic aneurysm
- splenic abscess/infarct
- valve dehiscence
- intracardiac fistula
- complete heart block
empiric therapy for acute bacterial endocarditis
vanc + gent
empiric therapy for subacute bacterial endocarditis
ceft + gent OR
pencillin + gent OR
ampicillin + gent (enterococci)
empiric therapy for prosthetic valve IE
vanc + gent + rifampin OR
vanc + cefepime + gent
targeted antibiotic therapy: S. viridans
ceftriaxone 4 week
targeted antibiotic therapy: HACEK
ceftriaxone
targeted antibiotic therapy: penicillin senstive S. aureus
Nafcillin, Oxacillin, cefazolin
targeted antibiotic therapy: MRSA
vanc
targeted antibiotic therapy: S. epidermidis
vanc
targeted antibiotic therapy: enterococci
ampicillin + gent
targeted antibiotic therapy: fungal
ampho + valve replacement
surgery required for optimal outcome
- heart failure
- failure of antibiotic therapy
- partially dehisced prosthetic valve
- S. aureus prosthetic valve endocarditis wit intracardiac complication
surgery strongly considered
- perivalvular extension of infection
- persistant fever, culture negative
- large vegetations on left valves
- recurrent emboli
- abscess formation
- fungal endocarditis
- large, hypermobile vegetations
who may complete outpatient therapy for endocarditis?
fully compliant patients with:
* sterile blood cultures
* no fever
* no ECG findings
* no clinical findings
when should prophylaxis be used in patients with cardiac conditions that predispose them to IE?
prior to:
* dental procedures with blood
* respiratory procedures
endocarditis ppx is not needed for
- GI, GU, OBGYN procedures
- native valve disease
endocarditis ppx regimen for patients without penicillin allergy
amoxicillin 2g PO 30-60 min before procedure
endocarditis ppx regimen for patients with penicillin allergy
clindamycin 600 mg
most important factor for endocarditis prevention
maintenance of good oral hygiene
- inflammatory and immunologic disease
- usually in children
- follows GAS infection
acute rheumatic fever
valve leaflets deformed by chronic inflammation, fibrosis, and vascular proliferation
acute rheumatic fever
autoimmune response to strep antigens resulting in cross reaction to myocardial tissue antigens
acute rheumatic fever
necessary to dx rheumatic fever
- preceding GAS infection
- two major or 1 major/1 minor or Jones criteria
necessary to dx rheumatic fever
- preceding GAS infection
- two major or 1 major/1 minor or Jones criteria
major criteria: Jones
- migratory polyarthritis
- pancarditis
- subcutaneous nodules
- erythema marginatum
- chorea
minor criteria: Jones
- fever
- arthralgia
- increase in acute phase reactants
shortening, thickening and fusion of chordae tendinae
rheumatic heart disease
- fibrous adhesions between free edges of cusps
- thickening and fusion of mitral valve leaflets
rheumatic heart diease
reduction in valve orifice are and increased diastolic pressure
rhuematic heart diease
- dilation of left atrium
- atrial fibrillation
rheumatic heart disease
- left atrial appendage thrombus and embolic events
- years/decades later
rheumatic heart disease
pulmonary hypertension & right side heart failure
rheumatic heart disease
acute pulmonary edema
rheumatic heart disease
