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PHAR255 > Endocarditis > Flashcards

Endocarditis Flashcards

1
Q

What is endocarditis?

A

infection of the heart valves and other endocardial tissue
-the endocardium is the membrane that lines the chambers of the heart and covers the valves

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2
Q

Which populations is endocarditis seen more often in?

A

older adults (>50) and PWID
-uncommon in pediatrics

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3
Q

Describe the pathophysiology of endocarditis.

A
  1. altered endocardial surface produces a suitable site for bacterial attachment and colonization
    -trauma, turbulence, previously damaged valve
  2. formation of platelet-fibrin thrombus on the altered surface
  3. bacteremia
    -most commonly hematogenous spread
    -results in bacterial adhesions and colonization
  4. formation of vegetation of fibrin, platelets and bacteria
    -fibrin and platelets provide a cover for bacteria to grow
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4
Q

What are the two classifications of endocarditis?

A

acute and subacute

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5
Q

Describe acute endocarditis.

A

severe and rapid clinical course
often involves normal valves
history of bacteremia
requires early treatment
often Staph aureus

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6
Q

Describe subacute endocarditis.

A

illness lasts months before diagnosed
usually prior valve disease
often a history of dental work or procedures
usually Streptococcal or Enterococcal

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7
Q

Differentiate between early onset and late onset prosthetic valve endocarditis.

A

early onset: within 1yr of surgery
-organism introduced at time of surgery
-usually S. aureus
-can be gram - bacilli or fungal
late onset: after 1yr
-same organisms as native valve endocarditis (strep)

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8
Q

How is prosthetic valve endocarditis usually treated?

A

hard to sterilize prosthetic valves, treatment usually involves surgery

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9
Q

What are the risk factors for endocarditis?

A

> 60 yrs
male
structural heart disease
prosthetic valve
diabetes mellitus
IV drug use
poor oral hygiene/dental pathology
skin infection
prior infective endocarditis
indwelling CV device
chronic hemodialysis
intravascular catheter

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10
Q

Which organisms most commonly cause endocarditis?

A

Staphylococci
-coagulase + S.aureus
-coagulase - S.aureus
Streptococci
-Viridans group
Enterococci

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11
Q

Describe Streptococci as a cause of endocarditis.

A

mostly coming from oral and respiratory flora
dental or resp tract procedure may introduce bacteria
also group D strep-resides in GIT

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12
Q

Describe Staph aureus as a cause of endocarditis.

A

especially seen in IV drug users and early prosthetic valve endocarditis

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13
Q

Describe Enterococci as a cause of endocarditis.

A

from gut or urinary tract
GI/GU procedure may introduce into blood

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14
Q

What are the signs and symptoms of endocarditis?

A

fever
heart murmur (new or worsening)
fatigue, weakness, arth/myalgia, nightsweats, HA, wt. loss
Osler nodes
Janeway lesions
splinter hemorrhages
petechiae
vascular embolic event

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15
Q

What are Osler nodes?

A

purplish SC nodes on tips of fingers and toes
painful or tender
caused by immune complex deposition

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16
Q

What are Janeway lesions?

A

erythematous, nonpainful macules on palms and soles

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17
Q

What are splinter hemorrhages?

A

thin, linear hemorrhages under nailbeds

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18
Q

What are petechiae?

A

small, red, painless hemorrhagic lesions
frequently on trunk, buccal mucosa, palate and conjunctivae

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19
Q

Describe IV drug use in the context of endocarditis.

A

more often leads to right sided endocarditis
often presents as pulmonary syndrome:
-fever, cough, hemoptysis, pleuritic chest pain

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20
Q

What are lab changes seen in endocarditis and labs carried out for endocarditis?

A

normocytic, normochromic anemia
increased WBC
increased ESR or CRP
RF may be increased
blood cultures and sensitivity
-get shedding of bacteria from vegetation
-3 samples at different times or sites
echocardiography
-visualize vegetation and cardiac abnormalities

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21
Q

Describe the Modified Duke criteria for endocarditis.

A

major: + blood culture, evidence of endocardial involvement
minor: predisposition for IE, fever, vascular phenomenon, immunologic phenomenon, + blood culture
definite: 2 major; 1 major and 3 minor; or 5 minor
possible: 1 major and 1 minor; or 3 minor

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22
Q

What are the complications of endocarditis?

A

HF
cardiomyopathy
septic emboli
destruction of valves, fibrosis, abscess
glomerulonephritis
stroke

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23
Q

What is the function of vegetation?

A

protects bacteria from antibodies, macrophages and antibiotics

24
Q

What are the treatment principles for endocarditis?

A

generally IV for 4-6 weeks (sometimes 2 wks)
must be bactericidal; sufficient doses
often synergistic combinations are used
doses acknowledge ratios of AUC and MIC of drug to be bactericidal and above MIC for long enough time

25
Q

What is a synergistic antibiotic combination that is used for endocarditis?

A

PenG and AMGs
-synergistic against Viridans group, Enterococci, group D Strep

26
Q

What is the empiric therapy for endocarditis if the source is unknown and native valve?

A

PenG or ampicillin + AMG
if highly suspicious of S. aureus:
-add cloxacillin or use vancomycin + AMG

27
Q

What are the clues for S. aureus?

A

IV drug use
indwelling CV device
chronic skin disorders
burns
diabetes mellitus
prosthetic valve replacement
AIDS
solid organ transplantation

28
Q

In general, what is Streptococci highly sensitive to?

