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Cardiovascular system 16/17 > Infective endocarditis > Flashcards

Infective endocarditis Flashcards

1
Q

What is infective endocarditis?

A

Infection of endocardium, affecting the:

  • Heart valves
  • Inteventricular septum
  • chordae tendinae
  • intra-cardiac devices
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2
Q

Describe the epidemiology of IE

A 
Older patients
Degenerative aortic stenosis
Rheumatic heart disease
Invasive procedures 
Intracardiac devices
Valve disease
Prosthetic valves
CHD
IV drug abuse (usually affects R side)
Immunocompromised patients
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3
Q

Name some cardiac risk factors for IE

A 
MVP
VSD
AS
RHD
Prosthetic valves
Cardiac surgery for native IE
Prior native IE
Surgery for prosthetic IE
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4
Q

Name some non-cardiac risk factors for IE

A 
IV drug use
Indwelling medical devices
DM
AIDS
Chronic skin infections or burns
Genitourinary infections
Pregnancy/abortion/delivery
Alcoholic cirrhosis
GI lesions
Solid organ transplant
Homeless, lice
Pneumonia and meningitis
Infected farm animals
Dog/cat exposure
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5
Q

Describe the pathophysiology of IE

A

Damage to epithelium:
- Nonbacterial thrombotic endocarditis, sterile vegetation
- Mechanical disruption of valve endo.
Bacterial colonisation

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6
Q

What can cause bacteraemia?

A

Extracardiac infections
Invasive procedures
Gingival disease
Activities of daily living e.g. brushing teeth

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7
Q

What organism is most associated with acute onset IE?

A

Staph Aureus

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8
Q

What organism is most associated with sub-acute onset IE?

A

Streptococci

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9
Q

Describe some modes of acquisition of IE

A 
Health care related
 - nosocomial/idiopathic (hospital)
 - non-nosocomial (home based care)
Community acquired
IVDA
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10
Q

State some symptoms of IE

A 
Fever
Fatigue
Malaise
weight loss
headache
Musculoskeletal pain
Altered mentation (mental activity)
Murmur
Immune complex deposition e.g. splinter haemorrhages, vasculitic rash, Roth spots,
Oslers nodes, Janeway lesions
Nephritis
Signs of HF
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11
Q

Describe vasculitis rash

A

Diffuse, non-blanching red/purple (petechial) spots, purpuric

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12
Q

What does purpuric mean?

A

Rash caused by internal bleeding from small vessels

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13
Q

Describe Roth’s spots

A

Retinal haemorrhages, spots with a white pale centre at the back of the eye due to coagulated fibrosis

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14
Q

Describe Oslers nodes

A

Deep red spots, painful, raised, tend to be on finger pulps but can be on the palms or soles of the feet

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15
Q

Describe Janeway lesions

A

Flat, echymotic (like bruises) on palms or soles of feet, non-tender

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16
Q

What clinical sign is pathognomonic for IE?

A

Janeway lesions

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17
Q

When might some clinical signs be absent in patients?

A

Immunocompromised
Elderly
After antibiotic treatment
IE evolving less virulent/atypical organism

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18
Q

When should you be very suspicious of IE?

A 
New murmur
Pyrexia of unknown origin
Known IE causative organism
Prosthetic material
Previous IE
CHD
New conduction disorder
Immunocompromised
IVDA
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19
Q

What investigations would be used for IE?

A 
Full blood count e.g. CRP, ESR, U+Es
Urinalysis - blood = nephritis
ECG
CXR
ECG - TTE and TOE
Blood cultures
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20
Q

How should blood cultures be taken?

A

3 sets taken 6 hours apart from different sites of the body

If in septic shock, this is accelerated to only 2 sets taken an hour apart

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21
Q

Describe ECG taking when investigating IE

A

TTE first only

  • if positive straight to TOE
  • if negative no TOE unless clinical suspicion is high, and then repeat after 7/10 days
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22
Q

Why is TOE taken?

A

When suspicion is high, to find:

  • complications
  • abscesses
  • measure size of vegetation
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23
Q

When should ECG (TTE/TOE) be repeated?

