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Infective endocarditis Flashcards

1
Q

How is IE diagnosed

A

Dukes criteria - pathologicla or clinical

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2
Q

What is endocarditis

A

Infection and inflammation of endothelial surface of heart by microorganism

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3
Q

Pathogenesis of endocarditis

A

Tubulent blood flow -> dmaage smooth surfaces - accumulation of platelets/fibrin/leucocytes -> infected by any circulating microorganisms and form vegetation

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4
Q

What is vegetation

A

Infected mass attached to endocardial structure or on implanted intracardiac material

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5
Q

Vegetation on ECHO

A

Oscillating or non oscillating Intracardiac mass or other endocardial structures

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6
Q

Abscess appearance on ECHO

A

Thickened, non homogenous pervalvular area w echodense or echolucent appearance

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7
Q

What is a pseudoaneurysm and how does it look on ECHO

A

Perivalvular cavity communicating within cardiovascular lumen
Pulsatile perivalvular echo-free space with colour doppler flow detected

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8
Q

What is a perforation and how does it look on ECHO

A

Interruption of endocardial tissue continuity traversed by colour doppler flow
Can create a fistula

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9
Q

Valve aneurysm what is

A

Saccular outpuching (bulging on ECHO) of valvular tissue

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10
Q

How does dehiscence of prosthesis appear on ECHO

A

Paravalvular regugitation identified by TTE/TOE with or without rocking motion of prosthesis

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11
Q

Risk factors for IE

A

Any type of structural HD
RHD, mitral valve
Prosthetic valves, cardiac devices
Congenital HD
IVDUs
HIV
Extensive health care system contacts eg hospital interventions and time spent in hosptial

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12
Q

Bacterial causes of IE most common

A

Staoh ir strep 80% time
S.aureus, coagulase engative staph - rising due to hospital related infection
Enterococci - 3rd highest cause, related to healthcare contact
Gram negative and fungal pathogens rare but v severe and poor outcomes

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13
Q

Why cant always trust blood cultures in IE

A

10% patients have negative blood culture - either given antibiotics before or fastridious microorgansisms difficulty to isolate

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14
Q

List of causes of IE negative blood culture

A

Coxiella burnetti (livestocl, Q fever cause)
Bartonella spp (alcohol, homeless)
Brucella spp (livestock or abbattoirs)
Tropheryma whipplei
Brucella spp (middle east, unpasteurised diary)
Bartonella henseale (cats)
Aspergillus spp (healthcare contact w prosthetic valve)

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15
Q

Clinical history of IE why varies

A

Dependent on causative oraganism, cardiac disease etc -> varying presentation

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16
Q

Most common features of IE

A

Malaise, fever, cardiac murumurs

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16
Q

Symptoms that can signify endocarditis

A

Malaise, fever, new murmurs
Haematuria, Splenomegaly,
HF, petechiae ,arthralgia, cerbral emboli, mycotic aneurysm, clubbinng, oslers nodes, splinter haemorrhages, janeway lesions, Roth spots, conjunctival haemorrhages,

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16
Q

What does L sided IE cause

A

Infected emboli travelling through arteries systemically except lungs

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17
Q

What does R sided IE cause

A

Infected emboli -> lungs

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18
Q

Immunological manifestations of IE

A

Oslers nodes
Immune complex deposition glomerulonephitis
Systemic - Rf raised

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19
Q

What are oslers nodes

A

Arteriolar intimal proliferation w extension to venules and capillaries and may be accompanied by thrombosis and necrosis
Immune complexes within lesions

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20
Q

Investigation for IE

A

Bloods - inflam markers - CRP, ESR, WCC, Plts, U+Es, LFTs
Blood cultures
ECHO - TTE or TOE (more sensitive, can ick up emboli <5mm)

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21
Q

Blood cultures required for IE

A

3 sets within a period of time each 1-6 hrs apart
2 sets within 1 hr if septic patient from different sites