A

penicillin

29
Q

What is the treatment of endocarditis caused by Streptococci?

A

PenG or ceftriaxone x 4 wks (native valve) or 6 wks (prosthetic valve)

30
Q

What is the alternative treatment for endocarditis caused by Streptococci?

A

PenG or ceftriaxone with gentamicin x 2 wks in certain patients

31
Q

What is the treatment for more resistant strains of Streptococci?

A

4 weeks of penicillin; first 2 weeks add gentamicin OR ceftriaxone alone

32
Q

What is a determinant of treatment for endocarditis caused by Staphylococci?

A

whether MSSA or MRSA is suspected

33
Q

What is associated with higher cure rates and improved mortality in endocarditis caused by Staphylococci?

A

beta lactams associated with higher cure rates and improved mortality compared to vancomycin

34
Q

What can be used for endocarditis caused by Staphylococci if the patient has a non-anaphylactic penicillin allergy?

A

cefazolin instead of cloxacillin

35
Q

What is the treatment for endocarditis caused by MRSA?

A

vancomycin (or daptomycin) x 6 wks

36
Q

What are some considerations for therapy of endocarditis cause by Staphylococci if the patient has a native valve or prosthetic valve?

A

native valve: no need to add AMG
prosthetic valve: add AMG and rifampin

37
Q

What is the duration of therapy of endocarditis caused by Staphylococci?

A

6 weeks

38
Q

What is the relationship between Enterococci with MIC to penicillins and vancomycin?

A

higher MIC to penicillins and vancomycin than strep

39
Q

What are Enterecocci relatively impermeable to?

A

AMG

40
Q

What does treatment of endocarditis caused by Enterococci require?

A

synergistic action of cell wall active agent with an aminoglycoside
-some have high level resistance to AMG=synergy not an option

41
Q

What is the duration of therapy for endocarditis caused by Enterococci?

A

4-6 wks of penicillin or ampicillin + AMG
-high rates of nephrotoxicity

42
Q

What is the role of ampicillin + ceftriaxone for endocarditis caused by Enterococci?

A

ceftriaxone saturates penicillin binding sites
-cephalosporins not active against enterococci
-lower risk of nephrotoxicity

43
Q

What is the treatment of endocarditis caused by Enterococci if the organism is penicillin resistant?

A

vancomycin

44
Q

Is there a role for oral therapy in the treatment of endocarditis?

A

trial found changing to oral after 10 days of IV was inferior

45
Q

What should be done with anticoagulants when experiencing endocarditis?

A

discontinue all forms of anticoagulation in patients with mechanical infective endocarditis who have experienced a CNS embolic event for at least 2 weeks
-this time allows for thrombus organization and prevent acute hemorrhagic transformation of embolic lesions

46
Q

What are monitoring parameters for endocarditis?

A

blood cultures
-q24h until negative
-check susceptibility results to ensure best antibiotic
drug specific monitoring
-AE of antibiotics
-vancomycin and/or AMG serum concentrations
patients signs and symptoms (temp, WBC, appetite, fatigue)
signs/symptoms of HF
heart murmur will not go away but worsening is a poor sign
embolic phenomenon

47
Q

True or false: IE is much more likely to result from bacteremia associated with dental/GI/GU procedures compared to daily activities

A

false
more likely from daily activities

48
Q

What is the benefit of endocarditis prophylaxis?

A

prevents an exceedingly small # of cases, if any
-risk > benefit

49
Q

What is the best advice you can provide for endocarditis prophylaxis?

A

maintain excellent oral health and daily oral hygiene

50
Q

Which patients might it be reasonable to give endocarditis prophylaxis to?

A

prosthetic valve
previous IE
congenital heart disease
cardiac transplant

51
Q

What are the endocarditis prophylaxis regimens for a dental procedure?

A

oral:
-amoxicillin (adults: 2g)
unable to take oral:
-ampicillin or cefazolin or ceftriaxone
allergic to penicillin:
-cephalexin or clindamycin or azith/clarith
allergic to penicillin and unable to take oral:
-cefazolin or ceftriaxone or clindamycin

52
Q

Which dental procedures are reasonable to give endocarditis prophylaxis for?

A

procedures involving manipulation of gingival tissue or the periapical region of teeth or perforation of oral mucosa

53
Q

How should antibiotics be administered for endocarditis prophylaxis when given for a dental procedure?

A

30-60min before procedure
can be taken up to 2h after procedure

54
Q

Which patients require endocarditis prophylaxis for respiratory tract procedures?

A

same list as dental prophylaxis
-same prophylactic agents as dental prophylaxis
-only recommended if underoing invasive procedure of resp tract that involves incision or biopsy of the respiratory mucosa

55
Q

Which patients should receive endocarditis prophylaxis for procedures on infected skin or MSK tissue?

A

same list as dental prophylaxis
-should include coverage for staph and strep
-does not include vaginal delivery, hysterectomy, tattoos, piercings

56
Q

Which patients should receive endocarditis prophylaxis for GI/GU procedures?

A

no longer recommended due to concerns of resistance
-if active infection, cover for E. coli

57
Q

Which antibiotic should be given as endocarditis prophylaxis if the patient is already on an antibiotic?

A

different class than currently receiving
-consider delaying procedure until course is finished if possible
-if unavoidable, treat 30-60min before procedure

PHAR255 (24 decks)

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