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Systems: Cardiovascualar AB > Infective Endocarditis + Rheumatic Heart Disease > Flashcards

Infective Endocarditis + Rheumatic Heart Disease Flashcards

1
Q

What can infective endocarditis infect?

A
  • Infection of inner layer of heart (endocardium)
  • Heart valves
  • Interventricular septum
  • Chordae tendinae
  • Intra-cardiac devices
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2
Q

What type of heart valves can be affected by infective endocarditis?

A

Both native and prosthetic

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3
Q

What is the prognosis for infective endocarditis?

A
  • Poor prognosis

- High mortality

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4
Q

Why is IE not a uniform disease?

A
  • Various presentations
  • Possibly dependent on underlying cardiac disease
  • Microorganism involved
  • Presence/absence of complications
  • Underlying patient characteristics
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5
Q

Who is involved in the collaborative approach taken towards IE?

A
  • Primary care physicians/ acute medicine
  • Cardiologists
  • Surgeons
  • Microbiologists
  • Infectious disease
  • (Neurologists, neurosurgeons, radiologists, pathologists)
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6
Q

What is the incidence of IE?

A

-3-10/100,000
-Males to females 2:1
females have worse prognosis
- ~25% no underlying structural heart disease

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7
Q

Why has the epidemiology of IE changed substantially?

A
  • Earlier diagnosis
  • More acute presentations
  • Changes in micro-profile
  • Prophylaxis
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8
Q

Who is at risk of IE?

A
  • Older patients
  • Prosthetic valves
  • Mitral valve prolapse
  • Bicuspid aortic valve
  • Congenital heart disease
  • IV drug abuse
  • Immunocompromised patients
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9
Q

What are the cardiac risk factors for IE?

A
  • MVP, no murmur
  • MVP with MR
  • VSD
  • AS
  • Rheumatic heart disease
  • Prosthetic heart valve
  • Cardiac surgery for native IE
  • Prior native IE
  • Surgery for prosthetic IE
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10
Q

What specific predisposing valvular lesions are there for IE?

A
  • MR
  • AR
  • AS
  • CHD
  • Prosthetic valve
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11
Q

What CHDs can predispose someone to IE?

A
  • Cyanotic heart disease
  • Teratology of Fallot
  • VSD
  • PDA
  • Eisenmenger syndrome
  • ASD, Coarctation of the aorta
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12
Q

What non-cardiac risk factors are there for IE?

A
  • Injection drug use
  • Indwelling medical devices
  • Diabetes mellitus
  • AIDS
  • Chronic skin infections/burns
  • Genitourinary infections or manipulation
  • Alcoholic cirrhosis
  • GI lesions
  • Solid organ transplant
  • Homeless, body lice
  • Pneumonia/meningitis
  • Contact with containerised milk or infected farm animals
  • Dog/cat exposure
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13
Q

What is included in genitourinary manipulation?

A
  • Pregnancy
  • Abortion
  • Delivery
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14
Q

What is the pathophysiology of IE?

A
  • Adherence and invasion of nonbacterial thrombotic endocarditis
  • Mechanical disruption of valve endothelium
  • Physically normal endothelium
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15
Q

What is a nonbacterial thrombotic endocarditis?

A

A sterile fibrin platelet vegetation

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16
Q

What can cause a mechanical disruption of valve endothelium?

A
  • Turbulent blood flow/ Venturi effect
  • Electrodes
  • Catheters
  • Inflammation (rheumatic carditis)
  • Degenerative changes
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17
Q

What is the pathophysiology of physically normal endothelium involved in IE?

A

Local inflammation

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18
Q

What can cause bacteraemia?

A
  • Extra-cardiac infections
  • Invasive procedures
  • Gingival disease
  • Activities of daily living
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19
Q

What invasive procedures can result in bacteraemia?

A
  • Oral, abdominal, genitourinary surgery

- Intravascular catheters

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20
Q

What activities of daily living can result in bacteraemia?

A
  • Brushing teeth

- Bowel movements

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21
Q

What are the classifications of IE?

