Endocarditis

Question 1

what s the age breakdown of endocarditis? increase in cases of what?

Answer 1

1. Median age has increased a. Less than 30 years (26%) b. 31 – 60 years (54%) c. Greater than 60 years (21%) 2. Ratio of males to females has increased 3. Acute cases have increased 4. Decrease in classical physical findings 5. Decrease in streptococcal cases 6. Increase in cases of GNB, fungi, unusual microbes

Question 2

who gets endocarditis?

Answer 2

Susceptible host a. Pre-existing heart disease b. Drug addicts c. Cardiac surgery a. Early prosthetic valve endocarditis b. Late prosthetic valve endocarditis d. Nosocomial e. Ineffective endarteritis

Question 3

What are the clinical manifestations of endocarditis?

Answer 3

–Infectious process on involved valve –Embolization –Metastatic infection –Immunopathogenic manifestations

Question 4

explain what infectious processes on the involved valve manifests with?

Answer 4

–Infectious process on involved valve • Fever (80 – 90%), weight loss, fatigue • Heart murmur –New, changing –Systolic, diastolic • Heart failure • Non-specific complaints –Arthralgia, myalgia, backache –Lethargy, delirium

Question 5

What does embolization manifest with?

Answer 5

Embolization • Pulmonary infiltrates (right-sided) • Stroke • Splenomegaly • Renal dysfunction • Myocardial infarction • Large vessel occlusion (fungi) • Peripheral manifestations – Osler’s nodes – Janeway lesions – Splinter hemorrhages – Roth spots

Question 6

What does metastatic infection manifest with?

Answer 6

–Metastatic infection and mycotic aneurism • Virulent organism (staphylococci) • Multiple organ abcesses • Weakened vascular wall –Mycotic aneurism (CNS)

Question 7

Lab findings for endocarditis?

Answer 7

• Gallium scans • Serology –Fungal, Q fever, psittacosis • Echocardiography –Two-dimensional defects 2 mm –Variable sensitivity (<50 - >90% positive) –False positive rare –Valuable for local complications • Cardiac catheterization

Question 8

What are the causes of negative culture endocarditis?

Answer 8

1. Prior antibiotic use 2 weeks or less from obtaining the culture 2. Nutritionally variant streptococci 3. Cell wall deficient organisms 4. Brucella species 5. Q fever 6. Psittacosis 7. Mycobacterial species 8. Fungal organisms (especially cadida) 9. Marantic endocarditis

Question 9

What is on the differential when someone has endocarditis?

Answer 9

• Hematologic malignancies – Lymphomas, leukemias • Connective tissue disease – SLE, rheumatoid arthritis, vasculitis • Infections – Tuberculosis, osteomyelitis • Other – Rheumatic fever

Question 10

what are the complications in ineffective endocarditis?

Answer 10

1. Cardiac Complications a. Heart failure b. Conduction abnormalities c. Myocardial infarction from emboli to the coronary arteries 2. Embolization 3. Neurological manifestations 4. Mycotic Aneurysm

Question 11

Surgical indications for endocarditis?

Answer 11

1. Worsening Congestive Heart Failure 2. Evidence of Progressing Infection a. Perivalvular abscess b. Intramyocardial abscess c. Persistent fevers despite appropriate antibiotics 3. Repeated Major Emboli 4. Fungal Endocarditis 5. Resistant Gram Negative Endocarditis

Question 12

who needs Prophylaxis for endocarditis?

Answer 12

1.Dental procedures with bleeding 2.Oral surgery of teeth and gums 3.Pelvic manipulation in presence of infection (abortion, IUD, delivery) 4.Tonsillectomy, adenoidectomy 5.GU manipulation in presence of infected urine 6.Operations involving infected soft tissue Low Risk Procedures 1.Minor dental procedures 2.Cardiac cath. 3.Cardiac pacemaker insertion 4.Endotracheal intubation

Question 13

Prosthetic valve endocarditis incidence? which

Answer 13

–Incidence = 2.6% • EPV = 37% • LPV = 63% –Types of prosthesis • Porcine = 2.2% • Ball valve = 3.3% EPV= early prosthetic valve endocarditis Late=LPV

Question 14

What organism cause EPV? LPV?

Answer 14

EPV: Staph epidermis 27%, Streptococci 7%, Staph aureus 14%. Also fungi, GNB, and diptheroids. LPV: Streptococci 29%

Question 15

pathogenesis of EPV?

