Endocarditis Flashcards
Define endocarditis
inflammation of the endocardium, the membranes lining the chambers of the heart and covering the cusps of the heart valves
Define infective endocarditis (IE)
Infection of the heart valves by various microorganisms
How do you classify endocarditis?
- Based on the anatomical site of infection
- Based on the clinical presentation
- Based on the organism identified
What are the types of anatomical sites for endocarditis?
- Native valve
- Prosthetic valve
- Left side
- Right side
What are the clinical presentations for acute bacterial endocarditis?
- High fevers
- Systemic toxicity
- Leukocytosis
- Death within days if left untreated
What are the clinical presentations for subacute bacterial endocarditis (SBE)?
- Slow, low-grade fever
- Night sweats
- Weight loss
- Vague systemic complaints
(T/F) - SBE occurs in previous valvular damage patients
TRUE
(T/F) - SBE and acute are treated differently
FALSE - treated the same
Which gender is affected by endocarditis more?
Men - 2x
Which age-group is affected by endocarditis more?
Age > 50 yo
What are the predisposing risk factors of endocarditis?
- Presence of prosthetic heart valve
- Previous endocarditis
- DM
- Health-care related exposure
- Congenital heart disease with cyanosis
- Acquired valvular dysfunction
- Hypertrophic cardiomyopathy
- Mitral valve prolapse with regurgitation
- Chronic IV access
- IV drug abuse (IVDA)
(T/F) - In 25% of the cases, predisposing risk factors are absent
TRUE
What are the most common organisms associated with endocarditis?
- Staph
- Streptococci
- Enterococci
- HACEK organisms
What is the most common route of obtaining IE?
Hematogenous spread requiring sequential occurrence of several factors
What are the several factors in the sequential occurrence that develops IE?
- Endothelial surface of the heart is damaged
- Sterile platelet-fibrin thrombi form surface of damaged endothelial cells
- Bacteremia gives organisms access to and results in colonization of the endothelial surface
- After colonization of endothelial surface, a “vegetation” of fibrin, platelets and bacteria form
Which bacterial organisms adhere to endothelial surface due to their production of adherence products?
- Staph
- Strep
- Entero
What are secondary complications due to vegetation formation?
- Heart failure
- Septic emboli
- Antibody complexes can form and deposit in organs causing local inflammation and damage
(T/F) - Clinical presentation of endocarditis is usually variable and nonspecific
TRUE
What is the most common sign and/or Sx of endocarditis?
- Fever
- Heart murmur (sign)
What laboratory finding is the hallmark finding for endocarditis?
Positive blood cultures
What are nonspecific lab findings for endocarditis?
- Anemia
- Normal or slightly elevated WBC with a mild left shift
- Elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP)
Which diagnostic tests can be performed to confirm endocarditis?
- Transesophageal echocardiogram (TEE) [used more often]
- Transthoracic echocardiogram (TTE)
What are the peripheral manifestations that could occur due to endocarditis?
- Osler’s nodes
- Janeway lesions
- Splinter hemorrhages
- Petechiae
- Clubbing of the fingers
- Roth spot’s
Match the peripheral manifestation from the description below:
Small, erythematous, hemorrhagic lesions, painless
Petechiae
Match the peripheral manifestation from the description below:
Hemorrhagic, painless plaques on the palms of the hands or soles of the feet
Janeway lesions
Match the peripheral manifestation from the description below:
Proliferative changes in the soft tissue about the terminal phalanges observed in long standing endocarditis
Clubbing of the fingers
Match the peripheral manifestation from the description below:
Purplish, erythematous SQ papules or nodules on the pads of the fingers and toes; painful and tender
Osler’s nodes
Match the peripheral manifestation from the description below:
Retinal infarct with central pallor and surrounding hemorrhage
Roth’s spots
Match the peripheral manifestation from the description below:
Thin, linear hemorrhages found under the nail beds of fingers or toes
Splinter hemorrhages
Which peripheral manifestations are not specific for infective endocarditis?
- Osler’s nodes
- Splinter hemorrhages
What criteria is used to diagnose a major or minor criteria?
Modified Duke
What things would consider a patient to be under a major criteria?
- Positive blood culture test (separate 2 times)
- Evidence of endocardial involvement with diagnostic tests
What is considered definite IE?
Pt consist of
- 2 major criteria OR
- 1 major and 3 minor criteria OR
- 5 minor criteria
What is considered possible IE?
Pt consist of
- 1 major and 1 minor criteria OR
- 3 minor criteria
A patient who is susceptible to PCN and has streptococci endocarditis in their native valve would be given what treatment? For how long?
