Infective endocardidis

Question 1

endocarditis = infection involving the endothelial layer of the heart

Answer 1

1. heart valves commonly involved (tricuspid 50%, mitral and aortic )
2. low-pressure side of a ventricle septal defect
3. intracardiac devices

Question 2

Vegetative lesion

Answer 2

microoganism
platelets
fibrin
inflammatory cells

Question 3

initiating event for infective endocarditis

Answer 3

organism gain access to blood stream

Question 4

classification of infective endocarditis

Answer 4

consideration of the disease
1. evolution of disease
2. site of infection
3. cause of infection
4. predisposing factors

Question 5

acute endocarditis

Answer 5

b-hemolytic streptococci, s. aureus and pneumocococci

febrile illness
rapidly damages cardiac structures
seeds extracardiac sites
leads to death within weeks

Question 6

sub acute endocarditis

Answer 6

viridians streptocci, enterococci, coN & HACEK ( gram negatives)
indolent course
causes damage to the structure but is slower
rarely metastasizes elsewhere
progressive unless complicated by a major event

Question 7

risk factor for endocarditis

Answer 7

IVDA: tricuspid valve

Degenerative heart valve disease: calcific/sclerotic valves
Congenital heart disease: bicuspid aortic valve

Central lines:

intracardiac devices:

specific procedures: dentistry, upper resp, urologic, lower GI

elderly age

Question 8

infeccitve endocarditis
organisms & etiology

Answer 8

most common: gram-positive
less common: gram neg and fungi

native valve IE:
staphyloccous aureus

Prosthetic valve:
early: staphylococci spp (MRSA) consider
late: streptococcus spp

oral cavity ideology;
viridians streptococci ( gram-positive oral flora)

integumentary ediologylogy ( wounds)
staphylococci spp

resp etiology
HACEK organisms
gram-negative IE

Fungal etiology
rare and fatal
candida and aspergillus spp

Question 9

endocarditis clinical manifestations

Answer 9

Endothelial injury:
direct infection by virulent organisms
development of non-bacterial thrombotic endocarditis (NBTE): mitral reg, AS ,AR, VSD

New murmur;
concering for valvular damage or ruptured chordae

CHF
due to valvular dysfunction

Extention of infection beyond valve leaflets:
paravalvular abscess
cause intracardiac fistula

abscess in the aortic valve;
heart block

coronary artery emboli
MI

Question 10

infective endocarditis non cardiac manifistations

Answer 10

Janeway lesions
found on palms or soles, painless
caused by septic microemboli
syphilis?

Osler’s nodes
tips of the fingers or toes and painful
caused by a localized immunological-mediated response

Question 11

infective endocarditis - non cardiac clinical

Answer 11

arterial emboli
up to 50% of cases

increased risk of embolism
staph aureus infection
mitral valve

cerebral vascular emboli
septic emboli
purvulent meningittis
ICH
seizures

regional pain or ischemia
embolic arterial occlusion

Question 12

infective endocarditis DX

Answer 12

echocardiogram
2 D echo or TEE

labs;
cbc
blood culture

Modified Duke criteria:
Diagnostic tools based on clinical lab and echo
Major and minor criteria

persistent fever > seven days despite appropriate abx
paravalvular abscess
extracardiac abscess in the spleen or kidneys
embolic event

Question 13

infective encocarditis treatment

Answer 13

must eradicate vegetation
bactericidal and prolonged therapy

The duration of therapy depends on the organism.

antimicrobial anti-platelet and anti-couag therapy
not recommended in most cases
exception with Afib, DVT, prosthetists

Consider heparin or Lovenox.

empiric abx coverage
1 gm Vanco and Rocephin 2 gm daily

surgical; native valve with large embolism
vegetation > 30

removal of cardiac device