A
  • Acute
  • Subacute
  • Chronic
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22
Q

What is acute IE due to?

A

Staph aureus

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23
Q

What is subacute IE due to?

A

Strep

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24
Q

What type of IE is more common in IV drug users?

A

Right sided

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25
Q

What type of localisations of IE are there?

A
  • Left sided native valve
  • Left sided prosthetic valve (early/late)
  • Right sided
  • Device related
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26
Q

What are the modes of acquisition of IE?

A
  • Health care related
  • Community acquired
  • IVDA
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27
Q

What are the types of health care related IE?

A
  • Nosocomial/idiopathic

- Non-nosocomial

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28
Q

What is nosocomial/ idiopathic IE?

A

Sign/ symptoms >48hrs after hospitalisation

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29
Q

What is non-nosocomial IE?

A
  • Signs/symptoms <48hrs after admission/health care contact
  • Home based nursing/ IV therapy, haemodialysis <30 days before onset
  • Acute care facility <90 days before onset
  • Resident in nursing home or long term care facility
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30
Q

What 4 indicators are at the start of a diagnosis?

A
  • Variable presentation
  • High index of suspicion
  • Bacteraemic episode
  • Non-specific symptoms (fever, fatigue, malaise)
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31
Q

What clinical manifestations of IE are there?

A
  • Fever
  • Weight loss
  • Headache
  • Musculoskeletal pain
  • Altered mentation
  • Murmur
  • Peripheral stigmata petechiae
  • Janeway lesions
  • Osler’s nodes
  • Splinter haemorrhages
  • Clubbing
  • Neurological manifestations
  • Roth spot’s
  • Splenomegaly or infarct
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32
Q

What are the signs of IE?

A
  • Congestive heart failure
  • Vascular/ immunological phenomena
  • Embolic phenomena
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33
Q

What are indications of immune complex deposition?

A
  • Splinter haemorrhages
  • Vasculitis rash
  • Roth spots
  • Osler’s nodes
  • Janeway lesions
  • Nephritis
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34
Q

What are indications of embolic phenomena?

A
  • Focal neurological signs
  • Peripheral embolus/abscess
  • Pulmonary embolus/abscess
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35
Q

Where may peripheral embolus/abscess occur?

A
  • Renal
  • Cerebral
  • Spanchnic
  • Vertebral
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36
Q

When may a pulmonary embolus/abscess occur?

A

Right side IE

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37
Q

Describe vasculitis rash

A
  • Diffuse
  • Non-blanching
  • Petechial
  • Purpuric
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38
Q

What are Roth spots?

A

-Retinal haemorrhages with white/pale centres due to coagulated fibrosis

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39
Q

Describe Osler’s nodes

A
  • Deep, red spots
  • Painful
  • Raised
  • Finger pulps
  • Palms/soles
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40
Q

Describe Janeway lesions.

A
  • Flat,macular
  • Echymotic
  • Palms/soles
  • Non-tender
  • Pathognomonic
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41
Q

Who is included in the high index of suspicion for IE?

A
  • Fever
  • New murmur
  • Pyrexia of unknown origin
  • Known IE causative organism
  • Prosthetic material
  • Previous IE
  • Congenital heart disease
  • New conduction disorder
  • Immunocompromised/IVDA
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42
Q

Who might the signs of IE be absent in?

A
  • Elderly
  • After antibiotic treatment
  • Immunocompromised
  • IE involving less virulent/atypical organisms
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43
Q

What investigations are carried out for IE?

A
  • FBC
  • CRP
  • ESR
  • U+Es
  • Blood cultures
  • Urinalysis
  • ECG
  • CXR
  • ECHO
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44
Q

What investigations are markers of infection/inflammation?

A
  • FBC
  • CRP
  • ESR
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45
Q

What can U+Es indicate?

A
  • Nephritis
  • Infection
  • Sepsis
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46
Q

How should blood cultures be carried out for IE?

