Infective endocarditis Flashcards

1
Q

define infective endocarditis

A

Heart has 3 layers: epicardium, myocardium and endocardium.

Endocarditis - infection involving the endocardial surface

Valvular structures- native and prosthetic valves

Chordae tendineae

Sites of septal defects

Mural endocardium- posterior wall of the LA becomes rough and wrinkled

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

incidence of infective endocarditis

A

low incidence 3-10/100,000

affects males more than females but when females contract it they have a worse prognosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

risk factors for native valve IE

A
Mitral valve disease
Rheumatic heart disease
Congenital heart disease
Degenerative  heart disease
Asymmetrical septal hypertrophy
Intravenous Drug abusers
Alcoholic cirrhosis
Diabetic mellitus
Indwelling medical devices
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

what is mitral valve prolapse

A

Mitral valve prolapse is a condition in which the two valve flaps of the mitral valve do not close smoothly or evenly, but instead bulge (prolapse) upward into the left atrium

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

prevalence of mitral valve prolapse

A

high prevalence 2-4% of general population
20% are young female

52/100,000 who have MVP and a systolic murmur develop IE

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Congenital heart disease

A

10-20% of endocarditis case in young adults

ventricular septal defect, bicuspid aortic valve, patent ductus arteriosus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

how does endothelium become infective due to mechanical endothelium disruption?

A

Mechanical endothelial disruption exposures extracellular matrix protein → production of tissue factors.

Deposition of fibrin and platelets→ Non-bacterial thrombotic endocarditis (NBTE).

NBTE facilitates bacterial adherence and infection.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

how can an endothelial valve become damaged?

A

Turbulent blood flow (Venturi effect-low pressure )

electrodes

catheters

inflammation (rheumatic carditis)

degenerative valve disease (ECHO - 50% of asymptomatic patients >60yrs)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Venturi effect?

A

there’s a reduction in fluid pressure when a fluid flows through constricted area of pipe. High velocity but low pressure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

how does a normal valve become inflamed?

A

Inflammation of endothelial cell → expression of integrins (β1 family)

integrin acts like a hook that binds circulating fibronectin binding proteins on staph aureus

Adherent organisms trigger active internalisation into valve endothelial cells.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

examples of invasive procedures that can cause bacteraemia

A

Dental procedures requiring manipulation - gingival /periapical region

Dental procedures -perforation of oral mucosa

GU and GI surgery

Intravascular catheters

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

non-invasive activities that can lead to bacteraemia?

A

(chewing and tooth brushing)-low grade bacteraemia of short duration but with high incidence.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

pathophysiology of infective endocarditis

A

valvular endothelium - platelet-fibrin deposition - nonbacterial thrombotic endocarditis - adherence - colonisation = vegetation

mucous membranes - trauma - bacteremia - adherence - colonisation - vegetation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

causative organisms of IE

A
Viridans group streptococci
Staphylococcus aureus
Enterococci 
Coagulase-negative staphylococci				
Haemophils parainfluenzae
Strep bovis
Fungi
Brucella species
Culture-negative Haemphilus species
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

acute vs subacute

A
acute = days/weeks
subacute = weeks to months
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

mode of acquisition of IE

A

IVDU - IV drug users
healthcare
community

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Classification:- localisation of IE

A

+/- intra-cardiac material

L sided native valve IE
L sided prosthetic valve IE (PVE)

R sided IE
Device related IE (permanent pacemaker/cardioverter -defib)

18
Q

how can you tell if a patient has active infective endocarditis

A

IE with persistent fever (>38 °C) and positive blood cultures

active inflammatory morphology found at surgery

patient still under antibiotic therapy

histopathological evidence of active IE

19
Q

why is IE difficult to diagnose

A

it’s not a uniform disease
syndrome diagnosis determined by presence of multiple findings ie

Presence or absence of pre-existing cardiac disease

causative microorganisms

presence or absence of complication

underlying patient characteristics

mode of presentation

20
Q

atypical presentation of IE occurs in which patients?

A

elderly

immunocompromised

21
Q

diagnosis of acute IE

A

fever, embolic signs/symptoms (stroke, splenic infarct) or decompensated HF

22
Q

diagnosis of subacute IE

A

fever, non-specific constitutional symptoms or palpitation and immunologic/vascular phenomena.

