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Cardiovascular System > Infective Endocarditis > Flashcards

Infective Endocarditis Flashcards

1
Q

Infective endocarditis

A

Infection involving the endocardial surface

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2
Q

What other structures can it effect (4)

A
  • Valvular structures- native and prosthetic valve
  • Chordae Tendineae
  • Sites of septal defects
  • Mural endocardium
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3
Q

Incidence

A

More common in men

Worse prognosis in women

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4
Q

MDT (6)

A
  • Referring doctors/GPs
  • Microbiologists/Infectious disease team
  • Cardiothoracic surgeon
  • Radiologists
  • Neurologists/Neurosurgeon
  • Reference centre- complicated cases
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5
Q

Evolving epidemiological profile

A
  • Past- young adults (chronic/subacute course)
  • Present- older patients with degenerative heart disease, healthcare associated procedure, valve diseases, congenital heart disease, prosthetic valve, IVDU, Immunocompromised patients
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6
Q

Risk factors for Native IE (9)

A
  • Mitral valve disease
  • Rheumatic heart disease
  • Congenital heart disease
  • Degenerative heart disease
  • Asymmetrical septal hypertrophy
  • IV drug abusers
  • Alcoholic cirrhosis
  • Diabetes mellitus
  • Indwelling medical devices
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7
Q

Pathophysiology of IE in the valve endothelium (4)

A

Mechanical disruption exposes EM
Produces tissue factors
Deposition of fibrin and platelets
NBTE facilitates adherence and infection

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8
Q

Causes of damaged endothelial valve (5)

A
  • Turbulent blood flow (venturi effect-low pressure)
  • Electrodes
  • Catheters
  • Inflammation (rheumatoid carditis)
  • Degenerative valve disease
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9
Q

Venturi Effect

A
  • Reduction in fluid pressure when a fluid flows through constricted area of pipe
  • High velocity and low pressure
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10
Q

Pathophysiology of endothelial Inflammation (3)

A
  • Inflammation leads to expression of integrins (B1 family)
  • Integrin acts like a hook that binds circulating fibronectin on staph aureus
  • Adherent organisms trigger active internalisation into valve endothelial cells
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11
Q

Causes of Bacteraemia

A

Invasive procedures
Extra cardiac infections
Non invasive activities

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12
Q

Name 6 Causative organisms of IE

A
  • Viridans group streptococci
  • Staphylococcus aureus
  • Enterococci
  • Coagulase-negative staphylococci
  • Streptococcus bovis
  • Fungi
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13
Q

Classification of IE (6)

A
  • Acute- days/weeks
  • Subacute- weeks/months
  • Nidus- localisation
  • Mode of acquisition
  • Active
  • Recurrence
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14
Q

Localisation (2)

A

Left or Right sided

Native or Prosthetic valve

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15
Q

Mode of acquisition (4)

A

Nosocomical
Non Nosocomical
Community acquired
IV drug abuse

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16
Q

Active IE (4)

A

Persistent fever and positive blood cultures
Active inflammatory morphology
Histopathological evidence
Histopathological evidence of active IE

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17
Q

Recurrence

A

Relapse
Reinfection
less than 6 months since the last episode

18
Q

Diagnosis (5)

A
  • High index of suspicion
  • Bacteraemia with audible murmur should raise suspicion
  • Elderly or immunocompromised
  • Acutely- fever, embolic signs/symptoms or decompensated HF
  • Subacute fever, non-specific constitutional symptoms or palpitation
19
Q

Common symptoms (6)

A
  • Fever/chills
  • Night sweats, malaise, fatigue, anorexia, weight loss
  • Weakness
  • Arthralgia
  • Headache
  • SOB
20
Q

Clinical signs (10)

A
  • Cardiac murmur (regurgitant murmur)- with signs of HF
  • Janeway lesions
  • Petechial haemorrhage
  • Osler nodes
  • Roth spot- retinal haemorrhage
  • Meningeal signs
  • Splinter haemorrhage
  • Cutaneous infarcts
  • Vasculitic rash
  • Immune complex deposition
21
Q

Investigations (8)

