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ID Review > Cardiac and Cardiac Device Infections > Flashcards

Cardiac and Cardiac Device Infections Flashcards

1
Q

Most common complications of right sided endocarditis?

A

Septic thrombophlebitis and septic PE

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2
Q

Etiology of endocarditis in developed countries?

A

Staph followed by strep.

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3
Q

Etiology of endocarditis in developing countries?

A

Strep [oral]

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4
Q

What are the HACEK organisms?

A 
Haemophilus parainfluenza
Aggregatibacter [aphrophilus and actinomycetemcomitans]
Cardiobacterium hominis
Eikenella corrodens
Kingella kingae
5-10% of endocarditis cases.
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5
Q

Presentation of Endocarditis? [3]

A
  1. Fever in those with risk factors.
  2. NEW murmur in 85%
  3. Constitutional symptoms
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6
Q

Complications of endocarditis? [5]

A

CHF, ICH, CVA, metastatic infection, septic emboli

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7
Q

What are janeway lesions?

A

Nontender macules on the palms and soles. More common in Staph aureus endocarditis

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8
Q

What are osler nodes?

A

Tender subcutaneous violaceous NODULES on finger and toe pads. Come and go, suggestive of longstanding endocarditis with virdans strep

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9
Q

What are the “vascular phenomena” of endocarditis? [6]

A

Arterial emboli, septic pulmonary infarcts, mycotic aneurysm, conjunctival hemorrhage, janeway lesions.

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10
Q

What are the “immunologic phenomena” of endocarditis [4]

A

GN, Osler nodes, roth spots, RF high.

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11
Q

Causes of culture-negative endocarditis? [8]

A
  1. Coxiella burnetii - 48%
  2. Bartonella - 28%
  3. Brucella
  4. Legionella
  5. Mycoplasma
  6. Trophyeryma whipplei
  7. Abiotrophia
  8. Cutibacterium acnes
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12
Q

Non-infectious differential for endocarditis? [5]

A
  1. Acute rheumatic fever
  2. Libman-Sacks endocarditis [SLE associated]
  3. Marantic endocarditis [blanket term for non-infectious endocarditis]
  4. Rheumatoid arthritis
  5. Loeffler’s endocarditis [manifestation of eosinophilic myocarditis]
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13
Q

Describe the testing logic of echocardiography in endocarditis evaluation.

A
  1. Always start with TTE.
  2. Proceed to TEE in the following…
    • Poor quality TTE
    • Positive TTE
    • Negative TTE and high suspicion
    • Present of prosthetic valve.
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14
Q

What if TEE is negative but suspicion remains high for endocarditis?

A

Repeat TEE in 7-10 days.

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15
Q

When would TEE NOT be needed?

A

Negative TTE and low clinical suspicion of enodocarditis.

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16
Q

What are the major duke criteria? [3]

A
  1. Typical organism in the blood.
  2. IgG for Coxiella >1:800
  3. Positive echo
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17
Q

What are the minor duke criteria? [6]

A
  1. IVDU
  2. Predisposing heart condition
  3. Fever
  4. Vascular phenomena
  5. Immunologic phenomena
  6. Blood culture not fufilling major criteria.
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18
Q

Clinical diagnosis of definite endocarditis?

A
  • 2 major criteria
  • 1 major and 3 minor criteria
  • 5 minor criteria
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19
Q

Clinical diagnosis of possible endocarditis?

A
  • 1 major and 1 minor criteria

- 3 minor criteria

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20
Q

Treatment of Native Valve Viridans/Group D strep infection if penicillin MIC is <0.12

A

Penicillin G OR ceftriaxone + gentamicin for 2 weeks.

Penicillin G OR ceftriaxone for 4 weeks

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21
Q

Treatment of Native Valve Viridans/Group D strep infection if penicillin MIC is 0.12 - 0.5?

A

Penicillin G + gent for the first 2 weeks followed by ceftriaxone alone for 2 weeks.

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22
Q

Treatment of Native Valve Viridans/Group D strep infection if penicillin MIC is >0.5?

A

Ampicillin or penicillin + gent for 4 weeks.

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23
Q

Treatment of Prosthetic Valve Viridans/Group D strep infection if penicillin MIC is <0.12

A

Penicillin G or ceftriaxone +/- [gent for first 2 weeks]. Total of 6 weeks.

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24
Q

Treatment of Prosthetic Valve Viridans/Group D strep infection if penicillin MIC is >0.12

A

Penicillin G or ceftriaxone AND gent for 6 weeks.

