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CVS > Infective Endocarditis > Flashcards

Infective Endocarditis Flashcards

1
Q

What can be infected in IE

A 
Endocardium
Heart valve
Septum 
Chordae tendinae
Intra-cardiac devices
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2
Q

What are cardiac RF for IE

A 
Intra-cardiac device / procedure
Prosthetic valve 
Rheumatic HD
Valve disease - AS, MVP, MR, MS
Congenital - Biscuspid aortic valve / VSD
- If have VSD and culture staph must screen for IE 
HCM 
Previous IE
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3
Q

What are non cardiac RF

A 
Immunocompromised
- DM
- HIV 
IVDA 
Piecing 
Dental 
IV lines 
Haemodialysis 
Malignancy 
Chronic skin / dermatitis / wound 
Alcoholic cirrhosis 
Renal failure 
GI lesion
Organ transplant
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4
Q

What are common organisms on blood culture

A

S.Aureus = most common
Strep viridans
Enterococci vaecalis - prostate / UTI - high mortality
S.epidermidis - common after surgery as contaminant
Strep bovis
- If found must screen for colorectal cancer

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5
Q

What are common organisms if blood culture -ve

A 
Fungi - candidia / Aspergillis
Gram -ve HACEK - H.influenza - EXAM 
Chlamydia
Bartonella
Coxiella burnetti 
Brucella

Non-infective
SLE
Malignancy
Hyper-coagulable

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6
Q

What are non-specific symptoms then signs of end organ damage

A 
Fever - don't always have and may be low grade 
Rigors 
Malaise
Fatique
Weight loss
Night sweats

Organ

  • Anaemia
  • Splenomegaly - may be painful if infarction
  • Renal infarction / AKI
  • Congestive CF - SOB / palpitations
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7
Q

What are immunological signs

A

GN - haematuria in 70%
Roth spots - retinal haemorrhage on fundoscopy (may need ophthalmology review)
Osler node - painful raised spots
Splinter haemorrhage

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8
Q

What are vascular signs

A 
Emboli from vegetations 
Vasculitis rash
Splenomegaly
Clubbing
Janeway lesion - flat non tender
Petechiae or purpura
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9
Q

What does emboli cause

A

Focal neuro signs
PE
Peripheral emboli - renal failure

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10
Q

When can signs be absent

A

Elderly
Immunocompromised
Ax

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11
Q

What type of ECHO is done

A

TTE
If TTE -ve but high suspicion = TOE
If TTE +ve then TOE for complications

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12
Q

What is suggestive of IE

A

New murmur
- Typically pan systolic from mitral
Fever >1 week

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13
Q

When should you have a high degree of suspicion

A 
PUO
New murmur
IE causative agent cultured
Prosthetic
Previous IE
Congenital heart
Immunocompromised
IVDA
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14
Q

Who is more likely to have a fungal infection

A

Immunocompromised
IVDA
Prosthetic

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15
Q

How do you investigate IE

A 
Blood culture - 3 sets in 24 hours from different spots 
2 sets within 1 hour if severe sepsis 
Need to get one from line if in situ 
PCR / serology for culture -ve 
FBC, U+E, LFT, CRP, Mg
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16
Q

What does bloods show

A 
Normocytic normochrmic anaemia
Thrombocytopenia
Raised WCC / CRP
Raised Ig
Decreased C3
Abnormal U+E / LFT
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17
Q

What are other tests

A 
Urinanalysis / dip 
- Always look as emboli could cause NVH 
ECG
CXR
ECHO 
CT
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18
Q

What does urinalysis look for

A

Protein / haematuria

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19
Q

What does ECG look for

A

Conduction defects

Heart block

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20
Q

What does CXR look for

A

Signs of HF
Pulmonary abscess
Emboli

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21
Q

What type of ECHO is 1st line

A

TTE to visualise vegetations but normally TOE best

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22
Q

When do you use TOE

A

If TTE +Ve to look for complications, abscess and measure vegetations
If high clinical suspicion and TTE -ve
Repeat to asses Rx and look for complications

23
Q

What do you do a CT for

A

Look for emboli

24
Q

Where are the majority of vegetations found

A

Mitral valve

Aortic

25
Q

Where in IVDA

A

Tricuspid so more common real life

26
Q

What does everyone with a S.Aureus bacteraemia get

A

TTE ECHO

27
Q

What do you need to Dx IE

A

2 major Duke criteria
1 major and 3 minor
5 minor

28
Q

What is major Duke’s criteria

A

2 + specific blood culture

  • S.aureus
  • S.viridans
  • S.bovis
  • Enterococci
  • HACEK group

Evidence of endocardial involvement on ECHO

  • Vegetation
  • Abscess
29
Q

What are Duke’s minor criteria

A 
Predisposing heart
IVDA
Fever >38 
Vascular 
Immunological
Microbiology that doesn't meet major
Serology with organism consistent with IE that is culture -ve
30
Q

How do you treat IE

A

IV antibiotics for 4-6 weeks after culture

31
Q

What is blind treatment when no organism cultured

A

Gentamicin

Amoxicillin / flucloxacillin

32
Q

What do you do if allergic / MRSA

A

Gent
Vanc
Rifampicin

33
Q

What do you do for Staph

A

Flucloxacillin

Vanc + rifampicin if allergic / MRSA

34
Q

What do you do if prosthetic Staph

A

Use all 3

35
Q

How do you treat strep

A

Benzypenicillin

36
Q

What do you do if allergic

A

Gentamicin

37
Q

How do you treat enterococcus

A

Amoxicillin / Benzypenicillin
Gentamicin
Vancomycin if allergic

38
Q

What do you do for HAEK gram -ve

A

Ceftriaxone

39
Q

What do you do for prosthetic valve

A

Add rifampicin

40
Q

What do you do for fungal infections

A

Dual anti-fungal for life

Valve replacement

41
Q

How do you monitor

A

FBC, U+E, CRP daily
ECG 1-2 days
Weekly ECHO

42
Q

When is urgent surgery indicated / valve replacement

A 
Severe valve damage >10mm
Large vegetations 
Early infection with prosthetic
Aortic abscess lengthening PR
Resistant infection / overwhelming sepsis 
CF - resistant oedema/. shock 
Recurrent emboli
Fungal
Pregnant
43
Q

Who gets prophylaxis

A

Not recommended

44
Q

What suggests poor outcome

A 
S.Aureus
Fungal 
Heart failure
Co-morbid
Prosthetic valve
Low complement
CAn't identify organism 
IDDM
CVA
45
Q

What are the complications of IE.

A 
LVF = most common
Mitral regurgitation 
Prosthetic valve dysfunction
Emboli / stroke 
HF
Uncontrolled infection / sepsis
Fistula formation
Abscess
AV block
AF
Renal failure
46
Q

What else may patient present with

A 
OM
SA
Pneumonia
Neuro
GN
Vasculitis
Meningiitis
47
Q

What does septic emboli suggest

A

IVDA

48
Q

What needs to be +ve for definite Dx

A

All 3 blood cultures

49
Q

DDX

A

TB
Malignancy
Vasculitis

50
Q

When do you do TTE

A

All S.aureus bacteraemia

51
Q

What do you do if TTE -ve but high suspicion

A

TOE

52
Q

What are atypical presentation

A

Septic emboli

- Young IVDA who presents with Sx of stroke / spinal pain / renal failure

53
Q

RF vs IE

A 
IE = alpha haemolytic (Strep viridian)
IE = mitral regurgitation 
RF = beta haemolytic
RF = mitral stenosis common

CVS (30 decks)

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