Infective Endocarditis Flashcards
Prototypic lesion of IE
Vegetations
MC location of IE
Heart valves (native or prosthetic)
In NVE, infections are greatest during?
1st 6-12 months after valve replacement
Etiology of Community-acquired NVE via oral cavity
Viridans strep
Etiology of Community-acquired NVE via skin
Staphylococci
Etiology of Community-acquired NVE via Upper Respiratory Tract
HACEK
Etiology of Health care-associated NVE
S.aureus
CoNS (S.epidermidis, S.saprophyticus)
Enterecocci
Prosthetic valve endocarditis (PVE)
Within 2 months of surgery
Etio of PVE 2-12 months after surgery
CoNS
Etio of PVE >12 months after surgery
Oral cavity: Viridans strep Skin: Staphylococci URT: HACEK GIT: Streptococcus gallolyticus (bovis) GUT: Enterecocci
Commonly affected valves in CIED-associated endocarditis
Aortic
Mitral
MCC of CIED-associated endocarditis
MRSA or methicillin-resistant CoNS
MC site of Endocarditis among IV drug users
Right sided
Tricuspid valve
MCC of IV drug user-associated endocarditis
S.aureus
If left-sided: Pseudomonas, Candida
Pre existing cardiac conditions predisposing to NBTE
AR
MR
AS
VSD
Endocarditis caused by hypercoagulable states
Marantic endocarditis (uninfected vegetations seen in patients with malignancy and chronic diseases)
Bland vegetations complicating SLE and APAS
Cause of new regurgitant murmur
Due to valvular damage or ruptured chordae
Endocarditis with blunted fever
Elderly
Severly debilitated
Renal failure
Rapid progression of HF is due to
Aortic valve dysfunction (more than MV dysfunction)
Nonsuppurative peripheral manifestations of SBE and related to prolonged infection
Janeway lesions
Septic embolization manifesting as subungual hemorrhage in S.aureus endocarditis
Osler’s nodes
Highest risk of embolization
S.aureus
vegetations >10mm
mitral valve location
Focal dilations of arteries occuring at points in the artery wall that have been weakened by infection in the vasa vasorum or where septic emboli have lodged
Mycotic aneurysms
Definite IE based on Duke criteria
2 major or 1 major + 3 minor or 5 minor
Possible IE based on Duke criteria
1 major + 1 minor
or
3 minor
Diagnosis is rejected if
Alternative diagnosis is established
Symptoms resolve and do not recur = 4 days of antibiotics
Surgery or autopsy after = 4 days of antibiotics yields no histologic evidence of endocarditis
Blood culture protocol
If without prior antibiotics: 3 blood culture sets (2 bottles per set), separated from each other by at least 2 hours apart, from different venipuncture sites over 24 hours
Noninvasive and SPECIFIC echocardiography in IE
Transthoracic
Safe and more SENSITIVE echo
Transesophageal
Major Criteria for IE
Positive blood culture
Evidence of endocardial involvement
Minor criteria in IE
Fever Immunologic phenomena Vascular phenomena Predisposition Microbiologic evidence
(FIVe PM)
Positive blood culture
Typical microorganism for IE from 2 separate blood cultures
Persistently positive blood culture (cultures drawn 12h apart or 3 out of 4 with 1st and ladt drawn at least 1 hr apart
Single positive culture for Coxiella burnettinor phase I IgG antibody titer of >1:800
Positive Echocardiogram
Oscillating intracardiac mass on valve or supporting structures or in the path of regurgitant jets or in implanted material, in the absence of an alternative anatomic explanation
or
Abscess
or
New partial dehiscence of prosthetic valves
or
New valvular regurgitation
Treatment for penicillin-susceptible strep
Pen G x 4 weeks
Ceftriaxone x 4 weeks
Vancomycin x 4 weeks
Pen G/Ceftri + Genta x 2 weeks
Treatment for relative and moderately pen-resistant strep
Relative: Pen G/Cefti x 4 weeks + Genta x 2 weeks
Moderate: Pen G/Cefti x 6 weeks + Genta x 6 weeks
Pen preferred for prosthetic valves
Treatment for enterococci
Pen G + Genta x 4-6 weeks or Ampi + Genta x 4-6 weeks or Ampi + Ceftri x 4-6 weeks (for E.faecalis)
Treatment for Methicillin-susceptible staph
Nafcillin or Oxacillin x 4-6 weeks
Cefazolin x 4-6 weeks
Vancomycin x 4-6 weeks
Treatment for Methicillin-susceptible staph with prosthetic valves
Nafcillin/Oxacillin x 6-8 weeks \+ Genta x 2 weeks \+ Rifampin x 6 weeks
Treatment for Methicillin-resistant staph
Vanco x 6-8 weeks \+ Genta x 2 weeks \+ Rifampin x 6-8 weeks
Treatment for HACEK organisms
Ceftriaxone x 4 weeks
or
Ampi-Sulbactam x 4 weeks
Major indication for cardiac surgical treatment of endocarditis
Moderate to severe refractory CHF caused by new or worsening valve dysfunction
MCC of perivalvular infection
Aortic Valve
Indications for emergent surgical intervention
Acute aortic regurgitation plus preclosure of MV
Sinus of Valsalva abscess ruptured into right heart
Rupture into the pericardial sac
Prophylaxis indication
only for patients at highest risk for severe morbidity or death (before dental procedures and surgery of respiratory tract)
Prosthetic heart valves
Prior endocarditis
Unrepaired CHD, including palliative shunts or conduits
Completely repaired CHD during the first 6 months of repair
Incompletely repaired CHD with residual defects adjacent to prosthetic material
Valvulopathy developing after cardiac transplantation
