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Cardiology > Endocarditis > Flashcards

Endocarditis Flashcards

1
Q

How is endocarditis classified?

A

Infective endocarditis (IE)

Non-infective endocarditis (NIE)

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2
Q

What is endocarditis?

A

Inflammation of the endocardium of the heart

Often involves the heart valves

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3
Q

What is the hallmark sign of endocarditis?

A

Fever + murmur

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4
Q

What is the most common organism that causes IE?

A

Streptococcus viridans

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5
Q

Name other cocci that causes IE

A

Staphylococcus aureus (common)

Staphylococcus epidermidis - usually after prosthetic valve surgery

Strep bovis (needs colonoscopy, ?tumour)

Enterococci

Coxiella burnetti

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6
Q

What are the HACEK gram -ve bacteria that can cause IE?

A

Haemophilus
Actinobacillus
Cardioacterium
Eikenella
Kingella

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7
Q

Name other bacterial and fungal causes of IE

A

Bacteria
- diphtheroids
- Chlamydia

Fungi
- Candida
- Aspergillus
- Histoplasma

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8
Q

Which patient demographics are at increased risk of IE?

A

IV drugs user

Immunocompromised

Prosthetic valves

Congenital heart disease

Hypertrophic cardiomyopathy

Previous Hx of IE

Valvular heart disease

People with rheumatic fever - can cause rheumatic heart disease (which can cause IE); organism = Strep pyogenes

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9
Q

What are the septic signs of IE?

A

Fever

Rigors

Weight loss

Anaemia

Night sweats

Clubbing

Splenomegaly

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10
Q

What are the signs of IE?

A

Septic

Cardiac lesions

Immune complex deposition

Embolic phenomena

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11
Q

What are cardiac lesions?

A

Vegetations on the valves - can cause destruction and severe regurgitation, or valve obstruction

Any new murmur/change in pre-existing murmur should raise suspicion of endocarditis

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12
Q

How can cardiac lesions affect the ECG?

A

PR prolongation (caused by aortic root abscesses)

Can eventually lead to complete AV block

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13
Q

Name a common cause of death in IE

A

LVF

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14
Q

What conditions/signs in IE are caused by immune complex deposition?

A

Vasculitis

Microscopic haematuria - glomerulonephritis and AKI may occur

Roth spots - boat shaped retinal haemorrhage with pale centre

Splinter haemorrhages

Osler’s node - painful pulp infarcts in fingers and toes

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15
Q

What conditions/signs in IE are caused by embolic phenomena?

A

Abscesses in relevant organ e.g., kidney, spleen, liver

Janeway lesions - painless, palmar or plantar macules

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16
Q

Which criteria is used in the diagnosis of IE?

A

Modified Duke’s Criteria

17
Q

What are the components of the Modified Duke’s Criteria for IE?

A
18
Q

What other diagnostic tests can be done for IE?

A

Blood cultures - 3 at different times and different sites at the peak of fever
- 85-90% diagnosed from 1st 2 sets
- 10% are culture-negative

Bloods
- FBC - normochromic, normocytic anaemia, neutrophilia
- ESR/CRP - high
- RF
- U+E
- LFT
- Mg2+

Urinalysis
- microscopic haematuria

CXR
- pulmonary oedema
- cardiomegaly

Regular ECGs
- look for heart block

Echocardiogram
- vegetations > 2mm

CT
- emboli (spleen, brain etc)

19
Q

What is the initial ‘blind’ therapy for IE (native valve)?

A

Amoxicillin/ampicillin - consider adding low-dose gentamicin

If penicillin-allergic/MRSA suspected/severe sepsis = vancomycin + low does gentamicin

If severe sepsis + risk factors for Gram -ve infection = vancomycin + meropenem

20
Q

What is the therapy for IE (native valve) caused by staphylococci?

A

Flucloxacillin + rifampicin + low-dose gentamicin - for 6 weeks, review need to continue gentamicin at 2 weeks; if gentamicin to be continued beyond 2 weeks seek specialist advice

If penicillin-allergic/MRSA = vancomycin + rifampicin + low-dose gentamicin - for 6 weeks, review need to continue gentamicin at 2 weeks; if gentamicin to be continued beyond 2 weeks seek specialist advice

21
Q

What is the therapy for IE caused by fully-sensitive streptococci?

