Lecture 6: Endocarditis

Question 1

What valve is MC involved in endocarditis

Answer 1

Mitral valve

note: MC - LC = M > A > T > P

Question 2

What are the 4 major/specific types of Endocarditis

Answer 2

4 major types of Endocarditis

1. ABE (Acute Bacterial)
2. SBE (Subactue Bacterial)
3. Endocarditis in Drug Users
4. PVE (Prosthetic Valve Endocarditis)

Question 3

What are the other 2 classifications/types (more general) of Endocarditis
and which is MC?

Answer 3

Type of Endocarditis

1. Non-Bacterial
2. Transient Bacteremia

Question 4

Transient Bacteremia

3 main causes/sources of infection

Answer 4

Transient Bacteremia: causes/sources of infection

1. valvular adherence
2. Oral flora
3. GI/GU flora

Question 5

Transient Bacteremia: causes/sources of infection

- what is the MC cause

Answer 5

MC cause/source of Transient Bacteremia

- Dental procedures

Question 6

Transient Bacteremia:

what are 3 ways bacteria evade the host response

Answer 6

Transient Bacteremia: evading the host response b/c

1. bacteria sequestered by fibrin matrix
2. decr metabolic activity in vegetation
3. decr susceptibility to ABX that work on cell wall

Question 7

2 main things that contribute to the pathogenesis of Endocarditis

Answer 7

Pathogenesis of Endocarditis

1. Turbulent Flow
2. Structural Dz

Question 8

What is the classic triad a/w Endocarditis

Answer 8

Endocarditis triad

1. Fever
2. Anemia
3. Heart murmur

Question 9

Endocarditis: Other manif

• What categories of are common in Endocarditis (3 things)

Answer 9

Endocarditis: Other manif

1. Systemic manif (constitutional Sxs)
2. MSK manif
3. GI manif (HSM)

Question 10

Endocarditis: Peripheral Manifestations

- name the 6 seen

Answer 10

Endocarditis: Peripheral Manifestations

1. Conjuctival Petechiae
2. Splinter hemorrhages
3. Osler’s nodes
4. Janeway lesions
5. Roth’s Spots
6. Septic Emboli

Question 11

Endocarditis: Peripheral Manifestations

1. where are conjuctival petechiae located
2. where are splinter hemorrhages located, a/w?
3. where are osler’s nodes located, painful?
4. Where are Janeway lesions located?
5. What are they?/where are Roth’s spots located?

Answer 11

Endocarditis: Peripheral Manifestations

1. Conjuctival Petechiae = inner eyelid
2. Splinter hemorrhages = nails, a/w clubbing
3. Osler’s nodes = pads of fingers/toes
4. Janeway lesions = palms + soles
5. Roth’s Spots = hemorrhages on retina

Question 12

Endocarditis Dx

• 4 main tests used to Dx it

Answer 12

Endocarditis Dx

1. blood cultures
2. ECHO
3. EKG
4. Labs

Question 13

Endocarditis Dx and ECHO

1. Which type typically done first
2. Which type is better/more sensitive

Answer 13

Endocarditis Dx and ECHO

1. TTE = usu done 1st
2. TEE = better/more sensitive

Question 14

Endocarditis Dx and EKG

• 2 things seen on EKG a/w endocarditis

Answer 14

Endocarditis Dx and EKG

1. conduction abn
2. arrhythmias

Question 15

Endocarditis Dx and Labs

• what are the 3 MC lab abn a/w endocarditis

Answer 15

Endocarditis Dx and Labs

1. incr ESR
2. Anemia
3. Abn UA (hematuria)

Question 16

Endocarditis Dx and Duke Criteria

3 options for Dx based on clinical criteria

Answer 16

Endocarditis Dx and Duke Criteria (need 1 of below)

1. 2 major
2. 1 major + 3 minor
3. 5 minor

Question 17

What are the 2 major Duke Criteria

Answer 17

Major Duke Criteria

1. • blood culture
2. • TTE/TEE

Question 18

1. RF
2. T > 38
3. Vascular + embolic lesions
4. Immunologic lesions
5. Atypical organism
6. • blood cult (not meeting major criteria)
7. • ECHO (not meeting major criteria)

what are these examples of

Answer 18

Minor Duke Criteria

1. RF
2. T > 38
3. Vascular + embolic lesions
4. Immunologic lesions
5. Atypical organism
6. • blood cult (not meeting major criteria)
7. • ECHO (not meeting major criteria)

Question 19

What are the 2 main NON-cardiac complications a/w endocarditis

Answer 19

NON-cardiac complications a/w endocarditis

1. Emboli
2. Metastatic abscesses

Question 20

What is the general Tx for endocarditis (duration)

Answer 20

high dose, long term ABX (4-6 wks)

Question 21

Endocarditis Tx

What 3 species need synergy w/ABX tx

Answer 21

Endocarditis Tx: synergy for

1. Enterococci
2. Some Streptococci
3. Pseudomonas

Question 22

Tx of Fungal Endocarditis

1. what ABX can be attempted?
2. What is the typically necessary Tx method?

