Infective endocarditis

Question 1

Common bacteria that cause Infective Endocarditis

Answer 1

Tend to be gram +ve cocci
- Streptococci (31% of cases)
- S Aureus (28%)
- Enterococci
- Coag -ve S Aureus
- Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella (HACEK group)
- Fungal- more common in IVDU and prosthetic valves

Question 2

RFx for infective endocarditis

Answer 2

Cardiac
- Bicuspid aortic valve
- Mitral valve prolapse
- Rheumatic heart fever
- congenital heart disease
- Prosthetic heart valves and implanted cardiac leads

Non-Cardiac
- IVDU
- Long term IV Access e.g. haemodialysis
- Liver disease
- Steroid use
- Poorly controlled diabetes
- Immunocompromised

Question 3

CFx of Endocarditis

Answer 3

Neurological
- Impaired cognition
- Fluctuating consciousness
- Hemiparesis

Cardiac
- Cardiogenic shock
- Pulmonary oedema

Other and septic
- AKI
- Liver injury
- Night sweats
- Weight loss
- Splenomegaly
- Oslers nodes, Roth’s spots, Janeway lesions
- Splinter haemorrhages

Question 3

Modified Duke Criteria for Endocarditis

Answer 3

Likely if 2x major, 1x major and 3x minor, 5x minor

Major criteria
- Positive blood cultures: typical organisms in 2x samples
- Evidence of endocardial or valve involvement on ECHO or CT: vegetation. abscess, perforation, aneurysm formation, prosthetic valve lesion, paravalvular lesion

Minor Criteria
- RFx
- Fever
- Vascular phenomena: arterial emboli, splenic infarct, ICH, Janeway lesions
- Immunological phenomena: Oslers nodes, Roth’s spots, +ve rheumatoid factor

Question 4

Empirical antibiotics for endocarditis awaiting culture results

Answer 4

• Amoxicillin and gentamicin if stable
• Vancomycin and gentamicin if septic and no RFx for enterobacteria or pseudomonas
• Vancomycin and meropenem if septic and RFx for enterobacteria or pseudomonas

If prosthetic valve
- Vancomycin rifampicin and gentamicin

Question 5

Indications for cardiac surgery in infective endocarditis

Answer 5

• One or more embolic events and vegetation >10mm
• Severe valvular dysfunction and vegetation >10mm
• Large vegetations >15mm

Contraindication
- ICH or coma

Question 6

Indications for Abx prophylaxis in dental procedures

Answer 6

• Valvular heart disease
• Prosthetic heart valve
• HOCM
• Previous IE
• Congenital heart disease (Not ASD, repaired VSD or PDA)

Question 7

Issues with cardiac surgery in patients with infective endocarditis

Answer 7

• Bleeding: often coagulopathic and thrombocytopenic
• Heparin resistance: normally on pre-op
• Increased SIRS response to CPB
• Vasoplegia is common