A
  • Prior to staring antibiotics
  • 3 sets
  • Different sites
  • > 6 hrs between
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47
Q

How should blood cultures be carried out if the patient has sever sepsis/septic shock?

A
  • 2 sets
  • Different sites
  • Within 1 hour
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48
Q

What is looked for in urinalysis?

A

+ve blood

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49
Q

What is looked for on an ECG?

A

Conduction delay

50
Q

What is looked for on a CXR?

A
  • Heart failure

- Pulmonary abscesses

51
Q

What type of ECHO is performed?

A

TTE +/- TOE

52
Q

When would TOE not be performed for IE?

A
  • Good quality TTE
  • Normal TTE
  • Low clinical suspicion
53
Q

When would TOE be performed?

A
  • TTE normal

- High clinical suspicion

54
Q

When is TTE/TOE repeated after 7-10 days?

A
  • TTE/TOE normal

- Suspicion of IE remains high

55
Q

What happens if TTE is positive?

A

TOE is performed to look for:

  • Complications
  • Abscesses
  • Measure size of vegetation
56
Q

When would you repeat TTE+TOE with a new complication?

A
  • New murmur
  • Persisting fever
  • Embolism
  • Heart failure
  • Abscess
  • Atrioventricular block
57
Q

When would you repeat TTE+TOE in uncomplicated IE?

A
  • To assess ongoing treatment for silent complications and vegetation size
  • To assess treatment success on complication for valve morphology and cardiac function
58
Q

Why might blood cultures be negative with IE?

A
  • Prior antibiotic treatment
  • Fastidious organisms
  • Intracellular bacteria
59
Q

What organisms are most IE blood culture positive for?

A
  • Streptococci
  • Enterococci
  • Staphylococcus
60
Q

What streptococci are most common?

A
  • Oral (viridans)
  • S milleri, S anginosus group
  • Nutritionally variant defective streptococci recently reclassified
  • Group D streptococci
61
Q

Oral (viridans) strep

A
  • S. sanguis
  • S. mitis
  • S. salivarius
  • S. mutans
  • Germella morbillorum
62
Q

S milleri, S anginosus group

A
  • S, anginosus
  • S. intermedius
  • S constellatus
63
Q

Nutritionally variant ‘defective’ strep recently reclassified

A
  • Abriotrophia

- Granulicatella

64
Q

Group D strep

A
  • Associated with GIT

- S. bovine/equinus complex

65
Q

What species of enterococci can be responsible for IE?

A
  • E. faecalis
  • E faecium
  • E durans
66
Q

What species of staphylococcus can be responsible for IE?

A
  • S. aureus

- S epidermis

67
Q

Why may there be prior antibiotic treatment

A
  • Antibiotics given for unexplained fever
  • Before blood culture taken
  • Diagnosis of IE not been considered
  • Blood cultures may remain negative for many days after discontinuation of antibiotics
68
Q

If there is prior antibiotic treatment what is most likely to the causative agent of IE?

A
  • Oral strep

- CNS

69
Q

What organisms are fastidious?

A
  • Nutritionally variant strep
  • Fastidious Gram -ve bacilli (HACEK group)
  • Brucella
  • Fungi
70
Q

Give examples of gram -ve bacilli in the HACEK group.

A
  • H. parainfluenzae
  • H. aphrophilus
  • H. paraphrophilus
  • H. influenza
  • Actinobacillus actinomycetemcomitans
  • Cardiobacterium hominis
  • Eikinella corodens
  • Klingella kingae
  • K. dentrificans
71
Q

What intracellular bacteria can cause IE?

A
  • Coxiella burnetii
  • Bartonella
  • Chlamydia
72
Q

How are intracellular bacteria caused IE diagnosed?

A
  • Serological testing
  • Cell culture
  • Gene amplification
  • PCR
73
Q

What is the major criteria of the modified Duke criteria focused on?

A
  • Identifying organism

- Providing evidence of infection anywhere within the heart

74
Q

What is the minor criteria of the modified Duke criteria focussed on?