A

If suspicion is still high
New complication e.g. murmur, fever, embolism, HF
To assess treatment efficacy

24
Q

What % of IE cultures show positive blood cultures?

A

85%

25
Q

Why might IE blood cultures be negative?

A

Prior antibiotic therapy
Fastidious organisms
Intracellular organisms

26
Q

What 3 types of microorganism are most common in IE?

A

Streptococci
Enterococci
Staphylococcus

27
Q

Describe the pathology of IE

A

A mass of fibrin, platelets and infectious organisms forms vegetations along the edges of the valves. Virulent organisms destroy the valves, producing regurgitation and worsening heart failure

28
Q

What type of organism is most likely to be found in disease of a native valve?

A

Streptococci

29
Q

What type of organism is most likely to be found in disease of a prosthetic valve?

A

Staphylococci

30
Q

Name some Staphylococci species linked to IE

A

S. Aureus

S. Epidermidis

31
Q

Name some Streptococci species linked to IE

A

S.viridans
S.anginosus
S. bovis

32
Q

Name some Enterococci species linked to IE

A

E.faecalis
E.faecium
E.durans

33
Q

Name some fastidious organism species linked to IE

A

Brucella
Fungi
Nutritionally variant streptococci
Fastidious gram -ve bacilli/HACEK group

34
Q

Name some organisms that belong to the HACEK group

A

Haemophilus spp.

Cardiobacterium spp.

35
Q

Name some intracellular bacteria spp. linked to IE

A

Coxiella burnetii
Bartonella
Chlamydia spp.

36
Q

How can you test for intracellular bacteria?

A

Serological testing
Cell culture
Gene amplification
PCR

37
Q

What criteria is used for IE diagnosis?

A

Modified duke criteria

38
Q

What criteria is needed for a definite IE diagnosis

A

2 major
1 major + 3 minor
5 minor

39
Q

What criteria is needed for possible IE diagnosis

A

1 major

3 minor

40
Q

What counts as a major criteria for IE?

A

Positive blood cultures

Evidence of endocardial involvement

41
Q

What counts as mine criteria for IE?

A

Fever
Predisposition
Vascular phenomena
Immunological phenomena

42
Q

How are all drugs for IE given?

A

IV for 2 weeks, then oral for another 2-4 weeks

43
Q

What drug is used for MSSA - flucloxacillin or vancomycin?

A

Flucloxacillin

44
Q

What drug is used for MRSA - flucloxacillin or vancomycin?

A

Vancomycin

45
Q

Why is gentamicin only used in severe cases?

A

Nephrotoxic

Ototoxic

46
Q

How do you dose gentamicin?

A

Dose to body size unless obese (then use ideal body size)

47
Q

How do we prevent toxicity of gentamicin?

A

Take serum levels after 4th dose
Daily FBC, U+Es and CRP
ECG every 1-2 days
Weekly echocardiogram

48
Q

What should the trough level of gentamicin be (pre dose)?

A

<1mg/L

49
Q

What should the peak level of gentamicin be?

A

1hr post dose

3-5mg/L

50
Q

When are fungal infections in IE common?

A

Immunocompromised
Prosthetic valves IE
IVDA

51
Q

What are common fungal causative agents of IE?

A

Aspergillis spp

Candida spp

52
Q

State some complications of IE that indicate need for surgery

A 
Heart failure
Fistula formation
Leaflet perforation or obstruction
Uncontrolled infection
Abscess formation
AV heart block/damage to conduction system
Embolism
Enlarging vegetation
Prosthetic valve dysfunction/dehiscence
53
Q

What is the Gerbode defect?

A

Shunt from fistula between left ventricle and right atrium

54
Q

What cardiac conditions are at highest risk of IE?

A

Acquired valvular disease
Structural CHD
Hypertrophic cardiomyopathy
Previous IE

55
Q

When should prophylaxis be offered?

A

Person at risk e.g. IVDA

Undergoing GI/GU/site of suspected infection procedure

56
Q

What % of IE cases are caused by health care associations?

A

30%

57
Q

When is prophylaxis not given?

A 
Tattoo/piercing
Dental procedures
Urological/gynaecological/childbirth
ENT procedures
Bronchoscopy

Cardiovascular system 16/17 (40 decks)

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