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22
Q

Why dont wait for temperature spike in IE

A

Bactaraemia is constant in IE

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23
Treating endocarditis
National guidelines 4-6 weeks (L side longer) in hosptial - Outpatient when available 2 weeks if v sensitive IV fo duration
24
Indicaitons for surgery with IE
Heart failure Uncontrolled infection Prevention of embolism
25
What is counted as uncontrolled infection in IE?
Abscess, aneurysms, fistula, enlarging vegetation despite antibiotics (risk of infected emboli high) Persisting + blood cultures despite appropriate antibiotic PVE caused by staph or non-HACEK gram - bacteria Infection caused by fungi or multiresistant organisms
26
What surgical criteria for preventing embolism in IE
Aortic or mitral valve NVR or PVE w persitent vegetations >10mm after one or more embolic episode despite antibioticsn Aortic or mitral NVE w vegetations >10mm ass w severe valve stenosis or regurg and low operative risk Aortic or mitral NVE or PVE w isolated large vegetations >15mm Aortic or mitral NVE or PVE w isolated v large vegetations >30mm
27
HF signs in IE
Aortic or mitral NVE/PVE Severe acute regurgutatuon, obstruction or situal -> refractory pulmonary oedema or cardiogenic shock OR symptoms of HF, ECHO signs of poor haemodynamic tolerance
28
Prognosis for IE
100% death if no treatment optimal treamtnet 20-25% die of IE
29
Predictors of poor otuomes IE
Older, prosthetic valve, diabetes, comorbiditiy Clinical comps - HF, rneal failure, >moderate area ischaemic stroke, brain haemorrhaege, septic shcok Micororgansism - staph aureus, fungi, non-HCAEK gram negative bacteria ECHO findings
30
ECHO findings that suggest poor prognosis
Periannular comps, severe L sided valve regurgitiation Low left ventricular ejection fraction Pulm HPTN Large vegetations Sev prosthetic valve dysfunction Premature mitral valve closure or other signs of elevated diastolic pressure
31
Pathological criteria for IE
Micororganisms demostrated by culture or histology Need a biopsy of vegetation
32
Clinical criteria for IE how many need confirmed vs possible
Confirmed: 2 major criteria 1 major criteria and 3 minor criteria 5 minor criteria Possible: 1 major criteria and 1 minor criteria 3 minor criteria
33
Rejected IE diagnosis criteria
Alternate diagnosis Resolution with anitbitoic therapy <4 days No pathologic evidence of IE at surgery or autopsy w antibiotics <4 days
34
What is the new criteria for IE
ESC 2023
35
Major criteria for endocarditis Dukes
+ blood culture for IE Evidence of endocardial involvement
36
Evidence of endocardial involvement DUKES criteria
+ ECHO for IE New valvular regurgitation Vegetation abscess new partial dehiscence of prosthetic valve
37
What need for + blood culture IE major criteria
typical microorganism from two separate cultures >12hrs apart OR 3 or 4 cultures of blood - first and last 1 hr apart Eg separated in time and space Must be one of: Viridans strep, strep bovis (ganolyticus - ass bowel cancer) or HACEK group OR CAP S.aureus, enterococci without obvious primary source infection Single positive culture for C.burnettu or antiphase 1 IgG antibody titre >1:800
38
mINOR dUKES CRITERIA FOR ie
Predisposition Fever >38.0 Vascular phneomena Immunological phenomena Microbiological phenomena PCR - broad range of 165 ECHO findings - consistent w IE but not major criterion
39
What are predispositions in DUKES
Predisposing heart condition or IVDU
40
Vascular phenomena counting as minor dukes criteria for IE
Major arterial emboli, septic pulmonary infarcts CXR, mycotic aneurysm, IC haemorrhage, conjunctival haemorrhage, janeways lesions
41
Immunological phenomena minor dukes criteria IE
Glomerulonephritis, oselers nodes, roth spots, Rf
42
Microbiological phenomena minor dukes criteria IE
+ blood culture but doesnt meet major criterion or serologuical evidence of activa=e infection with organism consitent with IE
43
Dukes criteria vs ESC 2023 xriteria
Imaging in major criteria Dukes - ECHO ESC - Cardiac CTs or nuclear imaging Removed ECHO findings from minor criteria Removed broad range PCR from minor criteria
44
What bacteria causing IE blood culture sample only need one for
C burnetti
45
What are oslers nodes
Red v painful spots on pulps of fingers and toes pale in middle
46
Cardiac risk factors for endocarditis
Prev IE Valvular HD stenosis or regurg Hypertrophic CM Prosthetic heart valve Central venous catheter or arterial catheter Transvenous cardiac implantable electronicdevice Congnital HD
47
Non cardiac risk factors for IE
Central venous catherer IVDU Immunosupression Recent dental or surgical procedures Recent hospitalisation Haemodilaysis
48
What are janeway lesions