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25
Q

Treatment of native valve endocarditis due to MSS [aureus or coag negative]

A

Oxacillin, nafcillin, cefazolin. 6 weeks total.

If there is a brain abscess

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26
Q

Treatment of native valve endocarditis due to MRS [aureus or coag negative]

A

Vancomycin for 6 weeks.

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27
Q

Treatment of prosthetic valve endocarditis due to MSS [aureus or coag negative staph

A

Oxacillin OR nafcillin AND rifampin AND gentamicin for AT LEAST 6 weeks. Gent should be used for the first 2 weeks.

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28
Q

Treatment of prosthetic valve endocarditis due to MRS [aureus or coag negative staph

A

Vancomycin AND rifampin AND gent for AT LEAST 6 weeks. Gent should be used for the first 2 weeks.

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29
Q

Treatment of pan-susceptible enterococcus endocarditis

A
  1. Amp OR penicillin G + gentamicin for 6 weeks

2. Amp + ceftriaxone for 6 weeks

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30
Q

Treatment of gentamicin resistant enterococcus endocarditis

A

Amp + ceftriaxone for 6 weeks [NOT FOR faecium]

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31
Q

Treatment of penicillin resistant enterococcus

A

Vancomycin + gent for 6 weeks

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32
Q

Treatment of vancomycin, penicillin, and aminoglycoside resistant enterococcus

A

Linezolid or daptomycin or AT LEAST 6 weeks

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33
Q

Treatment of endocarditis due to HACEK organisms?

A

Ceftriaxone OR ampicillin OR cipro [ceftriaxone preferred] for 4 weeks.

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34
Q

Treatment of fungal endocarditis

A

Amphotericin B followed by life-long suppression with azoles.

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35
Q

Treatment of culture negative native valve endocarditis with acute symptoms

A

Vancomycin + cefepime for 6 weeks

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36
Q

Treatment of culture negative native valve endocarditis with subacute symptoms

A

Vancomycin + unasyn for 6 weeks

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37
Q

Treatment of culture negative PVE <1 year since surgery

A

Vanco + rifampin + gent + cefepime

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38
Q

Treatment of culture negative PVE >1 year since surgery

A

Vanco + ceftriaxone

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39
Q

Indications for early cardiac surgery in left sided IE? [10]

A
  1. Acute heart failure
  2. Fungal endocarditis
  3. IE due to highly resistant organisms
  4. Heart block
  5. Annular or aortic abscess
  6. Bacteremia >5 days despite adequate abx with no other sites of infection.
  7. Severe regurgitation
  8. Mobile lesion >10 mm
  9. PVE with recurrent emboli despite abx
  10. Relapsing PVE
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40
Q

Indications for early cardiac surgery in right sided IE? [4]

A
  1. Severe tricuspid valve regurg with right heart failure unresponsive to medical therapy
  2. Tricuspid valve vegetation >20 mm
  3. Recurrent PE despite appropriate therapy
  4. Persistent infection with difficult to treat organism.
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41
Q

Cardiac conditions requiring abx prophylaxis for IE? [4]

A
  1. Prosthetic heart valve
  2. Previous IE
  3. Congenital heart disease
    • Unrepaired cyanotic defect
    • Repaired defect with prothetic material or device during first 6 months post repair
    • Repaired defect with residual defect adjacent to prothetic material or device
  4. Cardiac transplant with residual valvulopathy.
42
Q

Procedures that require IE prophylaxis?

A
  1. All dental procedures with manipulation of gingival tissue, perforation of mucosa, or periapical region of teeth
  2. Procedures involving surgery in the respiratory mucosa [tonsillectommy, bronchoscopic biopsy]
  3. Procedures on infected skin, skin structures, or MSK tissue.
43
Q

Most common noninfectious causes of pericarditis?

A

Malignancy, uremia, connective tissue disease

44
Q

What medications can lead to pericarditis?

A

Penicillin, doxorubicin, hydralazine, minoxidil.

45
Q

Most common viral causes of pericarditis?

A

Coxsackie A and B, echovirus 8, adenovirus, HIV.

46
Q

Most common cause of pericarditis in the developing world?

A

TB

47
Q

Most common fungal cause of pericarditis?

A

Histoplasma capsulatum [6% incidence noted during large outbreaks with disseminated disease]

48
Q

Diagnosis of viral pericarditis?

A

Nasopharyngeal swabs or stool PCRs. If there is a pericardiocentesis done fluid should be sent for PCR.