A

Benzylpenicillin sodium - 4-6 weeks (6 weeks for prosthetic valve)

If penicillin allergic = vancomycin (or teicoplanin) + low-dose gentamicin - for 4-6 weeks (stop gentamicin after 2 weeks)

22
Q

What is the therapy for IE caused by less-sensitive streptococci?

A

Benzylpenicillin sodium + low dose gentamicin - 4-6 weeks (6 weeks for prosthetic valve), review need to continue gentamicin at 2 weeks; if gentamicin to be continued beyond 2 weeks seek specialist advice

If penicillin allergic or highly penicillin resistant = vancomycin (or teicoplanin) + low-dose gentamicin - for 4-6 weeks , review need to continue gentamicin at 2 weeks; if gentamicin to be continued beyond 2 weeks seek specialist advice, stop at 2 weeks if pathogens moderately sensitive to penicillin

23
Q

What is the therapy for IE caused by enterococci?

A

Amoxicillin/ampicillin + ((low dose gentamicin) OR (benzylpenicillin sodium + low-dose gentamicin))
for 4-6 weeks (stop gentamicin after 2 weeks), review need to continue gentamicin at 2 weeks; if gentamicin to be continued beyond 2 weeks seek specialist advice

If penicillin-allergic or highly penicillin resistant = vancomycin (or teicoplanin) + low-dose gentamicin - for 4-6 weeks , review need to continue gentamicin at 2 weeks; if gentamicin to be continued beyond 2 weeks seek specialist advice

If gentamicin resistant = amoxicillin/ampicillin, add streptomycin (if susceptible) for 2 weeks
Suggested duration of Tx = at least 6 weeks

24
Q

What is the therapy for IE caused by HACEK?

A

Amoxicillin/ampicillin + low dose gentamicin for 4 weeks (6 weeks for prosthetic valve); stop gentamicin after 2 weeks

If amoxicillin-resistant = ceftriaxone (or cefotaxime) + low dose gentamicin for 4 weeks (6 weeks for prosthetic valve); stop gentamicin after 2 weeks

25
Q

What is the initial ‘blind’ therapy for IE (prosthetic valve)?

A

Vancomycin + rifampicin + low-dose gentamicin

26
Q

What is the prognosis of IE?

A

50% require surgery

20% in-hospital mortality (overall)
- Staphs = 30%
- bowel bacteria = 14%
- Streps = 6%

15% recurrence at 2 years

27
Q

TRUE OR FALSE
Antibiotic prophylaxis is no longer recommended for those at risk of IE undergoing invasive procedures

A

TRUE

However, if they are given Abx for other procedural reasons it should cover the common IE organisms

28
Q

What info about prevention of IE can you give to patients?

A

Importance of maintaining good oral health

Symptoms that indicate IE and when to seek expert advice

The risk of invasive procedures inc. non-medical procedures e.g., body piercing or tattooing

29
Q

What are the NIEs?

A

Nonbacterial thrombotic endocarditis (NBTE)

Libman-Sacks endocarditis

30
Q

What are the characteristics of NBTE?

A
  • most commonly found on previously undamaged valves
  • vegetations are small, sterile and tend to aggregate along the edges of the valve or the cusps
  • does not cause an inflammation response from the body
  • usually occurs in a hypercoagulable state e.g., system-wide bacterial infection, pregnancy
  • can also occur in patients with venous catheters
  • can also occur in malignancies esp. mucinous adenocarcinoma
31
Q

What are the characteristics of Libman-Sacks endocarditis?

A
  • occurs more often in SLE
  • thought to be due to deposition of immune complexes
  • involves small vegetations (unlike NBTE) - IE contains large vegetations
  • does not have a preferred location of deposition (unlike NBTE) - may form on the valves’ undersurfaces or even on the endocardium
  • Mx = anticoagulant in cases with previous thromboembolic event for prevention, surgical intervention if significant valvular dysfunction
  • has high morbidity and mortality
32
Q

Sources

A

Pg 150 Oxford Handbook of Clinical Medicine

https://en.wikipedia.org/wiki/Endocarditis

https://en.wikipedia.org/wiki/Nonbacterial_thrombotic_endocarditis

https://en.wikipedia.org/wiki/Libman%E2%80%93Sacks_endocarditis

https://www.nhs.uk/conditions/endocarditis/causes/

https://bnf.nice.org.uk/treatment-summaries/cardiovascular-system-infections-antibacterial-therapy/

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