infective endocarditis Flashcards
what are the three layersof the heart walls
- epicardium (outer, viscwreal pericardium)
- myocardium (middle, makes up majority of heart)
- endocardium (inner, lines chambers, valves, vesels
what causes infective endocarditis
when bacteria enters the bloodstream and lodges onto a heart valve, especially those with prior damage or turbulent blood flow
what are common oral etiologies of infective endocarditis
- dentla extractions
- periodontal surgery
- tooth brushing
- chewing candy
what are non-oral causes of bacteremia
- IV drug use
- EGD
- colonoscopy
- TURP
- IV catheters
the localization of infection is determined by what?
production of turbulent blood flow
what type of IE is more common
Left-sided IE is more common, except among IVDU
what is the main organism causing native valve endocarditits
staph aureus
followed by strep
what valve/heart disorders increase risk for infective endocarditis
- rheumatic valvular disease
- congenital heart disease (PDA, VSD, tetralogy of Fallot)
- MVP with MR
- degenerative heart disease, AS d/t bicuspid AV, marfans
what is the most common organism causing prosthetic valve endocarditis
staphylococci MC for early
Strep MC for late
what is the MC causative organism in IV drug user endocarditis?
- staph aureus (MC)
- strep
what valve is MC affected in IV drug user endocarditis
tricuspid
what are MC causative organisms for nosocomial/healthcare-assocaited endocarditis
- G+ cocci (MC Staph)
- enterococci
- nonenterococcal strep
when is fungal endocarditis MC
in IVDU and ICU patients who receive broad-spectrum ABX
what are cardiac risk factors for endocarditis
- previous endocarditis
- prosthetic valve or pacemaker
- valvular disease or congenital heart disease
what are non cardiac risk factors for endocarditis
- IVDU
- IV catheter
- immunosuppression
- recent dental or surgical procedure
what is the MCC of death in endocarditis patients
heart failure
What are complications for infective endocarditis
- valve regurgitation
- vegetation obstructing orifices or making emboli
- conduction system affected by myocardial abscesses
- intramyocardial abscess or septal rupture
- supric systemic or pulmonary emboli
what are the MC symptoms of endocarditis
- fever (present in 90%)
- chills
- weakness
- SOB
- night sweats
- loss of appetite
- weight loss
- MSK pain (back pain)
what are the symptoms of endocarditis related to?
- systemic infection
- emboli
- other complications such as CHF
what are the PE findings in endocarditis
- heart murmur (80% except IVDU which is only 33%)
- CHF (66%)
- septic emboli
- petechiae ( does not blanch strep/staph)
- splinter hemorrhages (strep/staph)
- janeway lesions (staph)
- osler nodes (strep)
- roth spots (strep)
how long does it take endocarditis to manifest?
may manifest severely in 2 weeks or may be minimal for 6 months. (wow, thats so helpful)
in a endocarditis patient presenting with a pulmonary emboi, what additional signs and symptoms may you see?
- pleuritic chest pain
- blood tinged sputum/cough
- cavitating lesions on CXR
where may systemic emboli present in a patient with endocarditis
- renal arteries
- cerebral arteries
- coronary arteries
- mesenteric arteries
what are splinter hemorrages
linear red/brown streaks in nail beds caused by vasculitis or emboli (strep/staph)
what are janeway lesions
erythematous/hemorrhagic macular or nodules, painless patchees on palms or soles caused by emboli (staph)
what are osler nodes
painful nodes on pads or fingers or toes caused by vasculitis (strep)
what are roth spots
oval, pale, retinal lesions surrounded by hemorrhage caused by vasculitits (strep)
what are neurologic manifestations of endocarditis
- CNS emboli (most serious)
what are symptoms of CNS emboli (CVA)
- HA
- seizures
- toxic encephelopathy
- meningoencephalitis
What INITIAL diagnostic tests should be ordered in endocarditis suspicion
- CBC
- Blood cultures
what would you see on lab tests CBC, UA, ESR, CRP, LDH and lactic acid for endocarditis?
