Infectious Endocarditis Flashcards
What two symptoms should make you think endocarditis?
Fever
Murmur
What are risk factors for infective endocarditis?
prosthetic valve
IV drug use
Poor dental hygiene
Hemodialysis
Indwelling catheters
Diabetes mellitus
What is infective endocarditis?
Microbial infection of the endocardium of the heart
Inner lining of the heart
Chordae Tendinae
Valves
What organisms cause IE?
Staph aureus (Gram +, slow clearing)
Coagulase neg Staph (early prosthetic valve IE)
Steptococi
- mutans
- sanguis
- bovis (elderly)
HACEK IE stands for …
Haemophillus Actinobacillus Cardiobacterium hominis Eikenella Kingella kingae
Major criteria for IE
- Laboratory Evidence of IE
2+ blood cultures
1+ blood culture - Coxiella burnetti - Endocardial involvement - TTE/TEE
- New valvular regurgitation
Minor criteria for IE
- Predisposing heart condition
- Fever
- Valvular phonmenon
- emboli (JL), mycotic aneurysm, hemorrhages
- Immunologic phenomenon
- GN, Osler’s nodes, RH factor
- Positive blood culture - not a major
How is IE diagnosed?
2 Major
1 Major + 3 Minor
5 Minor
What is an Osler Node? Size and shape? Course? Types of endocarditis its seen with? Culture? Histology?
Painful, swollen, subQ nodule on the pulp of the fingers and toes
1 mm to > 1 cm Hours to days Subacute Negative culture, usually Vasculitis
What is a Janeway Lesion?
Size and shape? Course? Types of endocarditis its seen with? Culture? Histology?
Non-tender nodule on the palms or soles
Macules of variable size and irregular shape Days to weeks Acute Positive culture, usually Septic microemboli
What are the signs and symptoms of IE?
Fever Weight loss Fatigue Heart failure Night sweats Heart murmur Splenomegaly Skin petechiae Conjuctival hemorrhage Splinter hemorrhage Septic shock Osler nodes Janeway lesions
What is the treatment of IE? What things do you have to consider?
Is it G+?
PCN sensitive?
Yes - PCN or Ampicillin + Aminoglycoside
No - Vancomycin + Aminoglycoside
2-6 weeks IV antibiotics
Should we anti coagulate someone with IE?
NO
- doesn’t prevent embolism
- may increase risk of bleeding
What is the best first test in someone with suspected IE?
Blood cultures
What finding would you see on the optic disk in someone with IE?
What finding on external eye exam?
Roth spots
Subconjuctival petechiea
What finding would you see on the nails of someone with IE?
Splinter hemorrhage
What type of murmurs are usually seen with IE?
Regurgitant murmurs
–bacteria eats at valve
What is the number one reason to operate on a heart valve?
Valve rupture
What murmur presents as a holosystolic murmur?
Mitral regurgitation
What murmurs increase with inspiration?
Decrease?
R sided murmurs increase with inspiration
L sided murmurs decrease with inspiration
What findings might you see on a chest X-ray of someone with with IE?
Infectious cavitary lesions
These are seen when there is also tricuspid regurgitation
After performing the blood cultures, what is the next best step?
Start antibiotics
Best empiric choice is vancomycin and gentamicin
If cultures grow sensitive Staph aureus, switch vancomycin to nafcillin
If after starting vancomycin and gentamicin, the patient develops redness and flushing at the neck line, what should you do?
Decrease the rate of infusion of the AB
Strep bovis endocarditis is also associated with …
lesions in the colon
Should perform colonoscopy
“when you say bovis, I say buttocks”
What is different with the diagnosis/initial management of a patient with suspected IE and a prosthetic heart valve?
Go straight to TEE
- more things to look for and harder to see with TTE
- look for dehiscence, abscesses, and vegitations
Homeless man, alcoholic, flea bitten. Fever and murmur. Blood cultures negative. Echo shows vegetation. Diagnosed by PCR. Which organism?
Bartonella
Trench fever!
What are indications for prophylaxis to prevent IE?
Prosthetic valve
Heart transplant recipient
Previous endocarditis
Uncorrected cyanotic heart disease
PLUS
Dental work with bleeding –> i.e. extraction
Tonsillectomy/Adenoidectomy
When are some examples of times that prophylaxis is not needed for IE?
GI procedures
GU procedures
Fillings
TTE vs TEE - testing value
TEE more sensitive
Usually try TTE first though