maculopapular on palms or soles non painful few mms
49
What organisms can mean no blood culture +
Fastidious gram negative bascilli - HACEK group eg aggregatibacter aphrophilus Others - Haemophilus, caerdiobacterium hominis, eikenella corrodens and kingella kingae
50
Why use oral antibiotics instead of IV endocarditis
Hospital stay - increased risk of hospital complications After patient stable rare to get bad again
51
What is POET
Partial oral antibiotic endocarditis therapy Stabilised endocarditis patietns treated initially with IV antibiotics Then test continuing w oral or IV
52
Method of POET
Stable adults receiving IV antibiotics for L sided endocarditis, native or prosthetuic valves, fulfilled modified Duke critiera, + blood cultures for strep, enterococcus, staph aureus, coag negative staph Antibiotics w moderate to high bioavailability Put half on combined PO antibiotic therapy
53
What did POET record (events)
All cause mortality, unplanned cardiac surgery, embolic events, relapse of bactaraemia for 6 months A
54
POET study finding
No significant statistical differnece between oral and IV antibiotics
55
Side effects from PO
Allergy, bone marrow suppression, GI side effects
56
Conclusins of POET study
Efficacy and safety of shifting to oral antibiotic treatment was non inferior to continued IV antibitoic treatment Oral antibiotics may safely be administered during half the recommended antibiotic treatment periods - can be oupatient - reduce hospital stays May apply to >50% endocarditis patients in future
57
What cardiac conditions are not risk factors for IE
Isolated ASD Fully healed VSD, PDA
58
Management of IE
Blood culture and ECHO/imaging -> empirical broad spec IV antibiotics Adjust anitbiotics according to sensitivities and complications treating -> cardiac surgery or
59
Organisms would match with recent dental extraction IE
Viridans strep - mitis group
60
Organisms would match with recurrent UTIs IE
Enterococcus faecalis
61
Organisms would match with hickmans line IE
Candida albicans Staph aureus, coag negative staph
62
Organisms would match with IVDU IE
Staphg aureus, candida albicans
63
Reasons for blood culture negative IE
Intracellular pathogens eg legionella, brusella, bartonella, mycoplasma Specific culture needed eg mycobacteria Long incubation periods - routine culture doesnt work 16s RNA PCR for bacteria, 18s RNA PCR for fungi
64
What imaging pathway do for endocarditis first
TTE If +, poor quality or theres a prosthetic valve IC device -> TOE If negative but high clinical sus -> TOE Repeat TOE in 7-10 dyas if negative but still high clinical sus
65
What antibiotic can reduce duration of treamtnet for IE
Gentamicin increased bactericidal acitivity due to syndergism When caused by penicllin sensitive strep
66
Why differnet treatment for prosthetic HV
Biofilm risk - need penetrating agents 6 weeks antibiotics vs 4 for native valves
67
MRSA IE treat
Vancomycin, dactomycin
68
HACEK group what stand for
Haemophilus Aggregabactae Cardiobacterium Eikenella Kingella Fastidious gram negative
69
First line treatment for HACEK
Ceftriaxone CAnt use amoxicillin as some produce beta lactamases
70
Septic/unstable patients with IE treatmet if risk factors for resistant bacteria
Vancomycin, meropenem If none - vancomycin with gentomycin Otherwise amoxicillin +/- gentomycin Pending blood cultures or negative - vancomycin, gentamycin, rifampacin - for biofilm
71
Staph IE treat
Fluclox, vancomycin, gentomycin, rifmapacin
72
Strep IE treat
Benzylpenicillin, ceftriazone, gentamizin, vancomycin, teicoplanin
73
Enterococcal IE treat
Prolonged treat in combo gentomycin or ceftriazone Amoxicillin Penicillina Vancomycin, teicoplanin
74
Fungal IE treat
Low threshold for surgery Look for complications Fluconazole, variconazole, amphotericin, itaconazole Remove lines
75
HACEK manageent IE
Cephalosporin or amoxicillin Gentamicin Ciprofloxacin
76
Complications of IE
Neurological Infective aneurysms Splenic complications Myocarditis, pericarditis Heart rhythm and conduction distubrances Osteoarticular infection
77
Follow up for IE
Monitor for 1 year Development HF end treatment TTE Recurrence Rehabilitation, psych support
78
Ideal cultures for IE
three sets from peripheral sites >6 hours between them if chronic or subacute If acute from different sites with as ling between as can leave clinicaly safely
79
When do you start antibiotics with IE
Chronic - wait for culture senstivities before commence Septic/acute - commense broad spectrum while waiting cultures
80
FROM JANE signs/symptoms of IE
Fever Roth spots Oselers nodes Murumur Janeway lesion Anaemia Nail haemorrhage Emboli

Infectious disease (37 decks)

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