A

The endocarditis complex of clinical findings

75
Q

What would indicate blood cultures positive for IE that fits major modified Duke criteria?

A
  • Typical organisms consistent with IE from 2 separate blood cultures
  • Organisms consistent with IE from persistently positive blood cultures
  • Single +ve blood culture for Coxiella burnetii (or phase I IgG antibody titre>1:800)
76
Q

What counts as typical organisms consistent with IE?

A
  • Staph aureus
  • S viridans
  • S bovis
  • HACEK
  • Community acquired enterococci
77
Q

What would be evidence of endocardial involvement in the major modified Duke criteria?

A
  • Positive ECHO

- New valvular regurgitation/murmur

78
Q

What would suggest a positive ECHO?

A
  • Any endocardial surface including normal myocardium
  • Intracardiac device/mass
  • Para-annular abscess
  • New dehiscence of prosthetic valve
79
Q

What factors are included in the minor modified Duke criteria?

A
  • Predisposition
  • Fever
  • Vascular phenomena
  • Immunological phenomena
  • Microbiological evidence
80
Q

What is included under predisposition in the minor modified Duke criteria?

A
  • Predisposing heart condition

- Injection drug use

81
Q

What is included under fever in the minor modified Duke criteria?

A

Temperature >38C

82
Q

What is included under vascular phenomena in the minor modified Duke criteria?

A
  • Major arterial emboli
  • Septic pulmonary infarcts
  • Mycotic aneurysm
  • Intracerebral haemorrhages
  • Conjunctival haemorrhages
  • Janeway lesions
83
Q

What is included under immunological phenomena in the minor modified Duke criteria?

A
  • Glomerulonephritis
  • Osler’s nodes
  • Roth spots
  • Rheumatoid factor
84
Q

What is included under microbiological evidence in the minor modified Duke criteria?

A
  • Positive blood cultures that do not meet the major criteria
  • Serological evidence of active infection with organism consistent with IE
85
Q

What is required of the modified Duke criteria for a definite diagnosis?

A
  • 2 major
  • 1 major + 3 minor
  • 5 minor
86
Q

What is required of the modified Duke criteria for a possible diagnosis?

A
  • 1 major

- 3 minor

87
Q

What is the treatment for IE?

A

Antibiotics +/- surgery

88
Q

When should antibiotics be started for IE?

A
  • Started as soon as all blood cultures have taken

- IV

89
Q

What is the choice of antibiotics dependent on for IE?

A
  • Received prior antibiotics
  • Native/prosthetic valve (early/late PVE after surgery)
  • Knowledge of local epidemiology, antibiotic resistance and specific culture-negative pathogens
90
Q

What are the antibiotics of choice for native valves?

A 
-IV gentamicin (1mg/kg 12 hourly)
AND
-IV amoxicillin (2g 4 hourly)
OR WITH
IV vancomycin (per protocol)
91
Q

When would vancomycin be used instead of amoxicillin?

A
  • Penicillin allergy
  • Severe sepsis
  • MRSA
92
Q

What are the antibiotics of choice for prosthetic valves?

A 
-IV gentamicin (1mg/kg 12 hourly)
AND
-IV vancomycin (per protocol)
AND
-Rifampicin (300-600mg IV/PO 12 hourly)
93
Q

What is antibiotic choice dictated by?

A
  • Microorganism involved
  • Sensitivities
  • Resistance
94
Q

How should gentamicin be dosed?

A
  • Dosed to body weight

- If obese, dose to ideal body weight

95
Q

What are the complications of gentamicin?

A
  • Nephrotoxic

- Ototoxic

96
Q

When should serum gentamicin levels be carried out?

97
Q

What serum gentamicin levels should be checked?

A
  • Trough (pre-dose) <1mg/L

- Peak (post-dose) 1hour after dosing 3-5mg/L

98
Q

What investigations should be carried out daily as part of continuing treatment?

A
  • FBC
  • U+Es
  • CRP
99
Q

What investigation should be carried out every 1-2 days as part of continuing treatment?

100
Q

What investigation should be carried out weekly as part of continuing treatment?