A
  • Blood culture (3 sets and sites 30mins apart)
  • FBC. ESR/CRP elevated acute inflammatory markers
  • U+Es- renal failure
  • Urinalysis for blood
  • ECG- prolongation of PR interval >200ms
  • CXR: pulmonary congestion or abscess
  • MSCT, MRI, PET.CT and leucocyte SPECT/CT
  • Transthoracic or transoesophageal echocardiography
22
Q

Modified Duke’s Criteriea (1)

A
  1. Blood cultures positive for IE
    A. Typical micororganisms consistent with IE from 2 seperate blood culture
    B. Microorganisms consistent with II from persistently positive cultures
    C. single positive blood culture
23
Q

A. Typical micororganisms consistent with IE from 2 seperate blood culture

A

Viridans streptococci, Streptococcus gallolyticus (Streptococcus bovis), HACEK group,
• Staphylococcus aureus; OR
• Community-acquired enterococci, in the absence of a primary focus;

24
Q

C. single positive blood culture

A

Coxiella burnetii or phase I IgG antibody titre >1:800

25
Q

Modified Dukes Criteria (2)

A

Imaging positive for IE
A. Vegetation
B. Abnormal activity around the site of prosthetic valve
C. Definite paravalvular lesions by cardiac CT

26
Q

A. Echocardiogram positive for IE:

A
  • Vegetation
  • Abscess, pseudoaneurysm, intracardiac fistula •Valvular perforation or aneurysm
  • New partial dehiscence of prosthetic valve
27
Q

B. Abnormal activity around the site of prosthetic valve implantation

A

detected by 18F-FDG PET/CT (only if the prosthesis was implanted for >3 months) or radiolabelled leukocytes SPECT/CT.

28
Q

ESC 2015 Modified Duke’s Criteria- Minor Criteria (5)

A
  1. Predisposition such as predisposing heart conditions or IV drug use
  2. Fever defined as temperature above 38
  3. Vascular phenomena
  4. Immunological phenomena
  5. Microbiological evidence
29
Q

Diagnosis of definite IE (3)

A
  • 2 major
  • 1 major +3 minor
  • 5 minor
30
Q

Diagnosis of possible IE (2)

A
  • 1 major + 1 minor

* 3 minors

31
Q

Rejection of the diagnosis of IE

A

• Resolution of endocarditis with antibiotic therapy

32
Q

What does the treatment depend on (3)

A
  • Whether patient received previous antibiotic therapy
  • Whether infection affects native or prosthetic valve
  • The mode of infection
33
Q

Treatment for community acquired native or late prosthetic valves (3)

A

Ampicillin
Flucloxacillin
Gentamicin
IV

34
Q

Treatment for community acquired native or late prosthetic valves with penicillin allergy

A

Vancomycin and Gentamicin IV

35
Q

Early PVE post surgery or noscomical or non-nosocomial (3)

A

Vancomycin
Gentamicin
Rifampin

36
Q

Patient characteristics that can cause complications (4)

A

Older age
Prosthetic valve
DM
Comorbidity

37
Q

Clinical complications of IE

A 
HD
Renal failure
Ischaemic stroke
Brain Haemorrhage
Septic shock
38
Q

Microorganism complications (3)

A

Staph aureus
Fungi
Non-HACEK gram negative bacilli

39
Q

ECHO findings (7)

A 
Periannular complications
Severe left-sided valve regurgitation
Low left ventricular ejection fraction
Pulmonary hypertension
Large vegetation
Valve dysfunction
elevated systolic pressure
40
Q

Complications and Indications for Surgery (4)

A
  • Heart failure in IE
  • Uncontrolled infection
  • Migration of cardiac vegetation to brain/spleen from left IE
  • Pulmonary embolisms are the result of right sided IE
41
Q

Principles of prevention of IE (3)

A

• Antibiotic prophylaxis must be limited with patients with the highest risk of IE
 Patients with prosthetic valves
 Previous IE
 Congenital heart disease
• Good oral hygiene and regular dental review are more important than antibiotic prophylaxis to reduce the risk
• Aseptic measures

42
Q

Preventative measures (7)

A
  • Strict dental hygiene
  • Disinfection of wounds
  • Curative antibiotics
  • No self-medication with antibiotics
  • Strict infection control
  • Discourage piercing and tattooing
  • Limit the use of infusion catheters and invasive procedures

Cardiovascular System (42 decks)

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