- Aqueous crystalline PCN G or ceftriaxone for 4 weeks
- Aqueous crystalline PCN G or ceftriaxone + gentamycin for 2 weeks
- Vancomycin for 4 weeks
(T/F) - Vancomycin is only given if patient cannot tolerate PCN or ceftriaxone
TRUE
A patient who is relative resistant to PCN and has group A streptococci endocarditis in their native valve would be given what treatment? For how long?
- Aqueous crystallin PCN G or ceftriaxone for 4 weeks with gentamycin for 2 weeks
- Vancomycin for 4 weeks
A patient who is resistant to PCN and has group A streptococci endocarditis in their native valve would be given what treatment? For how long?
Vancomycin + gentamycin for 6 weeks
A patient who is susceptible to PCN and has group A streptococci endocarditis in their prosthetic valve would be given what treatment? For how long?
- Aqueous crystalline PCN G or ceftriaxone for 6 weeks +/- gentamicin (clinician’s choice) for 2 weeks
- Vancomycin for 6 weeks
A patient who is relative or fully resistant to PCN and has group A streptococci endocarditis in their prosthetic valve would be given what treatment? For how long?
- Aqueous crystalline PCN G or ceftriaxone + gentamicin for 6 weeks
- Vancomycin for 6 weeks
A patient with an MSSA infection and has staphylococcal endocarditis in their native valve would be given what treatment? For how long?
- Oxacillin or nafcillin for 6 weeks
- Cefazolin for 6 weeks (if patient is allergic to PCN)
A patient with an MRSA infection and has staphylococcal endocarditis in their native valve would be given what treatment? For how long?
- Vancomycin for 6 weeks
- Daptomycin for 6 weeks
A patient with an MSSA infection and has staphylococcal endocarditis in their prosthetic valve would be given what treatment? For how long?
- Nafcillin or oxacillin for 6 weeks or more AND
- Rifampin for 6 weeks or more AND
- Gentamicin for 2 weeks
A patient with an MRSA infection and has staphylococcal endocarditis in their prosthetic valve would be given what treatment? For how long?
- Vancomycin for 6 weeks or more AND
- Rifampin for 6 weeks or more AND
- Gentamicin for 2 weeks
A patient susceptible to PCN, gentamicin, vancomycin and has enterococcal endocarditis in their prosthetic or native valve would be given what treatment? For how long?
- Ampicillin or aqueous PCN G + gentamicin for 4-6 weeks
- Ampicillin or ceftriaxone for 6 weeks
- Vancomycin + gentamicin for 6 weeks
Which regimen is only given if the CrCl baseline < 50 mL/min or decreases < 50 with a gentamicin-containing regimen?
Ampicillin or ceftriaxone for 6 weeks if a patient has enterococcal endocarditis and are susceptible to PCN, gentamicin, and vancomycin.
A patient susceptible to PCN but resistant to aminoglycosides and has enterococcal endocarditis in their prosthetic or native valve would be given what treatment? For how long?
Ampicillin or ceftriaxone for 6 weeks
A patient susceptible to vancomycin and aminoglycosides but resistant to PCN and has enterococcal endocarditis in their prosthetic or native valve would be given what treatment? For how long?
Vancomycin + gentamicin for 6 weeks
A patient resistant to PCN, vancomycin, aminoglycosides and has enterococcal endocarditis in their prosthetic or native valve would be given what treatment? For how long?
Linezolid or daptomycin for > 6 weeks
A patient with HACEK endocarditis in their prosthetic or native valve would be given what treatment? For how long?
-Ceftriaxone
- Ampicillin/sulbactam
- Ciprofloxacin
If it’s a native valve infection it’s for 4 weeks long
If it’s a prosthetic valve infection it’s for 6 weeks long
(T/F) - HACEK endocarditis can be given another 3rd or 4th cephalosporin instead of ceftriaxone
TRUE
(T/F) - Ciprofloxacin is a fluoroquinolone that can be given for HACEK endocarditis as an alternative for beta-lactam intolerance
TRUE - but other fluoroquinolones can be given as well
Can surgery be used to help treat endocarditis in a patient?
Yes
Which patients are indicated to have surgery for endocarditis?
- HF
- Persistent fever
- Recurrent embolic events
- Prosthetic valves
- Abscess
- Fungal IE
- Ineffective antibiotic therapy
What is done in surgery to help reduce/treat endocarditis?
Remove and replace valve(s) to remove infected tissue and restore hemodynamic function
Are there any prevention therapy for patients to reduce recurrent endocarditis events?
Yes
Who are high risk patients who are allowed to have prevention therapies?
- Prosthetic heart valve
- Previous IE
- Congenital heart disease (CHD)
- Cardiac transplant recipient who develops cardiac valvulopathy
