Infective Endocarditis

Question 1

What are the three layers of the heart?

Answer 1

EPICARDIUM = Outer Layer, Visceral Pericardium
MYOCARDIUM = Middle Layer, Makes up majority of the heart mass
ENDOCARDIUM = Inner Layer, Lines the chambers, valves, & vessels (focus of this lecture)

Question 2

How does infectious endocarditis present?

Answer 2

Ranges from septic and life threatening to a mild murmur and fatigue/benign symptoms

Question 3

What patients get infective endocarditis?

Answer 3

Some sort of dmg or turbulent blood flow - not in normal, healthy patients

congenital defect or injury is necessary

Question 4

What is the pathogenesis of endocarditis?

Answer 4

A needle can penetrate
Exposes blood stream
Grow in the heart (part of the valve can break off)
Release into blood stream and can cause a bunch of problems in (spleen, brain, etc)

Question 5

What is the MC way that infections enter the body and lead to endocarditis? What are some other ways?

Answer 5

Oral source is MC
IV, surgery, catheters, anything that allows bacteria to enter into the blood stream (more bacteria the worse it is), colonoscopy, IV drug use

Question 6

What is importnat patient education for prevention of endocarditis?

Answer 6

ORAL CARE

someimtes need to be cleared by dentist prior to surgery

Question 7

What side of heart is the MC cause of EC in population? IV drug users?

Answer 7

Population: Left side (higher pressure system)

IV drug users: right side (inject into the venous system and effects the tricuspid valve).

Question 8

What is the MC causative agent of endocarditis?

Answer 8

Staph aureus then Strep

Question 9

What puts you at risk for endocarditis?

Answer 9

Valve/heart disorders including rheumatic fever

Question 10

If prostehtic valve is within two months of EC, what is MC? After that?

Answer 10

Staph is for early (within 2 months)
Strep is after

Question 11

MC causative organism for IV drug user endocarditis? What valve?

Answer 11

Staph, then strep (same as normal) effects the tricuspid valve

Dirty water (particulate) enters the valve

Question 12

MC cause of nosocomial endocarditis?

Answer 12

Staph aureus from exposure to catheter ect

Question 13

MC patient to have fungal endocarditis

Answer 13

IVDU and ICU patients who receive broad-spectrum abx

Question 14

What are some complications of endocarditis? MC cause of death for these patients?

Answer 14

Regurgitation
Emboli
Conduction system abnormalities
Abscess
Septal rupture
Pulmonary or systemic emboli (worse)

MC cause of death is heart failure

Question 15

What are the s/s of endocarditis?

Answer 15

Underlying cause

symptoms
fever, chills, weakness, SOB, night
sweats, loss of appetite, weight loss

signs
fever is in over 90% of patients, heart murmurs, CHF (dyspnea, swelling), septic emboli (pleuritic chest pain)

Question 16

What are the skin signs of endocarditis and what causes them?

Answer 16

Petechiae on conjunctiva, buccal mucosa, palate

Splinter hemorrhages (linear red-brown streaks)

Janeway lesions (painless)
Osler nodes (painful, from strep) can palpate!

Question 17

What are the eye exam findings of endocarditis?

Answer 17

Roth spot hemmorage from chronic strep (rare)

Question 18

What are the neurologic manifestations of endocarditis?

Answer 18

CNS embolization is one of the most serious complications of IE
IE must be in DDx in young pt with CVA
May complain of headache or develop seizures, possibly due to toxic encephalopathy, meningoencephalitis

Question 19

What do you order for labs for endocarditis and what do you see?

Answer 19

CBC: anemia
inflammation (ESR, CRP, LDH)
UA
Blood cultures before antibiotics

Question 20

What imaging do you order for endocarditis? When is one preferred?

Answer 20

Echo (TTE or TEE)
look for vegetation

TTE is preferred first
Trans-esophageal (higher sensitivity but more invasive - done if larger body habitus or undiagnosed TTE)

Question 21

What is the diagnostic criteria before an echo?

Answer 21

Duke criteria (makor and minor)

Definitive: 2 major criteria, or 1 major and 3 minor, or all 5 minor

Possible IE: 1 major and 1 minor, or 3 minor

Question 22

What is the major criteria of Duke’s criteria?

Answer 22

Positive blood cuture
Evidence of endocardial mass
New regurgitant murmur

Question 23

What are the minor criteria of Duke’s criteria?

Answer 23

Predisposing heart condition or IVDU
Fever (>38 C or >100.4 F)
Vascular and embolic phenomena
including major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage, or Janeway lesions
Immunologic phenomena
glomerulonephritis, Osler nodes, Roth spots, and rheumatoid factor
Microbiologic evidence
Single positive blood culture or serologic evidence of active infection with typical organism

Question 24

What is the big-picture management of infectious carditis?

