INFECTIVE ENDOCARDITIS Flashcards
INFECTIVE ENDOCARDITIS
• Definition: __________ of the heart’s __________ surface.
• Incidence: Commoner in the (developed or underdeveloped?) countries.
• Age: more in __________, but the incidence
increasing in children with ______ or central
indwelling ______________.
Infection ; endocardial
developed ; adults,
CHD ; venous catheters.
Common aetiology of IE
• _________________ group - common after
_________________.
• _________________ – common in patients
with _________________ disease.
• _________________ - common following _________________ manipulation.
• Streptococcus viridans ; dental extraction.
• Staphylococcal Aureus ; no underlying heart disease.
• Enterococcus ; GIT or GUT manipulation.
Others organisms that can cause IE besides the common 3
– __________________
– Fungi
– Enteric gram negative bacilli
HACEK (Haemophilus species, Aggregatibacter
species, Cardiobacterium hominis, Eikenella
corrodens, and Kingella species)
Predisposing Factors to IE
•Congenital heart disease – especially __________ CHD.
•_______________ disease
•Prosthetic _______
•Previous episode of ________________
•Surgical systemic to pulmonary shunts and conduits
•Cardiac ______________
•Central ______________
•_______ manipulations
•IV drug use
Cyanotic ; Acquired valve
valve; bacterial endocarditis
transplantation; venous catheters
Dental
Pathogenesis of IE
• Step 1: Formation of ______________ (_________)
– _____________ from acquired or congenital heart disease traumatizes __________
– which serves as a place for _________ and _________ ___________
• Step 2: Pathogen seeds blood
– Occurs via ________ to a mucosal surface from such daily activities as teeth brushing or chewing, or invasive activities like dental, GI, or GU procedures
non-bacterial thrombotic embolus (vegetation)
Turbulent flow; endothelium
fibrin ; platelet ; deposition
trauma
Pathogenesis of IE
• Step 3: Pathogen adheres to _________________ or ______
– Gram-positive cocci (Staph, Strep) most common pathogens
– Gram-negative bacteria (HACEK organisms) and fungi (Candida, Aspergillus) can also adhere
• Step 4: Pathogen promotes _____ deposition
– Micro-organism stimulates more fibrin deposition on pre-existing aseptic vegetation
– Creates secluded area within which pathogen can proliferate
fibrin-laden endothelium ; device
fibrin
Consequences of IE
• _______ damage
• ___________
•_________-mediated
Valvular
Emboli
Immune
Consequences of IE
• Valvular damage: Pathogen destroys _______ - cause _________ and possibly even ___________
• Emboli: ________ emboli travel to ______,_______ (CVA, mycotic aneurysm), kidney(microscopic hematuria & nephritis), or __________ and cause local infection and ischemia/infarction
• Immune-mediated: Circulating immune
complexes can possibly mediate __________,_________
valves; regurgitation; heart failure
Septic; lung ; brain; extremities
glomerulonephritis ; vasculitis
Clinical Findings of IE
• The presentation generally is indolent, with prolonged ____________ and a variety of non-specific somatic complaints - fatigue, weakness, arthralgia, myalgias, headache, anorexia, weight loss, rigors, and diaphoresis.
• Occasionally, presentation may be fulminant – acutely ill, rapidly changing symptoms and high, spiking fevers requiring urgent intervention.
Cause is most likely Streptococcus
pneumoniae or S aureus.
low-grade fever
Clinical findings of IE
• Valvulitis may result in changing cardiac auscultatory findings or CCF.
• Classic signs –
–____ spots
– _________ lesions
– _________ nodes
– _________ hemorrhage
Other features – skin petechiae, Splenomegaly, ±Underlying heart defect, ± Carious teeth or periodontal or gingival disease, ±Finger clubbing.
Roth; janeway; osler; splinter
Clinical findings of IE
• Classic signs –
– Roth spots (_________ hemorrhages with a _________ center)
– Janeway lesions (________________ on fingers and soles)
– Osler nodes (_________ lesions on _________ and _________)
– splinter hemorrhage – are (common or rare?) in children
retinal hemorrhages with a pale center
non tender macules on fingers and soles
painful lesions on hands and feet
rare in children
Clinical Findings in neonates
• Non-specific.
