Infective Endocarditis Flashcards

1
Q

IE Incidence

A
  • Infective endocarditis
  • Uncommon
  • Increased incidence in elderly, IDU, and prosthetic heart valves
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2
Q

Risk Factors

A
  • Congenital heart disease + cyanosis
  • Rheumatic heart disease following rheumatic fever
  • Mitral valve prolapse with regurgitation
  • Degenerative valvular lesions; stenosis, regurgitation
  • Prosthetic valves
  • IDU
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3
Q

IE Pathogenesis

A
  1. Endothelial surface of heart damaged
  2. Platelet and fibrin deposition leading to nonbacterial thrombotic endocarditis formation
  3. Bacteremia results in colonization of endocardial surface
  4. Gram “+” more likely to adhere to NBTE from adhesion factors
  5. After colonization, fibrin, platelets, and bacteria continue to aggregate and a “vegetation” forms
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4
Q

Heart Valves Involved

A
  1. Mitral (86%) - most commonly caused by S. viridans when rheumatic heart disease is abnormality
  2. Aortic (55%) - more acute infections
  3. Tricuspid (20%) - common site of staph endocarditis in IDU
  4. Pulmonic (1%)
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5
Q

Acute v.s. Subacute

A
  • Subacute: indolent infections with less invasive organisms (Viridans), common with prior valvular heart disease
  • Acute: fulminant infection following infection of a previously normal valve
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6
Q

Non-virulent Organisms

A
  • Low grade fever
  • Malaise
  • Fatigue
  • Weight loss
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7
Q

Virulent Organisms

A
  • High grade fever (common)
  • Chills, sweat
  • Septic picture
  • Embolization complications
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8
Q

IE Clinical Features

A
  • Heart murmur - common and on a scale of 1-6
  • Skin lesions
  • Other: renal failure, splenomegaly, back pain, abdominal pain, chest pain, etc.
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9
Q

Peripheral Manifestations

A
  • Osler nodes: purple/red subcutaneous papules/nodules that appear on toes and fingers and can be painful and tender
  • Roth spots retinal hemorrhages usually caused by immune complex mediated vasculitis
  • Janeway lesions: hemorrhagic, painless plaque that develop on palms and soles
  • Splinter hemorrhages: thin, linear under nailbeds
  • Petechiae: small, erythematous hemorrhagic lesions that aren’t painful or tender
  • Finger Clubbing: proliferative change in the soft tissue at the ends of fingers
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10
Q

Labs + Significant Tests

A
  • Blood cultures
  • Hematologic: WBC, BUN/SCr
  • ESR
  • Echocardiogram: TEE more sensitive for detecting vegetation
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11
Q

IE + Major Criteria

A
  • Blood: two blood cultures positive for typical IE organism
  • Echo: Positive for IE, myocardial abscess, development of partial dehiscence of a prosthetic valve, new-onset valvular regurgitation
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12
Q

IE + Minor Criteria

A
  • Predisposing heart condition or IDU
  • Fever > 38C
  • Vascular phenomenon
  • Immunological phenomenon
  • Positive blood culture results not meeting major criteria
  • Echo results consistent with IE but no other major criteria
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13
Q

Vascular phenomenon

A
  • Major arterial emboli
  • Septic pulmonary infarcts
  • Intracranial hemorrhage
  • Conjunctival hemorrhage
  • Janeway lesions
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14
Q

Immunological Phenomenon

A
  • Glomerulonephritis
  • Osler nodes
  • Roth spots
  • Rheumatoid factor
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15
Q

Diagnosis

A
  • Definite Endocarditis: microorganism by vegetation culture or cardiac abscess confirmed OR meeting 2 major criteria, 1 major and 3 minor criteria, or 5 minor criteria
  • Possible Endocarditis: Findings consistent with IE but falls short of definite
  • Rejected: Firm alternative diagnosis or resolution of symptoms in less than 4 days or no pathological evidence at surgery or autopsy
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16
Q

Treatment Guidelines

A
  • Firm diagnosis: presumptive therapy
  • Identify organisms: repeat blood cultures
  • Bactericidal antibiotics
  • Combo therapy needed often
  • Duration: 4-6 weeks
  • Surgical intervention may be required
17
Q

Empiric Treatment + Native Valve

A
  • Vanco + Zosyn

* *Empiric = Highly dependent on potential cause of endocarditis**

18
Q

Empiric + Prosthetic Valve

A

-Vanco + Gentamicin + Rifampin

19
Q

Treatment: V. streptococci/S. Bovis + PCN Susceptible

A
  • **PCN G x 4 weeks
  • Ceftriaxone x 4 weeks
  • PCN G x 2 weeks (when?)
  • Ceftriaxone + Gent x 2 weeks
20
Q

Treatment: V. streptococci/S. Bovis + PCN Intermediate

A
  • (0.12 < MIC < 0.5)
  • PCN + Gent x 2 weeks
  • Ceftriaxone + Gent x 2 weeks
21
Q

Treatment: V. streptococci/S. Bovis + PCN Allergy

A
  • Ceftriaxone x 4 weeks

- Vanco x 4 weeks

22
Q

Treatment: Enertococci or PCN-R V. Strept. + First Line

A
  • PCN G + Gent x 4-6 weeks for Strep
  • Amp + Gent x 4-6 weeks - Enterococci
  • Amp + Ceftriaxone
23
Q

Treatment: Enertococci or PCN-R V. Strept. + PCN-R enterococci or PCN allergy

A

Vanco + Gent x 6 weeks

24
Q

Treatment: Enertococci or PCN-R V. Strept. + High-level AMG Resistance

A

-Amp + Ceftriaxone x 6 weeks

25
Q

Treatment: Staphylococci + Native Valve

A

Methicillin-susceptible

  • **Nafcillin x 6 weeks
  • Cefazolin x 6 weeks
  • Vanco x 6 weeks (preferred with allergies)

Methicillin-resistant/PCN Allergy

  • **Vanco x 6 weeks
  • Daptomycin x 6 weeks
26
Q

Treatment: Staphylococci + Prosthetic Valve

A

Methicillin-susceptible

  • Naficillin AND
  • Rifampin x 6 weeks AND
  • Gent x 2 weeks

Methicillin-resistant

  • Vanco AND
  • Rifampin x 6 weeks AND
  • Gent x 2 weeks
27
Q

IE Prophylaxis

A
  • 15-25% from invasive procedures that produce bacteremia
  • 10% of IE can be prevented with preprocedure antibiotics
  • Consider prophylaxis in those with high-risk conditions and procedures
28
Q

High-risk Conditions

A
  • Presence of prosthetic heart valve
  • History of endocarditis
  • Cardiac transplant recipients who develop cardiac valvulopathy
  • Congenital heart disease with a high-pressure gradient lesion
29
Q

High-risk Procedures

A
  • Any procedure manipulating gingival tissue or periapical region of teeth or perforation of the oral mucosa
  • Any procedure involving incision in respiratory mucosa
  • Procedures of infected skin or musculoskeletal tissue including incision and drainage of an abscess
  • Prophylaxis: no longer routinely recommended for GI and GU procedures