Answer 24

Management of patients with IE involves multiple aspects
Antibiotic therapy (Involve ID for this)
Management of CHF
Management of systemic/pulmonary sequelae
Surgery

multiple weeks of treatment

Question 25

What is the treatment of native valve IE, IVDU, Prosthetic bacterial IE? What if it is fungal? Curative?

Answer 25

Vanc go to for all of them, wait for what it is sensitive to and then change (often curative)

Fungal needs Amphotericin B (not curative) and then surgery

Question 26

What is the surgery protocol of IE?

Answer 26

Involves open sternotomy valve replacement, repair or debridement
Timing and necessity is individualized for each patient (only ~25% undergo surgery)
Prosthetic valve IE rarely occurs after valve replacement for IE, so delaying surgery to prolong antibiotic therapy is never appropriate if patient remains hemodynamically unstable or fulfills one of the following criteria

Question 27

What are the surgery indications for IE that MUST be memorized?

Answer 27

CHF refractory to standard medical therapy (most common indication for early surgery)
Fungal IE
Persistent sepsis after 72 hrs of appropriate abx therapy
Recurrent septic emboli, especially after 2 weeks of abx
Rupture of an aneurysm of the sinus of Valsalva
Conduction disturbances caused by a septal abscess
Kissing infection of the anterior mitral leaflet in patients with IE of the aortic valve

Question 28

What do dentists do during IV treatment of IE?

Answer 28

Inpatients should be thoroughly evaluated by a dentist to identify and eliminate oral disease
The examination should focus on periodontal inflammation and pocketing around teeth and caries that may result in infection and subsequent abscess
A full series of intraoral radiographs should occur when the patient is stable

Question 29

What percentage of infectious endocarditis are preventable and what need AB?

Answer 29

Only 10% can be prevented by AB, which is why 90% can be from lifestyle prevention (good teeth cleaning) gingivitis is MC cause!

Question 30

What are the at-risk patients for infectious endocarditis?

Answer 30

Prosthetic heart valves
Prior endocarditis
Cyanotic congenital heart disease (unrepaired, repaired, or partially repaired)
Cardiac transplantation recipients who developed cardiac valvulopathy

Question 31

With high-risk patients, when should they receive propylatic AB?

Answer 31

Dental procedures
Respiratory tract procedures
Infect skin/ msk tissue

No longer for GI or GU procedures (even though they can cause it)

Question 32

Prophylatic AB treatment for endocarditis

Answer 32

amoxicillin
if allergy clinda, cephalexin, azithro/clarithro
if unable to do PO ampicillin, cefazolin, ceftriaxone, clinda

Question 33

What is the quick recap of infectious carditis?

Answer 33

In infective endocarditis there’s first some damage or injury to the heart valves, which serves as a place for bacteria to adhere to and then form vegetations.

Infective endocarditis should be suspected in individuals with fever and risk factors like presence of a prosthetic valve or cardiac device, intravenous drug use, immunosuppression, or a recent dental or surgical procedure.

Diagnosis is then confirmed according to the Duke’s criteria, which take into account the clinical presentation, blood cultures for microbiologic data, and echocardiography.

Treatment usually consists of high doses of intravenous antibiotics for six weeks to maximize diffusion into the vegetation.

Finally, some individuals need surgical debridement of infected material and replacement of the valve with a mechanical or bioprosthetic artificial heart valve.

For prevention:

If Antibiotic prophylaxis is recommended:
amoxicillin orally or ampicillin intravenously or intramuscularly one hour before the procedure.

Question 34

A 45-year-old homeless male presents to the emergency department with fever, chills, shortness of breath, and cough of 4-days duration. The patient reports he has also noticed several new skin lesions that were not present before, some of which are painful to the touch. The patient uses intravenous heroin and reports he last used heroin yesterday.

Temperature is 38.7°C (101.6°F), pulse is 106/min, respirations are 24/min, BP is 100/62 mmHg.

Fever
Non Painful Erythematous lesions
Evidence of Valvular Regurgitation
Nail Bed Hemorrhage

Answer 34

Evidence of Valvular Regurgitation (sometimes from echo)

Question 35

A 65-year old man with a past medical history of bicuspid and aortic valve replacements (the most recent being 6 months ago) comes to the emergency department because of a 1-week history of fever and chills.

He denies any recent cough, sinus congestion or drainage, night sweats, weight changes, recent travel, or sick contacts.

On PE:
He is febrile and you notice bilateral lower extremity petechial rashes. In addition, there is a 4/6 systolic ejection murmur and lung sounds are normal on auscultation. There are no neurological deficits and the remainder of the physical exam was otherwise unremarkable.

What is the most appropriate first step in management of this patient?

Perform a transesophageal echocardiogram

Obtain a plain film chest radiograph

Draw blood samples for culture

Administer intravenous broad spectrum antibiotics

Order a head and neck computed tomography scan

Answer 35

Obtain blood samples for culture