Lecture 7 Part 1: Endocarditis Flashcards
In what layer of the heart are the valves and vessels located?
Endocardium
For infective endocarditis to occur and actually affect a valve, what conditions generally need to be present?
- Valvular damage/abnormality
- OR
- Turbulent blood flow
What is the MC route for IE to occur?
Oral
- Dental extraction/surgery
- Chewing candy
- Tooth brushing
Where does IE tend to occur in hearts? What is the exception?
- Mainly on the left-side.
- Exception: IV drug users (IVDU)
Direct injection goes straight to the right side first. TV is also the most common among IVDU as a result.
What is a kissing valve infection?
Both valves infected, i.e. mitral valve and aortic valve.
What is the MC causative organism in native valve IE?
Staph Aureus
2nd is streptococcus
MC bacteria in the mouth and skin as well.
For a prosthetic valve, what are the most common causative organisms?
- If prior to 2 months, staph is MC.
- If post 2 months, strep is MC.
A is before R, so STA before STR
For IVDU, what is the MC causative organism for IE?
Staph, specifically affecting the TV.
Followed by strep (viridans) and enterococci.
For nosocomial IE, what is the MC causative organism?
Staph aureus
In what demographic is fungal IE MC in?
IVDU or ICU patients receiving broad-spectrum abx.
What is the MCC of death for patients with IE?
Heart failure
What is the common clinical presentation of IE?
- Fever (90%)
- Chills
- Weakness
- SOB
- Night sweats
AKA all constitutional symptoms.
What are the most common conditions present in someone with IE?
- Heart murmurs (unless IVDU)
- CHF
- Septic emboli
What are the common physical exam findings for IE?
- Murmurs
- Petechiae
- Splinter hemorrhages
- Janeway lesions
- Osler nodes
- Roth spots
What is a Janeway lesion vs an Osler node?
Janeway lesion: PAINLESS patches on palms or soles, caused by staph.
Osler node: PAINFUL nodules on pads of fingers/toes, caused by vasculitis. MC: strep.
Probably know that jane is a painless staph.
What are Roth spots?
- Oval, pale, retinal lesions surrounded by hemorrhage caused by vasculitis.
- Usually chronic
- MC: Strep
What is the MC neurologic manifestation that may occur due to IE?
CVA
For bacteremia, what is the procedure for blood cultures?
- 3 sets of cultures from different sites
- First and last samples must be drawn at least 1 hr apart.
Need prior to initiation of ABX
Only need to get 1 set before starting ABX.
When might a TEE be preferred over TTE?
TEE would be preferred if the vegetation is small and/or large body habitus.
What are the major Duke Criteria?
- Blood culture positive
- Endocardial involvement on echo (including new murmur)
What are the minor Duke criteria?
- Fever > 38C
- Immunologic phenomena
- Vascular phenomena
- Echocardiography minor criteria ELIMINATED
- Predisposition
- Microbiologic evidence
FIVE PM
What is the Duke criteria mnemonic?
- Blood culture positive
- Endocardial involvement
- Fever > 38C
- Immunologic phenomena
- Vascular phenomena
- Echocardiography minor criteria ELIMINATED
- Predisposition
- Microbiologic evidence
BE FIVE PM
What is required for a definitive diagnosis of IE via Duke criteria?
- 2 major
- 1 major + 3 minor
- 5 minor
What is required for a possible diagnosis of IE via Duke criteria?
- 1 major + 1 minor
- 3 minor
For native valve IE, what is the first-line abx?
- Pen G + gent, but Vanco for the big boys
penguins gentleman
For IVDU IE, what are the first-line abx?
- Nafcillin
- Gent
- Vanco
For prosthetic valve IE, what are the first-line abx?
- Vanco
- Gent
- Rifampin
For Fungal IE, what is the first-line abx?
Amphotericin B
Still need sx!
What surgery is used for IE management?
Open sternotomy valve replacement, repair, or debridement.
When is surgery indicated for IE?
- Refractory CHF (MCC for early sx)
- Fungal IE
- Sepsis post 72 hrs of abx
- Recurrent septic emboli after 2 wks of abx
- Rupture of aneurysm of sinus of Valsalva
- Conduction disturbances 2/2 septal abscess
- Kissing infection of anterior mitral leaflet and aortic valve.
What is a common evaluation we should consider to help prevent people who are at risk of IE?
Dental evals!
What oral disease is the MCC of spontaneous bacteremia?
Gingivitis
What kind of patients are at high risk for IE and should be prophylaxed?
- Prosthetic valves
- Prior endocarditis
- Cyanotic CHD
- Cardiac transplantation patients with valvulopathy
What procedures need endocarditis prophylaxis?
- Dental procedures
- Respiratory tract procedures
- Procedures on infected skin or MSK tissue.
NO MORE GI/GU prophylaxis
What are the preferred abx for endocarditis prophylaxis?
- Axoxicillin
- Clinda/keflex/azithro/claritho (for PCN allergy)
- Ampicillin IM
- Cefazolin/rocephin IM
Usually about 1 hour prior to the procedure.
Example: 4 tabs of amoxicillin 500mg 1 hour prior to dental procedure
How do we diagnose IE and how long is tx?
- Duke’s criteria for diagnosis
- 6 week treatment!