101
Q

Who is normally affected by IE caused by fungi?

A
  • PVE
  • IVDA
  • Immunocompromised
102
Q

What fungi can be responsible for IE?

A
  • Candida

- Aspergillus

103
Q

What is the mortality of IE caused by fungi?

A

Very high >50%

104
Q

What is the treatment for IE caused by fungi?

A
  • Dual anti-fungals
  • Valve replacement
  • Often maintained long term, sometimes for life
105
Q

What are the possible complications for IE?

A
  • Heart failure
  • Fistula formation
  • Leaflet perforation
  • Uncontrolled infection
  • Abscess formation
  • Atrioventricular heart block
  • Embolism
  • Prosthetic valve dysfunction/dehiscence
106
Q

What indications for surgery are there?

A
  • Heart failure
  • Fistula formation
  • Leaflet perforation
  • Leaflet obstruction
  • Uncontrolled infection
  • Enlarging vegetation
  • Abscess formation
  • Atrioventricular heart block
  • Prevention of embolism
  • Embolism + vegetation>10mm
  • Isolated vegetation>15mm
107
Q

What would indicate uncontrolled infection?

A
  • Persisting fever

- +ve blood cultures> 7-10 days

108
Q

What may be responsible for uncontrolled infection?

A

-Inadequate antibiotic treatment
-Resistant organisms
-Infected lines
-Locally uncontrolled infection
-Embolic complications
Extracardiac site of infection
-Adverse reaction to antibiotics

109
Q

Why might surgery be carried out for the prevention of embolism?

A
  • Size/mobility vegetation
  • Increased size despite antibiotics
  • Staph, Strep bovis or Candida
  • Previous embolism
  • Multivalvular IE
110
Q

What is the most severe form of IE?

111
Q

What is PVE often associated with?

A
  • Difficulties in diagnosis
  • Difficulties with optimal therapeutic strategy
  • Poor prognosis
  • Removal of prosthetic material
112
Q

What is medical therapy alone associated with?

A
  • High mortality

- Risk of recurrence

113
Q

What is the recommended treatment for intracardiac devices (prosthetic valves)?

A
  • Removal recommended
  • Prolonged antibiotic course
  • IV antibiotics for as long as possible prior to removal
  • Sterilise device
114
Q

What are the current NICE guidelines on prophylaxis?

A
  • Avoid extensive non-evidence based use of antibiotics

- Limit prophylaxis to highest risk patients

115
Q

What can transient bacteraemia be caused by?

A
  • After dental/invasive procedures
  • Tooth brushing
  • Flossing
  • Chewing
  • Poor dental hygiene
116
Q

Why is prophylaxis not routinely used?

A
  • Huge no. of patients would require it to prevent 1 case of IE
  • Majority of patients no potential index procedure can be identified
  • Small risk of anaphylaxis
  • Emergence of resistance microorganisms
  • Lack of scientific evidence for the efficacy of IE prophylaxis
117
Q

What cardiac conditions are at highest risk of IE?

A
  • Acquired valvular heart disease
  • Valve replacement
  • Structural congenital heart disease
  • Hypertrophic cardiomyopathy
  • Previous IE
118
Q

What structural congenital heart diseases are not at high risk of IE?

A
  • Isolated ASD
  • Fully repaired VSD or PDA
  • Closure devices that are endothelialised
119
Q

When should prophylaxis be offered?

A
  • An antibiotic that covers organisms that cause IE
  • If a person is at risk of IE
  • Is receiving antimicrobial therapy
  • Due to under a GI or GU procedure
  • At a site where there is suspected infection
120
Q

What advice should be offered when it comes to body piercing/tattooing?

A
  • Education of patients at risk of IE
  • Discourage
  • If undertaken then should be performed under strict sterile conditions and antibiotic prophylaxis is recommended
121
Q

When are aseptic measures especially important to avoid health care associated IE?

A

Insertion and manipulation of venous catheters and invasive procedures

Systems: Cardiovascualar AB (42 decks)

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