23
Q

common symptoms of IE

A

fever/chills
night sweats, malaise, fatigue, anorexia, weight loss

weakness, arthralgia, headache (may be non-specific or embolic)

SOB

24
Q

Clinical signs of IE

A
cardiac murmur (regurgitant murmur) with signs of HF
janeway lesions 

immune complex depostion:- olser nodes, roth spot

meningeal signs
splinter haemorrhage
cutaneous infarcts
vasculitis rash

25
what are janeway lesions
painless, small erythematous or haemorrhagic macular or nodular lesions on the palms or soles indicative of infective endocarditis
26
what are olser nodes
small, painful nodular lesion found on pads of fingers or toes
27
what are roth spots
Retinal haemorrhage with a white or pale centre
28
in diagnosis of IE often use high index of suspicion - give some examples
new regurgitant murmur embolic events of unknown origin sepsis of unknown origin fever
29
investigations carried out for IE
Blood culture- Timing. 3 sets and sites 30mins apart. +/- cultures Echocardiography FBC.ESR/CRP- elevated acute inflammatory markers urea and electrolytes- renal failure Urinalysis- +ve for blood ECG: PR interval prolongation ≥200ms CXR: Pulmonary congestion or abscess. Further Imaging for subgroups – MSCT (multi-slice CT - accuracy similar to ECHO but superior perivalvular abscess), MRI, 18F-FDG -PET/CT and Leukocyte SPECT/CT –detect silent vascular phenomena/ endocardial lesions
30
preferred imaging option for possible IE in native valve?
repeat ECHO (TTE +TOE)/microbiology imaging for embolic events cardiac CT
31
preferred imaging option for possible IE in mechanical valve?
repeat ECHO (TTE +TOE)/microbiology ''F-FDG -PET/CT or Leukocyte SPECT/CT cardiac CT imaging for embolic events
32
What is an ECHO good at detecting in IE
vegetation abscess pseudoaneurysm intracardiac fistula valvular perforation or aneurysm new partial dehiscence of prosthetic valve (surgical complication)
33
what is 18F-FDG PET/CT good at detecting?
abnormal activity around the site of the prosthetic valve implantation (if it has been implanted for >3 months)
34
cardiac CT is good at detecting what in IE?
definitive paravalvular lesions
35
what do you need to diagnose definite IE?
``` 2 major criteria or 1 major + 3 minor or 5 minor criteria ```
36
IE rejection criteria
Resolution of endocarditis syndrome with antibiotics therapy for ≤ 4 days.
37
treatment of IE
Three sets of blood culture (taken 30min apart ) before initiating IV antibiotics PVE-Prosthetic valve Endocarditis –treat for 6weeks NVE-Native Valve Endocarditis – treat for 2-6 weeks
38
what does treatment of IE depend on?
Whether the patient has received previous antibiotic therapy Whether the infection affects a native valve or a prosthesis [and if so, when surgery was performed (early vs. late PVE)]. The place of the infection (community, nosocomial, or non-nosocomial healthcare-associated IE) and knowledge of the local epidemiology, especially for antibiotic resistance and specific genuine culture-negative pathogens.
39
Antibiotics to treat community acquired native or late prosthetic valves endocarditis
``` ampicillin with flucloxacillin or oxacillin with gentamicin ``` vancomycin with gentamicin (for penicillin allergic patients)
40
Antibiotics to treat early PVE or hospital/ non-hospital acquired endocarditis
``` vancomycin with gentamicin with Rifampin - only recommended for PVE ```
41
complications and indications for surgery
Heart failure in IE: valvular regurgitation- leaflet perforation etc 42-60% of Native Valve Endocarditis(NVE) Aortic IE> Mitral IE Uncontrolled Infection: Perivalvular abscess More common in Aortic IE (10-40%) in NVE 56-100% of Prosthetic valve endocarditis (PVE) Mortality rate 41% Prevention of systemic embolism: migration of cardiac vegetation to brain/spleen from left-IE Size and mobility of vegetation. Pulmonary embolism are the results of right sided IE.
42
antibiotic prophylaxis is limited to which patients?
those at highest risk of IE undergoing the highest risk dental procedures, patients with previous IE, patients with congenital heart disease, patients with a prosthetic valve, including a transcatheter valve or a prosthetic material used for cardiac valve repair good oral hygiene aseptic measures during venous catheter manipulation disinfection of wounds discourage piercing/tattooing