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What are the key features of infective endocarditis (IE)?
- Vegetations: collections of platelets, fibrin, microorganisms, and inflammatory cells; most often on valves
- Typical patient population:
- males
- > 50 yo
- hx of injection drug use
- Risk factors:
- hx of IE
- heart valve abnormalities
- heart valve replacement
- IV drug use
- hemodialysis
- prolonged hospital stay
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How is IE classified?
- By affected valve:
- aortic
- mitral
- pulmonary (rare)
- tricuspid (IV drug users)
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What are the symptoms of acute IE?
- Fever/chill
- leukocytosis/ceucopenia
- tachycardia
- tachypnea
- hemodynamic instability
- "sepsis-like"
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What are the symptoms of subacute IE?
- fever/chills/weakness
- night sweats
- weight loss
- Increased WBC
- Increased ESR (erythrocyte sedimentation rate)
- Splenomegaly
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What are the more specific symptoms of IE?
- Osler nodes
- Janeway lesions (S. aureus infection)
- Conjunctival petechiae (Roth's spots)
- Retinal infarct
- Splinter hemorrhages
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How would you describe the pathophysiology of IE?
- Endocardium damaged: platelet aggregation and fibrin deposits at site
- Bacteria colonize the damaged site:
- hematogenous route (bacteremia)
- direct inoculation (surgery)
- Immune response stimulated, but doesn’t clear infecting organism:
- more platelets and fibrin production
- vegetation grows
- Vegetations:
- protects bacteria
- penetrates valve, causing more damage
- can break off (septic emboli)
- can form antibodies against vegetation itself (tissue damage b/c antibodies are not very specific for the vegetation)
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What are the complications associated with IE?
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Damage to heart valves
- HF
- Arrhythmias
- Cardiac fistulas b/w ventricles
- Microembolic events
- Stroke
- Can be fatal
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What pathogens cause IE in the general population?
- Viridans streptococci
- S. bovis
- S. pneumoniae
- MSSA
- MRSA
- S. epidermidis
- E. faecalis
- E. faecium
- Haemophilus spp
- Actinobacillus
- Cardiobacterium hominis
- Eikenella corrodens
- Kingella kingae
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What is the HACEK group in IE?
- gram (-) organisms:
- Haemophilus
- Actinobacillus
- Cardiobacterium hominis
- Eikenella corrodens
- Kingella kingae
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What pathogens cause IE in IV drug users?
- MRSA
- P. aeruginosa
- polymicrobial
- Viridans streptococci
- S. bovis
- S. pneumoniae
- MSSA
- S. epidermidis
- E. faecalis
- E. faecium
- Haemophilus spp
- Actinobacillus
- Cardiobacterium hominis
- Eikenella corrodens
- Kingella kingae
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What is the theory behind antimicrobial therapy for IE?
- supportive care
- IV ONLY!! (never switch to PO)
- cidal agents only
- consider short-term use of Gentamicin and/or Rifampin for synergy
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What is the empiric therapy for IE?
- Vancomycin + Gentamicin +/- Rifampin
- (hold Gent if REALLY bad kidneys)
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What is the treatment for IE caused by streptococci highly susceptible to PCN?
- Pen G x 4wks
- Ceftriaxone x 4wks
- Pen G + SDD Gentamicin x 2wks
- Ceftriaxone + SDD Gentamicin x 2wks
- Vancomycin x 4wks
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What is the treatment for IE caused by streptococci relatively PCN resistant?
- High dose Pen G x 4wks + SDD Gentamicin x 2wks
- Ceftriaxone x 4wks + SDD Gentamicin x 2wks
- Vancomycin x 4wks
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What is the treatment for IE caused by Methicillin-susceptible staphyloccoci?
- Nafcillin x 6wks +/- Gentamicin x 3-5d
- Oxacillin x 6wks +/- Gentamicin x 3-5d
- Cefazolin x 6wks +/- Gentamicin x 3-5d
- Vancomycin x 6wks
- FOR UNCOMPLICATED RIGHT-SIDED IE, 2wk therapy is acceptable
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What is the treatment for IE caused by Methicillin-resistant staphylococci?
Vancomycin x 6wks
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What is the treatment for IE caused by HACEK?
- Ceftriaxone x 4wks
- Ampicillin sulbactam x 4wks
- Ciprofloxacin x 4wks
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What should be used to treat IE if Vancomycin is not working?
Daptomycin
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When is surgery required for IE?
- when patients require or have valve repair/replacement
- HF
- Pathogens that do not respond to treatment (P. aeruginosa, Brucella, Coxiella burnetii, fungal endocarditis, Enterococci
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When is prophylaxis recommended for IE?
- Prior to dental work in pts who have had:
- Prosthetic valve
- Previous IE
- CHD
- Cardiac transplant who develop cardiac valvulopathy
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What is the IE prophylaxis for dental procedures?
- Oral:
- Amoxicillin 2g PO (DOC)
- Unable to take oral meds:
- Ampicillin IM or IV
- Cefazolin IM or IV
- Ceftriaxone IM or IV
- Allergic to pen or ampicillin oral:
- Cephalexin
- Clindamycin
- Azithromycin
- Clarithromycin
- Allergic to pen or ampicillin and unable to take oral meds:
- Cefazolin IM or IV
- Ceftriaxone IM or IV
- Clindamycin IM or IV
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