•_______ from IE are common, resulting in foci of infection outside the heart (e.g., __________,__________,____________).
•_________ difficulties
•______________
• Tachycardia
•______-tension.
• New or changing ___________.
• Neurological signs and symptoms (e.g ____________ , hemiparesis, or apnea).
Septic emboli; osteomyelitis, meningitis, or pneumonia
Feeding; Respiratory distress; Hypo
heart murmur; seizures
Investigations in IE
• Blood m/c/s-
–____ blood cultures at ____ separate venipuncture sites within 1st ________. If child is very ill, take all the samples within ___________. Do initial gram stain to guide Rx.
– Take _____ more on day 2 if no growth.
• If child is not acutely ill and blood culture still negative, __________ for 48hrs and repeat culture.
3; 3; 24hours
1-2hours; 2
Stop antibiotics
Investigations in IE
• _______________.
• ______ –Normocytic normochromic anaemia, hemolytic anemia. Leukocytosis- <50%.
• ESR , C reactive protein –
• Urinalysis/microscopy- haematuria, proteinuria
• ___________ factor
Echocardiography
CBC
Rheumatoid
Diagnosis of IE
Diagnosis: Requires a high index of suspicion when evaluating infection in a child with an underlying risk factor.
– Definitive diagnosis: _________________
– Conclusive anatomic diagnosis:
Demonstration of ___________ on _________
Positive blood culture.
vegetation on 2D.
Modified Dukes Criteria- Major criteria
- ——————— for IE
- Evidence of endocardial involvement
A. Positive ____________
B. New ___________________
Positive Blood culture
echocardiogram
valvular regurgitation
Modified Dukes Criteria
Minor criteria
1._____________
2. _____________
3. _____________ phenomena
4. _____________ phenomena
5. _____________ evidence
1.Predisposition
2. Fever
3. Vascular phenomena
4. Immunologic phenomena
5. Microbiological evidence
Diagnosis of Infective Endocarditis: Definite
• Clinical criteria
– _________ criteria
– _________ and _________ criteria
– _________ criteria
• Pathologic criteria:
– Microorganism demonstrated by culture or histologic examination of vegetation,
emboli, intracardiac abscess; or Active endocardial lesions on pathology examination.
– TWO major criteria
– ONE major and TWO minor
criteria
– FIVE minor criteria
Diagnosis of Infective Endocarditis:
Possible
•_________ criterion and ______ criterion
• ________ criteria
Rejected
• Probable alternative diagnosis
• Resolution of symptoms __________ after initiation of antibiotic Rx.
• No definitive histological or
bacteriological confirmation at surgery or autopsy.
I major ; 1 minor ; 3 minor
4 days
COMPLICATIONS of IE
• ________
•________
•_________ embolism
• Other infections e.g. meningitis, brain abscess, arthritis, osteomyelitis, pneumonia, renal abscess
• ___________ obstruction.
CCF
CVA
Pulmonary; Valvular
Treatment of IE
• Treatment is for __________.
• Consult with Microbiologist
• General – IV ( _________ or __________ or ___________) + ____________.
• Final selection of antibiotics depends on the organism isolated and the antibiotic sensitivity test.
•____________ for anaemia
• Nutrition
• Surgical: ___________, ____________ and replacement.
4-6weeks
Penicillin or ceftriaxone or vancomycin
Genticin; Blood transfusion
Vegectomy ; valve excision
Treatment with linezolid appears to result in outcomes superior to those with ___________ against many types of infections caused by ________ and ___________.
vancomycin
MRSA and MSSA
Use of ___________ should be strongly considered instead of vancomycin in patients who are seriously ill.
linezolid
Another advantage of linezolid is that its _______________________________________ in patients with renal failure.
dose does not need to be adjusted
Prevention of IE
• __________________.
• _____________________ for patients at risk of IE
Good oral hygiene
Antibiotics prophylaxis
Cardiac Conditions Associated With the Highest Risk of Adverse Outcome From Endocarditis for Which Prophylaxis With Dental Procedures Is Reasonable.
- ______________ or _____________ used in repair
- _________ IE
- _________ heart disease
- ______________ recipients who develop
cardiac _____________
Prosthetic cardiac valve or prosthetic
material
Previous; Congenital
Cardiac transplantation; valvulopathy