49
Q

Most common infectious cause of myocarditis in developed countries?

A

Parvo-B19, HHV-6. This is followed by influenza A and B as well as hepatitis B and C.

50
Q

What bacteria can cause myocarditis in developed countires?

A

Diphtheriae, Borrelia spp.

51
Q

Myocarditis due to viruses in developing countries?

A

Mumps, rubella, dengue, chkungunya, polio, Ebola, yellow fever.

52
Q

Myocarditis due to bacteria in developing countries?

A

Leptospira, salmonella

53
Q

Myocarditis due to parasites in developing countries?

A

Trypanosoma cruzi, gambiense. Trichinella spiralis

54
Q

Diagnosis of myocarditis?

A

Cardiac biopsy - only done in those with refractory to conventional treatment, unexplained, or has progressive conduction system disease.

Cardiac biomarkers will be elevated for up to 1 week.

55
Q

Myocarditis treatment from ID standpoint

A
  1. Avoid exercise if viral.
  2. Avoid antivirals
  3. Supportive [general med CHF mgmt].
56
Q

How often dose acute rheumatic fever occur following GAS infection?

A

1-5 weeks.

57
Q

Acute rheumatic fever presentation?

A

Fever and arthritis occurs in 75% of cases. The arthritis is migratory, asymmetric, polyarticular, affecting mainly large points.

58
Q

Describe the carditis of ARF.

A

Can involve pericardium, myocardium, or endocardium. Valvulitis most commonly affects the mitral valve. Other findings include tachycardia and heart block.

59
Q

Describe the murmur of ARF.

A

Carey Coombs [short, mid-diastolic rumble best heard at apex] which resolves as the carditis resolves. Mitral regurg.

60
Q

Describe the choreiform movements.

A

Mostly upper body, worsen with purposeful action, disappear with sleep.

61
Q

Describe the subcutaneous nodules.

A

Appear predominantly on bony surfaces and tendons. Painless and are associated with presence of severe carditis.

62
Q

Major JONES criteria

A
  1. Joint involvement [polyarthritis]
  2. Carditis
  3. Nodules [subcutaneous]
  4. Erythema marginatum
  5. Sydenham Chorea
63
Q

Minor JONES criteria [4]

A
  1. Arthralgia
  2. Fever
  3. ESR/CRP elevation
  4. Prolonged PR interval
64
Q

Diagnosis of ARF?

A
  1. Two major JONES

2. One major and 2 minor JONES

65
Q

How is a recent strep infection demonstrated for ARF?

A
    • swab or culture or antigen test
    • serology
    • Antistreptolysin O
    • Anti-DNAase B
    • Antihyaluronidase
66
Q

Treatment of ARF?

A
  1. Penicillin EVEN if there is no pharyngitis
  2. ASA and NSAIDs will improve inflammation in 1-3 days.
  3. Steroids if there is no response to ASA/NSAIDs
67
Q

Treatment of chorea?

A

Carbamazepine or valproate

68
Q

What are treatment options for secondary prophylaxis in ARF? [4]

A
  1. Benzathine penicillin G q3-4 weeks
  2. Penicillin V BID
  3. Sulfadiazine qday
  4. Macrolide if penn/sulfa allergic
69
Q

Length of secondary prophylaxis for rheumatic fever in those with carditis and residual valve disease?

A

Until age 40 OR 10 years following disease [which ever is longer]. Consider lifelong.

70
Q

Length of secondary prophylaxis for rheumatic fever in those with carditis and NO residual valve disease?

A

10 years or until age 21, which ever is longer.

71
Q

Length of secondary prophylaxis for rheumatic fever without carditis or valve involvement?

A

5 years or until age 21, which ever is longer.

72
Q

Cause of cardiac implanted electronic device related infections?

A
  1. Skin organisms [coag negative staph, MSSA, MRSA]. This accounts for 75%.
  2. Cornebacterium, Cutibacterium
73
Q

Cardiac implanted electronic device related infections management principles.

A
  1. Remove the device and all hardware
  2. Get a TEE if there is a positive blood culture.
  3. Get a TEE if blood culture is negative because of premature abx administration.
  4. Culture the device once it is removed.
74
Q

Treatment of cardiac implanted electronic device related infections with NEGATIVE TEE.

A

2-4 weeks of abx if staph aureus [vanco or cefazolin]

2 weeks of targeted abx to other organism.

75
Q

Treatment of cardiac implanted electronic device related infections with POSITIVE TEE.

