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Cardiology > Infective Endocarditis > Flashcards

Infective Endocarditis Flashcards

1
Q

What is infective endocarditis?

A

This is the microbial infection of any structure within the heart. It usually affects the endocardium and its structures like the valves, implanted devices (pacemaker, LVAD, shunts etc).

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2
Q

What is the commonest cause of IE in developing countries?

A

Rheumatic valve disease

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3
Q

What is the commonest cause of IE in developed countries?

A

Older patients who have had any form of procedure with or without history of heart valve dx or replacement

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4
Q

What is the commonest isolated organism in patients with rheumatic valve dx

A

Streptococcal viridans

Others include;
Staphylococcus
Enterococcus
Fastidious

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5
Q

Classification of IE based on localization

A

Left sided IE
Right sided IE
Device related IE

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6
Q

Classification of IE based on route of acquisition

A

HEALTH CARE ASSOCIATED
• Non-nosocomial:- <48hrs after admission but previous contact with healthcare system eg hemodialysis, chemotherapy etc
• Community acquired:- <48hrs after admission with not previous contact with healthcare system
• Nosocomial:- >48hrs after admission before onset of first signs and symptoms.

INTRAVENOUS DRUG ABUSERS

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7
Q

What is Relapse IE

A

This is repeat IE that is caused by the same microbe < 6mnths after initial episode

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8
Q

What is re-infection IE

A

This is infection with a different microbe
OR
Repeat episode of IE caused by the same microbe > 6 months after the initial episode

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9
Q

List the aetiology of IE

A

STREPTOCOCCI
(a) Viridans streptococci:- Causes 55% of NVE
(b) Group D Streptococcus
(c ) Group A beta haemolytic streptococci:- Causes rapid valve destruction
(d) Group B streptococci
(e) Streptococcus pneumoniae

ENTEROCOCCI
(a) E.faecalis – 85% of enterococcal IE
(b) E.faecium – 10% of enterococcal IE

STAPHYLOCOCCI
(a) S.aureus
(b) S.epidermidis

GRAM NEGATIVE BACTERIA
(a) HACEK group; Haemophillus, Actinobacillus, Cardiobacterium, Eikenella, Kingella

FUNGI
(a) Aspergillus
(b) Toruposis

NONBACTERIAL THROMBOTIC ENDOCARDITIS

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10
Q

What are the predisposing factors for fungal IE

A

Valve replacement
Cardiac surgery
IVDA;
Intravascular catheters;
- glucocorticoids
- broad spectrum antibiotics
- cytotoxic drugs.

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11
Q

List the risk factors for IE

A

• Dental disease or procedures;
• Prolonged indwelling vascular catheters
• IVDUs who dissolve heroin in infected lemon juice;
• Urogenital manipulation
• Cardiac surgeries with devices (prostatic valves, assist devices)
• Underlying genitourinary disease or procedures;
• Prolonged hospitalization;
• Bowel Malignancy;
• Soft tissue infections;
- Native and Prosthetic valve endocarditis
(Early – within 12 months of valve surgery and late >12 months after valve surgery)

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12
Q

What are the clinical features of IE

A

• Fever
• Chills and sweats
• Anorexia, weight loss, malaise
• Myalgias, arthralgias
• Back pain
• New Heart murmur
• New/worsened regurgitant murmur
• Arterial emboli
• Splenomegaly
• Clubbing
• Neurologic manifestations;
- Seizures
- Psychosis
- Stroke

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13
Q

List the peripheral manifestations of IE

A

• Subconjunctival
• Cardiac murmur
• Conduction disorder
• Cardiac failure
• Hematuria
• Loss of Pulses
• Splinter hemorrhage
• Digital clubbing
• Poor dentition
• Roth spots
• Janeway lesions
• Osler’s nodes
• Subungual hemorrhages

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14
Q

What is the requirement for making a DEFINITIVE diagnosis of IE

A

Pathological Criteria
1) Microorganisms:- Positive culture of usual bacteria suspects of IE
2) Pathological Lesions:- Histological confirmation of active endocarditis from vegetations or intra-cardiac abscess

Clinical criteria
Modified Duke’s Criteria
• 2 major criteria
OR
• 1 major criteria and 3 minor criteria
OR
• 5 minor criteria

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15
Q

What are components modified duke’s major criteria

A

1) Positive blood culture
* Typical microorganisms for IE from 2 separate blood cultures
* Persistently positive blood culture
* Single positive blood culture for C.burnettii
* IgG Titre to C.burnettii > 1:800

2) Evidence of endocardial involvement
* Oscillating intra-cardiac mass (vegetation)
* Abscess
* New partial dehiscence of prosthetic valve
* New valve regurgitation

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16
Q

What are components modified duke’s minor criteria

A

• Predisposing condition or drug use
• Fever > 38°C
• Vascular Phenomena
- arterial emboli
- septic pulm. infarct
- mycotic aneurysm
- IC & subconjunctival hemor
• Janeway lesion
• Immunologic Phenomena
- GN
- Oslers nodes
- Roth spots
- Rh factor
• Echocardiogram
- Positive for IE but not meeting
major criteria

17
Q

What is a possible infective endocarditis

A

• 1 major criteria and 1 minor criteria
• 3 minor criteria

18
Q

List the investigations done for IE

A

• Blood culture
• Echocardiography
• Electrocardiography
• FBC
• LFT
• CXR
• E/U/Cr
• ESR/CRP
• Urinalysis:- Microscopic hematuria with or without proteinuria
• MRI

19
Q

How long does the standard treatment therapy for NVE take?

A

2-6 weeks

20
Q

How long does the standard treatment therapy for PVE take?

A

Over 6 weeks

21
Q

How long does the standard treatment therapy for Streptococcal IE take?

A

Within 2 weeks using beta-lactams with aminoglycosides

22
Q

What is the most widely used drugs for treatment of IE

A

Amoxicillin + Gentamycin

In case of beta lactams allergy, VANCOMYCIN can be used

23
Q

Treatment for IE caused by Coxiella Burnettii (Q-FEVER)

A

3-4 years treatment with Doxycycline + cotrimoxazole or rifampicin or quinolone.

24
Q

How would you manage IE cause by fungal infections

A

IV Amphotericin B with or without Flucytosine

25
Q

List the complications of IE

A
  1. Congestive heart failure
  2. Myocarditis
  3. Uncontrolled infection
  4. Systemic embolism (Brain, spleen, kidney and lungs)
  5. Neurologic events
  6. Acute renal failure
26
Q

What are the possible causes of relapse

A

1) Inadequate antibiotic Rx(agent,dose,duration)
2) Resistant microbes eg Brucella sp,Legionella sp, Mycoplasma sp
3) Empirical Antimicrobial therapy for culture negative IE
4) Periannular extension
5) Prosthetic valve endocarditis
6) Positive valve culture
7) Persistence of fever after 7th day post op

27
Q

List the poor prognostic factors

A

• Older Age
• PVE
• Co-morbidities eg cardio, renal or lung dx
• Micro-organism; Staph aureus, Fungal, Gram Neg Bacilli
• Echo findings;
- severe left sided valve regurgitation
- pulmonary HTN
- large vegetation
- severe prosthetic dysfunction

28
Q

What are the indications for prophylaxis treatment

A

•1) Prosthetic Heart Valves
•2) Prior Endocarditis
•3) Valvulopathy developing after cardiac transplantation
•4) Unrepaired cyanotic congenital heart disease, including palliative shunts or conduits
•5) Completely repaired congenital heart defects during the 6 months post repair
•6) Incompletely repaired congenital heart disease with residual defects adjacent to prosthetic material

Cardiology (3 decks)

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