Endocarditis

Question 1

Diagnosis of emdocarditis

Answer 1

Positive blood cultures and vegetations on endocardiogram

Question 2

Which group can have endocarditis on normal heart valve?

Answer 2

Injection drug users OR in severe and persistent bacteremia, in highly pathogenic organism infection (staph aureus), in dental procedures with blood (small risk).
in general the risk is proportional to the degree of valve damage

Question 3

Which type of valve is at highest risk for endocarditis

Answer 3

Prosthetic valves or cyanotic heart disease

Question 4

In a normal valve is there a risk of endocarditis after surgery of the mouth and upper respiratory tract?

Answer 4

Nope, there is a risk only if there is severe valvular disease

Question 5

Best initial test for establishing dx of endocarditis

Answer 5

Blood cultures (95-99% sensitive) first, then if positive do transthoracic echo if transthoracic echo doesn’t show vegetations then do transesophageal echo

Question 6

A man come to the ER with fever and a murmur. Blood cultures grow Strep bovis. Transthoracic echo shows vegetation. What is the next best step management?

Answer 6

Colonoscopy (because of strep bovis is associated with colonic patho and cancer)

Question 7

How to diagnose culture negative endocarditis?

Answer 7

1. oscillating vegetation on echo
2. Three minor criteria
   - fever
   - major risk (injection drug use, prosthetic valve)
   - embolic phenomena (roth spot, janeway, splimter hemorrhage…)

Question 8

Empiric tx for endocarditis

Answer 8

Vancomycin and gentamicin

When culture results arrive switch based on sensitivity

Question 9

Specific tx according to organisms:

Viridans strep

Answer 9

Ceftriaxone 4 weeks

Or penicillin or amicillin

Question 10

Specific tx according to organisms: staph aureus (sensitive)

Answer 10

Oxacillin, nafcillin or cefazolin

Question 11

Specific tx according to organisms: fungal

Answer 11

Amphotericin and valve replacement

Question 12

Specific tx according to organisms: staph epidermidis or resistant staph

Answer 12

Vancomycin alone

Question 13

Specific tx according to organisms: enterococci

Answer 13

Ampicillin and gentamicin

Question 14

Specific tx according to organisms: resistant organisms (resistant enterococcus)

Answer 14

Add aminoglycoside and extend duration of tx

Question 15

When do you do surgery in endocarditis?

Answer 15

CHF, ruptured valve or chordae tendineae
Prosthetic valves
Fungal endocarditis
Abscess
AV block
Recurrent emboli when on antibiotics

Question 16

Specific tx in prosthetic valve with staph:

Answer 16

Surgery and rifampin

Question 17

Most common cause of culture negative endocarditis

Answer 17

Coxiella burnetti and bartonella

Question 18

Specific tx according to organisms: HACEK

Answer 18

Heamophilus aphrophilus, h.parainfluenza, actinobacillus, cardiobacterium, eikenella, kingella
Ceftriaxone

Question 19

When is prophylaxis for endocarditis indicated?

Answer 19

If there is both:
Significant heart defect: prosthetic valve, previous endocarditis, unrepaired cyanotic heart disease or cardiac recipient with valvulopathy (careful, no need of prophyl in mitral valve prolapse)
And risk of bacteremia: dental work with blood, respiratory tract surgery producing a bacteremia

Question 20

What is the prophylaxis

Answer 20

Amoxicillin prior to procedure

If penicillin allergic: clindamicin, azithromycin, clarithromycin

Question 21

Sx of endocarditis

Answer 21

Fever, new or change in intensity murmur
Rarely: splinter hemorrhages, janeway lesions (flat and painless)
Oslers nodes (raised and painful), roth spots (retina)
Brain: mycotic aneurysm
Kidneys: hematuria and glomerulonephritis
EKG: rarely shows AV block (5-10%)
Conjunctival petichiae
Splenomegaly
Septic emboli to lungs (looks like pneumo)