Infective endocarditis

Question 1

When to suspect endocarditis

Answer 1

Fever+new murmur = endocarditis until proven otherwise

Fever lasting >1wk in at risk people needs blood cultures

Question 2

Acute IE presentation

Answer 2

Normal valves

Acute HF ± emboli

Question 3

Acute IE RFs

Answer 3

Skin breaches
Renal failure
Immunosuppression
DM

Question 4

Subacute IE presentation

Answer 4

Abnormal valves
Previous aortic/mitral valve disease (tricuspid in IVDU)
PDA, VSD or prosthetic valves also RFs

Question 5

IE common causative organisms

Answer 5

Staph. epidermis most common in subacute

Staph. aureus most common in acute

Question 6

IE immunocompromised/ prosthetic valve organisms

Answer 6

Rarely HACEK gram -ve in immunocompromised/ prosthetic valves:
Haemophilus
Actinobacillus
Cardiobacterium
Eikenella
Kingella

Question 7

IE signs

Answer 7

Sepsis signs + clubbing
New murmur
Splinter haemorrhages + Osler’s nodes + Janeway lesions
Emboli may cause abscess

Question 8

IE investigations

Answer 8

Blood cultures - 3 sets at 3 diff times at diff sites
Normochromic, normocytic anaemia with neutrophilia
CXR shows cardiomegaly + pulmonary oedema
TTE may shows vegetations if >2mm, TOE better for mitral/ aortic root abscess
CT for emboli

Question 9

IE surgical indications

Answer 9

HF

Valvular obstruction
Unstable infected prosthetic valve

Repeated emboli

Fungal IE
Persistent bacteraemia
Myocardial abscess

Question 10

IE prognosis

Answer 10

50% require surgery
20% inhospital mortality (30% for staph)
15% recurrence at 2 yrs

Question 11

IE prevention

Answer 11

No Abx prophylaxis but if already on antibiotics for other reasons then should cover IE organisms

Question 12

IE diagnosis

Answer 12

Duke criteria with:
2 major or
1 major + 3 minor or
all 5 minor criteria

Question 13

IE Duke major criteria

Answer 13

+ve blood culture:
typical in 2 cultures or
+ve for 12+ hours or
1 with Coxiella

Endocardium involvement:
+ve echo or
PET/CT or
Cardiac CT

Question 14

IE Duke minor criteria

Answer 14

Predisposition
Fever >38
Vascular phenomena e.g. Janeway lesions/emboli
Immunological phenomena (Osler’s nodes etc)
+ve blood culture not meeting major criteria

Question 15

Abx for IE

Answer 15

Blind therapy non-new prosthetic valve: Ampicillin + flucloxacillin + gentamicin (vanc if allergic)
Blind for prosthetic <1yr old: vanc + gentamicin + rifampicin
Ceftriaxone for HACEK
Amphotericin for Candida