Infective Endocarditis

Question 1

What would suggest IE immediately?

Answer 1

Fever + new murmur

Question 2

Most common organism?

Answer 2

Staphylococcus aureus

Question 3

What are risk factors for IE

Answer 3

Skin breaches
Renal failure
Immunosuppression
DM

Aortic or mitral valve disease
Tricuspid in IVDUs
Coarctation,
PDA
VSD

Question 4

What organism on prosthetic valves?

Answer 4

Staphylococcus epidermidis

Question 5

What other organism cause IE

Answer 5

Streptococcus viridans
Coagulase negative staphylococcus such as Staph. epidermidis
Streptococcus bovis
Others:
Gram negative HACEK - haemophilus, actinobacilus, cardiobacterium, eikenella, kingella

Question 6

Signs of IE?

Answer 6

Septic signs:
fever, rigors, night sweats, malaise, weight loss, anaemia, splenomegaly, clubbing

Cardiac lesions: new murmur or change in pre-existing murmur

Immune complex deposition - vasculitis, golmerulonephritis, Roth spots - retinal haemorrhage with pale centre, splinter haemmorrhages, Osler’s nodes - painful pulp infarcts in fingers or toes

Embolic phenomena - septic emboli, Janeway lesions, abscesses in brain, heart, kidney , spleen, gut

Question 7

What is used for IE diagnosis?

Answer 7

Modified Duke’s criteria

Question 8

What are the criteria for IE?

Answer 8

Major:
Positive blood cultures 2 separate cultures showing typical organisms
Persistent bacteraemia from 3 cultures >12h apart
1 culture for Coxiella burnetti

Endocardium involved
- positive echo
or new valvular regurgitation

Minor:
Predisposition (cardiac lesion/IVDU)
Fever > 38
Vascular phenomena: Janeway lesions, splinter haemorrhage, major emboli, splenomegaly, purpura
Immunological phenomena: glomerulonephritis, Osler’s nodes, Roth spots
Positive blood culture

2 major or 1 major 3 minor or 5 minor

Question 9

What investigations for IE?

Answer 9

Bedside:
Temperature
BP
Urinalysis - for microscopic haematuria
ECG - heart block

Bloods:
Cultures 3 sets at different times
FBC
ESR/CRP
RF - immunological
LFT
U&E

Imaging:
CXR - cardiomegaly, pulmonary oedema
Echo - valve lesions 
Aortic root abscess
CT for emboli

Question 10

How is IE native valve treated?

Answer 10

Blind therapy - native valve or prosthetic > 1 year = amplicillin, flucloxacillin and gentamicin

Staphs = flocloxacillin > 4weeks vancomycin if pen allergic or MRSA
Streps = benzylpenicillin 4-6 weeks or benpen+gentamixin or vancomycin +gentamicin if allergic or resistant

Enterococci - amoxicillin + gentamicin 4 weeks(vancomycin + gentamicin if pen allergic)

HACEK - ceftriaxone 4 weeks

Question 11

How is IE prosthetic valve treated?

Answer 11

Blind therapy - prosthetic valve = vancomycin + gentamicin + rifampicin

Staphs - flucloxaciilin + rifampicin + gentamicin for 6 weeks (vancomycin if pen allergic/resistant)

Streps - ben pen + gentamicin (vancomycin if pen allergic or resistant) 6 weeks

enterococci: amoxicillin + gentamicin (vancomycin if pen allergic) 6 weeks

HACEK - ceftriaxone 6 weeks