Infective Endocarditis Flashcards
Define: Rheumatic fever
Systemic immune response after beta-hemolytic strep infection
Features of RF
- Uncommon in US
- Peak: 5-15 yrs
- Self-limited carditis & valvulitis or progressive valvular deformity (MC = mitral)
RF: Minor criteria
“CAFE P”
- CRP elevated
- Arthralgia
- Fever
- ESR elevated
- Prolonged PR
RF: Major criteria
“CANCER”
- Carditis
- Arthritis
- Nodules
- Chorea
- Erythema margination
- Rheumatic fever
RF: What is the DDx?
- Rheumatoid arthritis
- Osteomyelitis
- Endocarditis
- SLE
- Lyme disease
- Sickle cell anemia
RF: Dx tests
- Echo
- ECG
- CRP/ESR
- CBC
- ASO
RF: Jones Criteria
- 2 major criteria OR
- 1 major & 2 minor OR
- 3 minor (if recurrent)
Tx of RF
- Supportive care
- Salicylates
- Penicillin
- Corticosteroids
- Education
- Prevention of recurrences
RF: Px
- Wks to mos in children
- Mortality 1-2%
- 30% of children die within 10 yrs
- Persistent carditis = poor px
RF: Complications
- Rheumatic valve disease
- HF
- Arrhythmias
- Pericarditis w/ effusion
- Rheumatic pneumonitis
RF: Referrals
- Pediatric ID
- Pediatric rheumatologist
- Pediatric cardio
Define: Rheumatic heart disease
Permanent heart valve damage, subsequent to ARF
What is the major cause of CV disease in developing nations?
RHD
What does RHD cause?
Symptomatic valvular heart disease
RHD: Dx
TTE
RHD: Tx
- Restrict activity
- Tx complications
- Prevent IE
- Referrals as needed
Define: infective endocarditis
Microbial infection of valvular or endocardial surface of heart
IE: Classification
- Native valve endocarditis
- Prosthetic valve endocarditis
- Injection drug users
Features of IE
- Men > women
- Pts over 60
- Mortality 16-37%
- Prosthetic valve endocarditis accounts for 10-30%
IE: Patho
- Thrombus formation on endothelial surface
- Bacteria circulates in bloodstream, infects site
- Bacterial proliferation –> vegetations on endothelial surface
- Valves involved
What valve is involved in native endocarditis?
Mitral, followed by aortic
What valve is involved in IDUs?
Tricuspid, followed by aortic
What organism is most common in native valve endocarditis?
S. aureus
What organisms are most common in prosthetic valve endocarditis?
- S. aureus
- Coagulase- negative staphylococci
What organisms are most common in intermediate-late endocarditis?
- Streptococci
- S. aureus
What organisms are most common in IDUs?
- S. aureus (most frequent)
- Streptococci
- Enterococci (least frequent)
IE: Cardiac involvement
- More likely to have right-sided IE
- Tricuspid valve involved in 30-70%
What are risk factors for IE?
- Age > 60
- Male
- IDU
- Poor dentition
- Valvular disease
- Congenital heart disease
- Prosthetic heart valve
- Hx of IE
- Chronic hemodialysis
- HIV
What are sx of IE?
- Fever
- Cough
- Dyspnea
- Arthralgias/arthritis
- Diarrhea
- Abd/flank/back pain
IE: What is seen on PE?
- Fever
- Regurgitant murmur
- Peripheral lesions (petechiae, hemorrhages, osler nodes, janeway lesions, roth spots)
What is the DDx of IE?
Bacteremia
IE: Dx tests
- Blood cultures
- Echo
- EKG
- CXR
- CT-torso
- Modified Duke Criteria
IE: Modified Duke Criteria (Definitive Dx)
- 2 major criteria OR
- 1 major & 3 minor OR
- 5 minor
IE: Modified Duke Criteria (Possible Dx)
- 1 major + 1 minor
- 3 minor
Features of bacterial endocarditis (“BE FIVE PM”)
- Blood culture +
- Endocardial involvement
- Fever
- Immunologic
- Vascular
- Echo findings
- Predisposition
- Microbial evidence
What is the overall general tx for bacterial endocarditis?
- Admit to hospital
- Empiric tx covering staphylococci, streptococci, enterococci
- Antimicrobial therapy (2-6 wks), monitor toxicity
- Consult ID
- +/- consult cardiac surgeon
What meds are given to those w/ native endocarditis?
Vancomycin + Ceftriaxone
What meds are given to those w/ prosthetic valve endocarditis?
Vancomycin + Rifampin + Gentamicin
What meds are used to tx viridans streptococci?
- Penicillin G IV x 4wks OR
- Ceftriaxone IV x 4wks OR
- 1 of the above + gentamicin IV x 2wks (Uncomplicated IE, rapid response to therapy, no underlying kidney disease)
What meds are used for other forms of streptococci?
- Penicillin IV x 4wks OR
- Cefazolin IV x 4wks OR
- Ceftriaxone IV x4wks
What meds are used for enterococci?
Combo therapy, PCN + gentamicin
- Ampicillin IV or penicillin G IV x 4-6wks
+
- Gentamicin IV x 4-6wks OR ceftriaxone IV 4-6wks (CrCl < 50 or gentamicin restsitance)
What meds do you use for staphylococci-methicillin- SUSCEPTIBLE S. aureus?
- Nafcillin or oxacillin IV x 6wks OR
- Cefazolin IV x 6wks
What meds do you use for staphylococci-methicillin- RESISTANT S. aureus?
- Vancomycin IV x 6wks OR
- Daptomycin IV x 6wks
What meds do you add to the tx of Staphylococci – methicillin- susceptible or resistant S. aureus if pt has prosthetic valve endocarditis?
Add rifampin x 6wks
Add gentamicin x 2wks
What meds do you use to tx against HACEK organisms?
Ceftriaxone IV x 4wks
What does HACEK stand for?
- Haemophilus
- Actinobacillus
- Cardiobacterium
- Eikenella
- Kingella
What is the general response to tx of endocarditis?
- Improves in 3-4 days
- Repeat blood cultures
- Monitor relapse
What does the f/u include for endocarditis?
- Baseline eval
- Dental eval
- Drug rehab
What are surgical indications of endocarditis?
- Worsening CHF
- Abscess
- Infection w/ fungi
- Staphylococci on prosthetic valve
- Failure of antibiotic therapy
- 2 major emboli or 1 major embolus w/ mobile vegetation
When is prophylaxis of IE indicated, according to AHA?
- Prosthetic valve
- Previous IE
- CHD
- Heart transplant w/ valvulopathy
What procedures require prophylaxis of IE, according to AHA?
- All dental procedures, which involve manipulation of gingival tissue or periodical region of teeth or perforation of oral mucosa
- Respiratory tract procedures, that involve incision of mucosa
- Procedures on infected skin, skin structure, or musculoskeletal tissue
What procedures DO NOT require prophylaxis?
- Ear/body piercing
- Tattooing
- Vaginal delivery
- Hysterectomy
- Routine dental work
What med are used for prophylaxis in dental & respiratory procedures?
Amoxicillin (most commonly)