- CBC - anemia
- elevated ESR, LDH, CRP, lactic acid
- UA - proteinuria and hematuria
what is the process of obtaining a blood culture in endocarditis
- obtain PRIOR to initiation of abx
- at least 3 sets of cultures from different venipuncture sites with 1st and last samples drawn at least 1 hour apart
what is reccomended in ALL cases of suspected IE
echocardiography (TTE is sufficient, TEE is more sensitive esp in patients with large body habitus)
what is the major diagnostic criteria for IE
- positive blood culture (2+ positive cultures)
- evidence of endocardial involvement on echo ( intracardiac mass, myocardial abscess, or partial dehiscence of a prosthetic valve)
- new regurgitant murmur
what would suggest evidence of endocardial involvement on echo
- intracardiac mass on a valve or supporting structure
- myocardial abscess
- partial dehiscence of a prosthetic valve
what are minor criteria for diagnosis of IE
what is the requirements for definitive IE
- 2 major criteria
- 1 major, 3 minor
- 5 minor
what is the requirements for possible IE
- 1 major and 1 minor
- 3 minor
what are the 4 aspects of management for patients with IE
- abx therapy
- management of CHF
- management of systemic/pulm sequelae
- surgery
what are the Abx treatments for Native valve IE
- Pen G and gentamicin
- MRSA or pen resistent strep use Vanc
what are the abx treatments for IVDU IE
- nafcillin
- gentamicin
- vanc
what are the abx treatments for prosthetic valve IE
- vanc
- gentamicin
- rifampin
how long do IE patients stay on abx
usually 4-6 weeks
what is fungal IE typically treated with
amphotericin B (not curative) requires surgery for definitive management
what is the surgical procedure done for patients with IE
open sternotomy valve replacement, repair or debridement
Is delaying surgery to prolong antibiotic therapy ever appropriate if the patient meets surgical criteria? why or why not?
sorry this is worded funky!
basically you will rarely see prosthetic valve IE after valve replacement for IE so delaying surgery to prevent prosthetic IE is not necessary.
what are indications for surgery
what dental management should be done in patients with IE
- thorough evaluation for periodontal inflammation, pocketing and caries.
- treatment/elimination of any oral diseases.
- full series of intraoral radiographs (when stable)
what percent of IE cases are a consequence of invasive procedures that produce a significant bacteremia
15-25%
what percent of people who develop a valvular infection after a procedure are candidates for antibiotic prophylaxis? what does this mean?
50%
this means only 10% of IE cases can be prevented by the administration of pre-procedure antibiotics
what endocarditis prophylaxis is just as effective as prophylactic antibiotics
maintaining good oral hygiene
what is the MC source of spontaneous bacteremia
gingivitis
who is antibiotic prophylaxis reserved for in endocarditis?
- patients at high risk of IE
- only for those procedures that have higher likelihood of bacteremia
what patients are considered at high risk of IE
- Prosthetic heart valves
- Prior endocarditis
- Cyanotic congenital heart disease (unrepaired, repaired, or partially repaired)
- Cardiac transplantation recipients who developed cardiac valvulopathy
what cardiac conditions do NOT require antibiotic prophylaxis
- mitral valve prolapse
- rheumatic heart disease
- bicuspid vlave disease
- calcified aortic stenosis
- congenital heart conditions (VSD, ASD, hypertrophic cardiomyopathy)
what procedures require endocarditis prophylaxis
- dental procedures (gingival tissue, periapical region of teeth, perforation of oral mucosa)
- respiratory tract procedures (tonsillectomy/adenoidectomy or incision of respiratory mucosa)
- procedures involving infected skin or msk tissue including I&D of abscess
- NO LONGER FOR GI OR GU
what is the antibiotic regimen for endocarditis prophylaxis
- amoxicillin 30-60 min prior
- if PCN allergy - clinda, cephalexin, azithromycin or claritromycin
- if unable to take PO - ampicillin IM/IV or cefazolin, cetriaxone, clinda IM/IV if PCN allergy
