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Cardiovascular Block: Week 6 > Infective Endocarditis Part 2 > Flashcards

Infective Endocarditis Part 2 Flashcards

1
Q

What should be considered when planning the treatment of infective endocarditis?

A
  • Native valve vs. Prosthetic valve

- Predisposing factors (IVDU, nosocomial infections etc,)

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2
Q

What are some of the principles of treatment of infective endocarditis?

A
  • Empiric antibiotic therapy to cover commonly implicated organisms
  • Always parenteral route (IV)
  • Prolonged duration of therapy (4-6 weeks)
  • NB: HIGH DOSE antibiotic therapy
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3
Q

How should response to therapy in IE be monitored?

A

Repeat blood cultures after one week of therapy.

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4
Q

What is the empiric therapy of Native Valve IE?

A

Penicillin (6 mU given 6 hourly IV) for 4 weeks
+
Gentamicin (3 mg/kg/day given 12 hourly IV) for 2 weeks
+/-
Cloxacillin depending on local epidemiology

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5
Q

What is the empiric therapy of Prosthetic Valve IE?

A

Vancomycin (30 mg/kg/day given 12 hourly IV) for 6 weeks
+
Rifampicin (15 mg/kg/day given 12 hourly po) for 6 weeks
+
Gentamicin (3 mg/kg/day given 12 hourly IV) for 2 weeks

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6
Q

What is the significance of the addition of Rifampicin to the antimicrobial regime required for prosthetic valve IE?

A

Required for penetration of the biofilm

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7
Q

What duration of therapy is required for prosthetic valve endocarditis?

A

Prosthetic valve endocarditis required prolonged duration antimicrobial therapy (MINIMUM 6 WEEKS)

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8
Q

What are indications for urgent heart valve surgery and parenteral antimicrobial treatment in prosthetic valve endocarditis?

A
  • Severe valve dysfunction
  • Abscesses
  • Large vegetations (>1cm) = high risk of embolization
  • Failure of conservative medical treatment
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9
Q

When should a conservative medical approach be taken to the management of prosthetic valve endocarditis?

A
  • If no indications for urgent surgery, a conservative medical approach should be the initial approach to therapy
  • Parenteral antimicrobial agents should be used in the conservative approach
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10
Q

What is considered complicated infective endocarditis requiring urgent surgical management?

A
  • Progressive heart failure
  • Multiple (>2) systemic embolic episodes
  • Persistent bacteremia despite effective antibiotic therapy
  • Fungal endocarditis
  • Cardiac complications: heart block, purulent pericarditis, cardiac abscess
  • Relapse following “adequate” trial of antibiotics (6-8 weeks)
  • Prosthetic valve rupture
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11
Q

What are some of the patient factors that predict poor outcomes in infective endocarditis?

A
  • older age
  • prosthetic valve IE
  • DM
  • comorbidity (frailty, immunosuppression, renal / pulmonary disease)
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12
Q

What are some of the complications that predict poor outcomes in infective endocarditis?

A
  • Heart failure
  • Renal failure
  • Greater than moderate areas of ischemia stroke
  • Brain hemorrhage
  • Septic shock
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13
Q

What are some of the microorganisms that predict poor outcomes in infective endocarditis?

A
  • S. Aureus
  • Fungi
  • Non-HACEK gram negative bacteria
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14
Q

What are some of the echocardiographic findings that predict poor outcomes in infective endocarditis?

A
  • Periannular complications
  • Severe left sided valve regurgitation
  • Low LV ejection fraction
  • Pulmonary hypertension
  • Large vegetations
  • Severe prosthetic valve dysfunction
  • Premature mitral valve closure and other signs of elevated diastolic pressure
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15
Q

What is the commonest risk factor of infective endocarditis in South Africa?

A

Rheumatic heart disease

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16
Q

What are the most common etiological agents of infective endocarditis?

A

Viridans streptococci, enterococci, and staphylococci

17
Q

What forms the cornerstone of IE diagnosis and informs therapeutic decisions?

A

Correctly taken blood cultures

18
Q

In summary what therapy is required for IE in general?

A

Prolonged IV therapy with surgery in certain instances

19
Q

What are commonly used non-valvular intracardiac devices?

A

Permanent pacemakers, ventriculo-atrial shunts, implantable cardioverter defibrillators etc.

20
Q

What are commonly used non-valvular arterial devices?

A

Peripheral vascular stents, vascular grafts, patches, etc.

21
Q

What is a major complication of implantable cardiovascular devices?

A

Infection (increasing)

22
Q

What does infection of implantable cardiovascular devices depend on?

A
  • Type and size of device
  • Size of implantation
  • Surgical technique used for device implantation
23
Q

Infections of non-valvular cardiovascular devices: what is the pathogenesis?

A

Microbial contamination of device with skin flora at time of insertion most commonly

  • adhere to device surfaces and produce biofilm
  • colonization and subsequent infection
24
Q

Infections of non-valvular cardiovascular devices: what organisms are usually involved?

A

Staphylococci predominantly
- CNS, Staph Aureus
Other gram negative and gram positive organisms

25
Q

Infections of non-valvular cardiovascular devices: what is the clinical presentation?

A
  • Pocket site infection commonly (localized inflammatory changes)
  • Occult bacteremia (without any localized inflammatory changes)
  • Endocarditis (associated with the device)
26
Q

Infections of non-valvular cardiovascular devices: what is the management?

A
  1. Removal of the device

2. Antimicrobial therapy

27
Q

Why is prevention of infective endocarditis important?

A
  • Serious morbidity and mortality (although overall mortality has since improved)
  • “Microbiologic cure” doe not prevent permanent cardiac valvular damage and other sequelae (impaired QOL etc)
28
Q

What are the current recommendations for the prevention of infective endocarditis?

A
  1. Maintain optimal oral and dental health in patients at risk for IE
  2. Implement interventions to prevent and promptly treat health care associated infections
  3. Antibiotic prophylaxis prior to surgical procedures = no longer standard of care, now restricted to certain procedures and patient groups only
29
Q

For which dental procedures is IE prophylaxis indicated?

A

Manipulation of the gingival tissue or peri-apical region of teeth or perforation of oral mucosa

30
Q

What should be given for IE prophylaxis prior to dental procedures?

A

Amoxicillin single dose, 30-60 minutes prior to procedure

31
Q

Apart from dental procedures, when else is IE prophylaxis indicated?

A

Also reasonable for procedures on respiratory tract or infected skin, skin structure or musculoskeletal tissue
- only for patient with cardiac lesions associated with high risk of adverse outcomes from IE.

Cardiovascular Block: Week 6 (4 decks)

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