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Y4 Cardiology > Cardiac infections > Flashcards

Cardiac infections Flashcards

1
Q

Define what is meant by a bacteraemia

A

The presence of bacteria in the bloodstream (bacteraemia) is a potentially life-threatening event - if not treated promptly the patient may develop septic shock and die.

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2
Q

When someone has a Implantable cardiac electronic devices (ICED) what are the 3 locations infection may occur ?

A

In either the Box (generator pocket), leads or Endocardium

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3
Q

How do generator pocket infections of a ICED usually present ?

A

Localized cellulitis, pain, swelling, discharge, wound breakdown.

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4
Q

What are often co-infections with a generator pocket infection of an ICED ?

A

Infective endocarditis (IE) or ICED lead infection (ICED-LI) frequently coexist

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5
Q

How may Infective endocarditis (IE) or ICED lead infection (ICED-LI) present alongside generator pocket infections & what is used to help diagnose these co-infections ?

A
  • Non-specific signs and symptoms of systemic infection (including fevers, chills, night sweats, malaise and anorexia) may be the only clinical features of ICED-IE/ICED-LI.
  • Dukes criteria used to help diagnose them
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6
Q

What is the initial investigations which should be done in someone with a suspected ICED infection ?

A

Not septic:

  1. 3 sets of blood cultures (≥ 6 hrs apart)
  2. Arrange Echo
  3. Arrange removal of entire system & temporary pacing if needed
  4. Empirical PO/IV Abx

If septic:

  1. 2 sets of blood cultures at different times within 1hr
  2. Commence empirical IV Abx’s following blood cultures within 1hr
  3. Urgent echo
  4. Prompt removal of entire system and temporary pacing if needed
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7
Q

What is the empirical Abx treatment for ICED infections ?

A

Teicoplanin IV (+ Gentamicin if high risk of infection)

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8
Q

Following initial investigations if there is echo evidence of lead or tricuspid valve vegetation/regurgitation how should the infection be treated?

A

ICED-infective endocarditis/ ICED-lead infection

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9
Q

Define what infective endocarditis (IE) is

A

This is infection of the endothelium of the heart valves

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10
Q

What are the risk factors for developing infective endocarditis ?

A
  • Heart valve abnormality - calcification/sclerosis in elderly, congenital heart disease, post rheumatic fever
  • Prosthetic heart valve
  • IVDU
  • Intravascular lines
  • Others: recent piercings, dental prcedures etc
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11
Q

Describe the pathogenesis of infective endocarditis

A
  1. Heart valve damaged
  2. Turbulent blood flow over roughened endothelium
  3. Platelets / fibrin deposited
  4. Bacteraemia (may be very transient) e.g. from dental treatment
  5. Organisms settle in fibrin/platelet thrombi becoming a microbial vegetation
  6. Infected vegetations are friable and break off, becoming lodged in the next capillary bed they encounter causing abscesses or haemorrhage - may be fatal
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12
Q

Can infective endocarditis occur on normal healthy valves ?

A

Yes - upto 50% of cases do

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13
Q

What are the 4 common organisms which cause infective endocarditis ?

A
  1. Staphylococcus aureus
  2. Viridans group streptococci
  3. Enterococcus sp
  4. Staphylococcus epidermidis
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14
Q

What is the most common organism causing infective endocarditis ?

A

Staphylococcus aureus

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15
Q

In people with previously normal heart valves what is the most common heart valve to be affected by infective endocarditis ?

A

The mitral valve

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16
Q

In IVDU’s what is the most common heart valve to be affected by infective endocarditis ?

A

Tricuspid valve

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17
Q

What organism is particularly associated with infective endocarditis in IVDU’s ?

A

Staph.aureus

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18
Q

What organism is particularly associated with causing infective endocarditis in patients with poor dental hygeine/following a recent dental procedure ?

A

Streptococcus viridans

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19
Q

What are the 2 key investigations to be done in someone with suspected infective endocarditis ?

A
  • 3 sets of blood cultures & TTE echocardiogram
  • Blood cultures should be taken before any antibiotics
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20
Q

If blood cultures are negative in someone with suspected infective endocarditis what should be considered ?

A

Consider serology for “atypical” organisms

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21
Q

How is infective endocarditis diagnosed ?

A

Based on the modified dukes criteria (shown in pic)

  • Definitive endocarditis = 2 major or 1 major & 3 minor or all 5 minor criteria
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22
Q

What are the 2 main ways in which infective endocarditis may present ?

A
  1. As acute IE
  2. Or as subacute IE
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23
Q

How does acute infective endocarditis present ?

A
  • Presents as overwhelming sepsis and cardiac failure
  • Usually due to aggressive (virulent) organisms such as Staphylococcus aureus
24
Q

Who is acute IE more common in ?

A

People with previously normal heart valves (naive)

25
Q

How does subacute IE present ?

A

Symptoms:

  • Fever
  • Malaise
  • Weight loss
  • Tiredness
  • Breathlessness

Signs:

  • Fever
  • New or changing heart murmur
  • Finger clubbing
  • Splinter haemorrhages
  • Splenomegaly
  • Roth spots, Janeway lesions, Osler nodes
  • Microscopic haematuria
26
Q

Who is subacute IE more common in ?