Answer 22

Tx of Fungal Endocarditis

1. Attempt Tx w/Amph B but….
2. typically need surgery

Question 23

1. CHF
2. uncontrolled sepsis
3. Conduction abn
4. Myocardial abscess
5. fungal endocarditis
6. Recurrent systemic embolization
7. Prosthetic valve

are indications for ______

Answer 23

1. CHF
2. uncontrolled sepsis
3. Conduction abn
4. Myocardial abscess
5. fungal endocarditis
6. Recurrent systemic embolization
7. Prosthetic valve

are indications for early surgical intervention

Question 24

What is the MC cause of ABE (acute bacterial endocarditis)

- what 2 groups of pts is this type common in

Answer 24

ABE

MC cause = staph aureus
- common in IVDA and HIV pts

Question 25

Tx of ABE - what are the 2 options (2 drugs in each)

Answer 25

Tx of ABE 1. Naficillin + Gentamycin or .... 2. Vanco + Gentamycin

Question 26

What is the MC cause of SBE (Subacute Bacterial Endocarditis)?

Answer 26

What is the MC cause of SBE = Strep Viridans

Question 27

Other than Strep Viridans what other 2 groups of bacteria cause SBE

Answer 27

Causes of SBE 1. Group D strep 2. Coag (-) Staph

Question 28

Causes of SBE: Coag (-) staph - what is its unique virulence factor - what other type of endocarditis is it MC a/w

Answer 28

Causes of SBE: Coag (-) staph 1. unique virulence factor = slime 2. MC a/w PVE

Question 29

How does the general Tx of SBE different from acute

Answer 29

can delay Tx in SBE if stable | acute --> immed Tx

Question 30

Tx of SBE (gentamycin always given) 1. what are the 2 main drug options given w/Gentamycin

Answer 30

Tx of SBE 1. PCN or Ampicillin w/Gentamycin

Question 31

ABE vs SBE 1. Which is a/w a damaged valve 2. Which is the source Dental or GI? IVDA, Skin? 3. Which is the MC cause Strep 4. Which has insidious onset and slower course 5. Which has marked fever/toxicity (pts ill appearing) 6. Which has rapid change in cardiac fxn and higher mortality?

Answer 31

ABE vs SBE 1. damaged valve = SBE 2. Source Dental or GI = SBE - Source IVDA, Skin = ABE 3. MC cause is Strep = SBE 4. Insidious onset and slower course =SBE 5. Marked fever/toxicity (pts ill appearing) = ABE 6. Rapid change in cardiac fxn and higher mortality = ABE

Question 32

Pts who is an IVDU presents to clinic for f/u after being diagnosed w/ endocarditis few months ago. What valve is most likely involved?

Answer 32

MC valve = TRICUSPID in IVDU

Question 33

What bacteria is the MC cause of Endocarditis in IVDU and what is there a high incid of in this pop

Answer 33

Endocarditis in IVDU MC cause = Staph Aureus w/high incid of MRSA

Question 34

PVE: Prosthetic Valve Endocarditis 1. What is the MC cause for early cases ( < 60 days) 2. What is the MC cause for late cases (> 60 days)

Answer 34

PVE: Prosthetic Valve Endocarditis 1. Staph Epidermis = MC cause for early cases ( < 60 days) 2. Strep Viridans = MC cause for late cases (> 60 days)

Question 35

Tx of PVE 1. what 3 ABX combo used for PVE assoc S. aureus 2. what is the typical method of tx

Answer 35

Tx of PVE 1. PVE assoc S. aureus --> Vanc + Gentamycin + Rifampin 2. typical Tx method = valve replacement

Question 36

4 main causes of Culture negative endocarditis

Answer 36

Culture negative endocarditis 1. Prior ABX 2. Fungi 3. Organisms that dont grow on cultures 4. Non-infectious causes

Question 37

Culture negative endocarditis | - 2 examples of organisms that dont grow on cultures

Answer 37

Culture negative endocarditis: organisms that dont grow on cultures 1. Coxiella burnetti 2. Chlamydia psittaci

Question 38

Culture negative endocarditis | - 2 examples of non-infectious causes

Answer 38

Culture negative endocarditis: non-infectious causes 1. Marantic endocarditis 2. Libman-sacks endocarditis

Question 39

1. Prosthetic heart valves 2. Prior endocarditis 3. Major Congential heart Dz 4. Cardiac transplant w/cardiac valve dz 5. Heart repairs using prosthetic materials are indications for ______

Answer 39

1. Prosthetic heart valves 2. Prior endocarditis 3. Major Congential heart Dz 4. Cardiac transplant w/cardiac valve dz 5. Heart repairs using prosthetic materials are indications for Endocarditis PPx

Question 40

Endocarditis PPx | - what should be given as PPX before dental procedure (in those pts that its indicated)

Answer 40

ppx for Endocarditis before dental procedure = PO Amoxicillin (2 g)