Endocarditis

Question 1

What is endocarditis?

Answer 1

-Life-threatening infection of the endocardium (particularly heart valve leaflets)
-Valve gets damaged>clot forms>have some bacteriemia>turns clot into vegetation

Question 2

Most common organisms

Answer 2

1. Staphylococcus aureus (worldwide)
2. Enterococcus species
3. Viridans group streptococci (formerly most common)

Question 3

Diagnostic approach to dx of IE

Answer 3

-Hx: risk factors, IV drug use, cardiac hx, prosthetic hardware
-PE: IE stigmata, cardiac murmur
-At least 3 sets of blood cultures (if positive repeat 2 sets of BC every 24-48 hours until negative)
-Persistent bacteremia (>72hrs)
-Echo: TTE vs. TEE, consideration of repeat TEE
-Multidisciplinary team

Question 4

IE Stigmata

Answer 4

-Splinter hemorrhages
-Osler nodes
-Janeway lesions
-Conjunctival petechiae
-Roth’s spots

Question 5

Modified Duke>Major criteria

Answer 5

-Positive blood cultures (strepto, staphy, enterococci, HACEK group, viridans)
-Single positive cx: coxiella
-Echo positive for IE

Question 6

Modified Duke Criteria: Minor

Answer 6

-Positive blood cx: doesn’t meet major
-Fever 38C
-Predisposing condition, IV drug use
-Immunological phenomena: stigmata
-Vascular phenomena: mycotic aneurysms, ICH, Janeway lesions, major arterial emboli

Question 7

Modified Duke Criteria Definition

Answer 7

-Definite IE: 2 Major, 1 Major + 3 minor or 5 minor
-Possible IE: 1 Major + 1 Minor or 3 minor

Question 8

What if initial TEE is negative but clinical suspicion remains high?

Answer 8

-Repeat TEE in 3-5 days

Question 9

Overall management of IE

Answer 9

-Consults: ID, Cards, cardiothoracic surgery, ICU
-TEE
-pet/ct
-ct/mri
-Abx therapy: goal is complete eradication of microorganisms within vegetations; typically 4-6 wks long
-Start date of antibiotic therapy begins on the first day of negative blood cultures

Question 10

What is the difference between native valve and prosethetic valve abx therapy?

Answer 10

-Prosthetic valve abx therapy typically longer i.e 6 weeks and usually plus an additional agent (i.e gentamicin)

Question 11

Culture-negative endocarditis

Answer 11

-Continuous bacteremia and high frequency of positive blood cultures are hallmarks of IE
-May have to use other methods for testing like serology or PCR

Question 12

AP for a dental procedure

Answer 12

-Only if procedure involves manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa
-If there is a prosethic cardiac valve or material
-Previous, relapse, or recurrent IE
-CHD
-Transplant recipients who develop cardiac valvulopathy

Question 13

Abx tx single dose 30-60 minutes before procedure

Answer 13

-Oral Amoxicillin = 2 g
-Unable to take PO = ampicillin 2 g IM or IV; Cefazolin/ceftriaxone 1 g IM or IV
-Allergic to penicillin or ampicillin = cephalexin or azithromycin or clarithromycin or doxycycline