A

People with abnormal heart valves

27
Q

Fever + new murmur = what until proven otherwise ?

A

Infective endocarditis

28
Q

What 2 clinical signs when seen together is pathognmoic of infecitve endocarditis ?

A

Janeway lesions + oslers nodes

29
Q

What clinical sign of IE is shown here ?

A
  • Janeway lesion = painless palmar or plantar macules
  • Roth spots = boat shaped retinal haemorrhages with a pale centre
30
Q

What clinical sign of IE is shown here ?

A

Oslers nodes = painful pulp infarcts in fingers or toes

31
Q

What are the 2 presentations of prosthetic valve IE & the typical organisms causing the infection ?

A
  1. Early- usually infected at time of valve insertion and usually due to Staphylococcus epidermidis or Staphylococcus aureus
  2. Late - up to many years after valve insertion - due to co-incidental bacteraemia. Wide range of possible organisms
32
Q

Go over the image of the potential embolic effects of IE

A
33
Q

What is the empirical treatment of Native valve indolent (Subacute) infective endocarditis ?

A

IV Amox + Gent

34
Q

What is the empirical treatment of Native valve severe sepsis (Acute) infective endocarditis ?

A

IV flucloxacillin

35
Q

What is the empirical treatment of prosthetic valve endocarditis

A
  • Vancomycin IV + Gentamicin IV
  • ­ Add in day 3 to 5 (delayed) rifampicin PO
  • ­often valve replacement is required
36
Q

What should be done if IE suspected but blood cultures are negative ?

A

Serology (blood & specific PCR)

37
Q

Following blood culture results specific treatments are given for IE what is the specific treatment for staph. aureus IE ?

A

IV flucloxacillin

38
Q

Following blood culture results specific treatments are given for IE what is the specific treatment for Strep.viridans ?

A

Benzylpenicillin iv & gentamicin iv

39
Q

Following blood culture results specific treatments are given for IE what is the specific treatment for enterococcus sp. ?

A

­Amoxicillin/ vancomycin & gentamicin IV

40
Q

Following blood culture results specific treatments are given for IE what is the specific treatment for Staph.epidermis IE?

A

­Vancomycin & gentamicin IV & rifampicin PO

41
Q

What monitoring is requried for patients with IE, how long are they treated for and what is usually done if Abx Tx is failing ?

A
  • IV antibiotics usually given for 4 - 6 weeks
  • Monitor cardiac function, temperature and serum C-reactive protein (CRP)
  • If failing on antibiotic therapy, consider referral for surgery early
42
Q

Should prophylactic Abx’s be given to patients undergoing the following to prevent IE risk?

  • dental procedures
  • upper and lower gastrointestinal tract procedures
  • genitourinary tract; this includes urological, gynaecological and obstetric procedures and childbirth
  • upper and lower respiratory tract; this includes ear, nose and throat procedures and bronchoscopy
A

No

43
Q

Define what myocarditis is

A

This is inflammation of the myocardium

44
Q

What is myocarditis mainly caused by ?

A

Mainly caused by enteroviruses -Coxsackie A & B, echovirus, but other viruses possible

45
Q

What are the signs/symptoms of myocarditis ?

A
  • Symptoms -fever, chest pain, shortness of breath, palpitations
  • Signs -arrhythmia, cardiac failure
46
Q

How is myocarditis diagnosed ?

A
  • By viral PCR.
  • Throat swab and stool for enteroviruses. Throat swab for influenza
47
Q

What is the treatment of myocarditis ?

A

Supportive

48
Q

What is acute pericarditis ?

A

Inflammation of the pericardium

49
Q

What are the clinical features of pericarditis ?

A
  • chest pain: may be pleuritic. Is often relieved by sitting forwards
  • other symptoms include non-productive cough, dyspnoea and flu-like symptoms
  • pericardial rub
  • tachypnoea
  • tachycardia
50
Q

What are the classical causes of pericarditis ?

A
  • viral infections (Coxsackie)
  • Post MI - dresslers syndrome
51
Q

What are the ECG changes suggestive of pericarditis ?

A
  • ‘saddle-shaped’ ST elevation
  • PR depression: most specific ECG marker for pericarditis
  • the changes in pericarditis are often global/widespread, as opposed to the ‘territories’ seen in ischaemic events
52
Q

Alongisde an ECG what should all patients with suspected pericarditis be investigated with ?

A

TTE echo

53
Q

What is the treatment of pericarditis ?

A

Supportive - NSAID’s + colchicine 1st line

54
Q

What can acute pericarditis lead to ?

A

Constrictive pericarditis = scarring, thickening, and muscle tightening, or contracture due to long-term chronic inflammation of the pericardium

55
Q

What are the features of constrictive pericarditis ?

A
  • dyspnoea
  • right heart failure: elevated JVP, ascites, oedema, hepatomegaly
  • JVP shows prominent x and y descent
  • pericardial knock - loud S3
  • Kussmaul’s sign is positive
  • Pericardial calcification on CXR

Y4 Cardiology (27 decks)

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