Answer 15

a) Intraoperative contamination Skin flora of patient and hospital personnel Bypass pump contamination Air contamination b) Postoperative contamination Organisms from valve, pacemaker, pressure monitoring device IV catheters Seeding from extra-cardiac infection

Question 16

What is the pathogenesis of LPV?

Answer 16

a. Pathogenesis as per NVE (native invasive endocarditis) Transient bacteremias

Question 17

how to diagnose prosethetic valve endocarditis?

Answer 17

1. Blood cultures (90% positive) 2. Echo (not helpful) 3. Cardiac cinefluoroscopy – detects valve instability 4. Cardiac catheterization - Degree of valve dysfunction - Evaluate left ventricular function - Evaluate for multiple valve involvement

Question 18

What are the indications for surgery with prosethetic valve endocarditis?

Answer 18

Management: Surgery •Heart failure due to valve dysfunction •Acute valve obstruction •Fungal etiology •Persistent bacteremia •Unstable prosthesis after fluoroscopy •Two or more emboli •Ruptured VSD or sinus of valsalva •Relapse after appropriate therapy •Progressive conduction disturbances

Question 19

what are the major forms of suppurative thrombophlebitis?

Answer 19

1. Superficial 2. Pelvic 3. Cavernous sinus 4. Infection of portal vein (pylephlebitis)

Question 20

What are the clinical manifestations of suppurative thrombophlebitis?

Answer 20

1. Upper extremities 2. Fever (70%) 3. Erythema, swelling, tenderness, warmth (94%) 4. Septic emboli

Question 21

What are the lab findings of suppurative thrombophlebitis?

Answer 21

1. Bacteremia (80 – 90%) 2. Persistent becteremia after appropriate antibiotic 3. Leukocytosis 4. Semiquantitative culture (>15 colonies) 5. Pulmonary abscesses

Question 22

Bacteremia Due to Percutaneous Intravascular Devices occurs as a result of? Primary bacteremias are usually? Cluster associated nosocomial bacteremias are?

Answer 22

1. Sporadic nosocomial bacteremia occur as a result of distant localized infection with seeding. 2. Primary bacteremias (those without distant infected focus) are usually device-related and account for 25% of bacteremias. 3. Cluster associated nosocomial bacteremias are related to devices 75% of the time.

Question 23

What are the complications of device related bacteremia?

Answer 23

4. Complications of device-related bacteremia are: a. Abscess b. Septic thrombophlebitis c. Endocarditis d. Sepsis

Question 24

What are the patient characteristics for a catheter associated infection?

Answer 24

Patient characteristics –Age (1 year old or younger, 60 years old or older) –Alteration in host defenses • Loss of skin integrity • Diminished granulocyte function • Immunosupression & immunodeficiency –Severity of underlying illness –Presence of distant infection

Question 25

what are hospital related risk factors for a catheter associated infection?

Answer 25

– Catheter material – Catheter type and function – Location of catheter – Type of placement (percutaneous vs cutdown) – Duration of placement – Emergent vs elective placement – Skill of venipuncturist – Alteration in microflora surrounding insertion site

Question 26

what are some factors that differentiate device associated bacteremia from other septic sources?

Answer 26

1. Local phlebitis and/or inflammation at catheter insertion site. 2. Lack of other source for bacteremia. 3. Sepsis occuring in patient not at high risk for bacteremia. 4. Localized embolic disease distal to cannulated artery 5. Hematogenous Candida in patients receiving TPN. 6. Presence of >15 CFU of bacteria on semi-quantitative culture of catheter tip. 7. Sepsis refractory to “appropriate” antibiotics. 8. Resolution of febrile syndrome after device removal. 9. Typical microbiology (Staph A or epi). 10. Unusual microbiology (P.cepacia, E. agglomerans). 11. Clustered infections (infusion-related organisms)

Question 27

How do we diagnose Mycotic aneurysm?

Answer 27

1. Persistent bacteremia without endocarditis 2. Echo of aorta 3. Gallium scan 4. Arteriography

Question 28

Therapy for mycotic aneurysm?

Answer 28

Location and status of lesion - Surgery - Antibiotics - Surgery and antibiotics

Question 29

Organisms implicated in catheter associated infection?

Answer 29

Question 30

etiologic agents of mycotic aneurysm?

Answer 30