A

4-6 weeks of targeted abx. [Vanco empiric]

76
Q

Treatment of pocket infection with negative blood cultures.

A

10-14 days of abx [Vanco empiric]

77
Q

Treatment of generator/lead erosion with negative blood cultures

A

7-10 days of abx [Vanco empiric]

78
Q

How do LVADs become infected? [3]

A
  1. Skin flora introduced during implantation
  2. Ascending infection through driveline
  3. Hematogenous spread.
79
Q

Most common organisms in LVAD infections? [6]

A
  1. Coag negative staph
  2. S. aureus
  3. Enterococcus
    [First 3 are responsible for >50% of infections]
  4. Enterobacteriaceae
  5. Pseudomonas
  6. Candida [25% mortality rate].
80
Q

How can LVAD infections present?

A
  1. Driveline exit site with or without tunnel involvement [most common]
  2. Pocket infection
  3. Mediastinitis [common in postoperative period]
  4. Pump or cannula infections.
  5. Endocarditis
  6. Bloodstream infection.
81
Q

LVAD infection work up principles

A
  1. Get blood cultures.
  2. Culture driveline exit site if there is drainage.
  3. Get imaging if suspect pocket infection or source is not clear.
  4. If there is bacteremia get an echo to rule out endocarditis.
82
Q

What should be cultured from LVADs?

A
  1. Inflow and outflow canula
  2. Internal pump.
  3. Pocket.
83
Q

Treatment principles for LVAD infection?

A
  1. Long term abx will be needed if device is retained.
  2. Superficial driveline infections that respond well to abx may NOT need long term abx
  3. Debridement with device retention
84
Q

In a patient with positive blood cultures and a valve vegetation when can the LVAD be reimplanted?

A

14 days after first negative blood culture

85
Q

In a patient with positive blood cultures and a lead vegetation when can the LVAD be reimplanted?

A

72 hours after first negative blood culture

86
Q

In a patient with positive blood cultures and NO vegetations when can the LVAD be reimplanted?

A

72 hours after first negative blood culture

87
Q

Common causes of mediastinits?

A
  1. Post CTS infection
  2. Esophageal rupture
  3. Extension of infections from oropharynx or neck
  4. Extension of pneumonia, pancreatitis, abscesses
88
Q

Most common causes of mediastinitis?

A

Staph

89
Q

Etiology of right sided endocarditis in IVDU?

A
  1. Staph - 77%
  2. Strep - 5%
  3. Enterococcus - 2%
  4. GRN - 5%
  5. Culture negative - 3%
90
Q

Etiology of left sided endocarditis in IVDU?

A
  1. Staph - 23%
  2. Strep - 15%
  3. Enterococcus - 24%
  4. GRN - 12%
  5. Candida - 12%
  6. Culture negative - 3%
91
Q

What type of bacteria does a prosthetic valve put you at risk for?

A

Staph Epi [coag negative]

92
Q

What are high risk finding on a TTE for endocarditis?

A
  1. Large or mobile vegetations
  2. Valve insufficiency
  3. Valve perforation
93
Q

Who gets enterococcus endocarditis?

What valve does it involve?

A

Old men

Aortic valve

94
Q

What are the “nutritionally variant” strep? [2]

A
  1. Abiotrophia

2. Granulicatella

95
Q

What is the danger of a nutritionally variant strep infection?

A

Often penicillin tolerant

Risk of relapse

96
Q

Treatment of nutritionally variant strep IE?

A

Penicillin OR ampicillin + gent for 4 weeks

97
Q

Treatment of Tropheryma whipplei endocarditis

A

Doxy + Hydroxychloroquine for 1 year or more

98
Q

Treatment of Bartonella quintana endocarditis?

A

Doxy + rifampin for 6 weeks

99
Q

Treatment of Q fever endocarditis?

A

Doxy + Hydroxychloroquine for 1 year or more

100
Q

What are the abx prophylactic regimens for IE?

A
  1. Amoxicillin
  2. Amp or ceftriaxone IF
  3. Clinda if penn allergic
101
Q

Common causes of driveline infections in LVAD?

A
  1. Staph aureus - 44%
  2. Pseudomonas - 28%
  3. Serretia - 9%
102
Q

Common causes of pocket infections in LVAD?

A
  1. Coag neg staph - 24%
  2. Enterococcus - 24%
  3. Pseudomonas - 19%
  4. Staph Aureus - 19%
  5. Candida - 10%

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