Infective endocarditis-Table 1

Question 1

What is endocarditis and where does it most commonly occur?

Answer 1

Infection of the endocardial surface of the heart, usually heart valves but can occur within septal defects or on mural endocardium

Question 2

What is the most common etiology of endocarditis?

Answer 2

Bacterial

Question 3

What is the 4th leading cause of life-threatening infectious dz syndromes?

Answer 3

Endocarditis

Question 4

If a L or right sided emboli worse?

Answer 4

L side, this can potentially dislodge and go into the brain whereas a R sided would go to the lungs (PE)

Question 5

What are risk factors for endocarditis?

Answer 5

•Male gender
•Older age
•Prosthetic valve
•Intra‐cardiac device
•Pre‐existing cardiac abnormality
•Injection drug use
Congenital heart abnormalities

Question 6

What are the types of infective endocarditis?

Answer 6

Acute infective and subacute infective

Question 7

What is characteristic of acute infective endocarditis?

Answer 7

• caused by highly virulent organisms like S. aureus
• damage to cardiac structures happens rapidly
• there are necrotizing, ulcerative, destructive lesions

Question 8

What is characteristic of subacute infective endo?

Answer 8

Less invasive, less virulent ( step viridans or bovis), and damage to cardiac structures is slow and gradual

Question 9

If it is an IV drug user, what is the culprit?

Answer 9

STAPH AUREUS

Question 10

What are characteristics of Left sided infective endo?

Answer 10

• Community associated and healthcare acquired
• Embolic stroke
• High mortality
• Surgical benefits greatest in early phase of IE

Question 11

What are characteristics of right sided infective endo?

Answer 11

IVDU
Septic pulmonary embolism common
High cure rate (>85%)
Surgery infrequently needed

Question 12

What is the clinical presentation of IE?

Answer 12

• Fever
• Chills
• Weakness
• Dyspnea
• Sweats
• Cough
• Anorexia
• Nausea
• Vomiting
• Chest pain
• Abdominal pain
• Heart murmur – around 20-40% only
• Septic Emboli- CT lung or brain
• Skin findings

Question 13

What are the skin findings in IE?

Answer 13

• Splinter hemorrhages under nailbeds of fingers or toes
• Petechiae - small, red painless lesions
• Osler’s nodes: red or purple, painful, subcutaneous nodules
• Janeway lesions: non-tender, red, hemorrhagic lesions; usually found on palms or soles

Question 14

What is the hallmark finding of IE?

Answer 14

continuous bacteremia (persistently positive blood cultures) caused by bacteria shedding from the vegetation into the bloodstream

Question 15

What diagnostic tests are used in IE?

Answer 15

•TTE (transthoracic echocardiogram) sensitivity- 58% to 63%
Test Question, cant trust this if it is negative**
•TEE (transesophageal echocardiogram) sensitivity- 90% to 100%
Way more invasive

Question 16

How is IE diagnosed off the duke criteria?

Answer 16

2 major, 1 major + 3 minor or 5 minor

Question 17

What are majors in the duke criteria?

Answer 17

1) blood cultures 2/2

2) evidence of vegetation on ECHO

Question 18

What are the minors in the duke criteria?

Answer 18

• predisposed heart condition
• fever
• vascular phenomena
• immunologic phenomena
• positive blood culture that doesn’t meet major criteria

Question 19

What is the main non pharm intervention for IE?

Answer 19

Surgery- repair or replace

Dependent on heart failure, uncontrolled infection, and prevention of embolism

Question 20

What are the four general principles when choosing therapeutic agents for infective endocarditis?

Answer 20

1.Use high dose therapy (to get adequate concentrations within vegetation)
2.Use parenteral (IV) therapy
3.Use bactericidal therapy
4.Count days of therapy from the first day on which blood cultures change to negative.
4-6 week tx from when blood culture is negative….after you start abx wait a few days and draw labs to see if still (+)

Question 21

Why should you never add gentamicin unless specifically indicated?

Answer 21

Increased risk of nephrotoxicity and renal dysfunction with little to no benefit

Question 22

What is the drug regimen for streptococcus IE with native valves and PCN susceptibility?

Answer 22

4 weeks: PEN G or CTX

2 weeks: PEN G_ gent OR CTX + gent

Question 23

What is the drug regimen for streptococcus IE with native valves and PCN intermediate?

Answer 23

4 and 2 weeks
PEN G x 4 weeks
PEN G + gent x 2 weeks 
CTX x 4 weeks 
CTX + gent x 2 weeks

Question 24

What is the drug regimen for streptococcus IE with prosthetic valves and PCN susceptible?

Answer 24

6 weeks
PEN G
CTX

Question 25

What is the drug regimen for streptococcus IE with prosthetic valves or native valves and PCN resistance?

Answer 25

6 weeks
PEN G? these are confusing
CTX

Question 26

What is tx for staph IE with native valves?

Answer 26

6 weeks

nafcillin IV

Question 27

What is tx for staph IE with prosthetic valves?

Answer 27

> /= 6 weeks
nafcillin
PLUS rifampin
PLUS gent x 2 weeks

Question 28

What is tx for staph IE with MRSA?

Answer 28

Vanco

Question 29

What is the tx for efaecalis IE?

Answer 29

Amp + gent for 4-6 weeks

Question 30

What is HACEK?

Answer 30

H – Haemophilus parainfluenzae, H.
aphrophilus, H. paraphtophilus, H.
influenzae
A – Actinobacillus actinomycetemcomitans
C – Cardiobacterium hominis
E– Eikenella corrodens
K – Kingella kingae, K. denitrificans

Question 31

How is HACEK IE tx with native valve?

Answer 31

4 weeks

CTX or AMP/sulb OR cipro

Question 32

How is HACEK IE tx with prosthetic valve?

Answer 32

6 weeks

ceftriaxone (CTX) OR amp/sulb OR cipro

Question 33

When is daptomycin used in IE?

Answer 33

FDA approved for the treatment of right‐ sided MSSA or MRSA endocarditis