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what 2 things do you need for IE to occur?
- trauma or turbulent flow at heart valve - plt/fibrin deposition
- bacteraemia - adhere and make veg
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what are symptoms of IE?
- if acute: high fever, rigor, embolic eg weakness due to stroke
- indolent: malaise, fatigue, low grade persistent fever
-
what are signs of IE?
- vascular: mycotic aneurysm or stroke (embolus)
- immune: haematuria, oslers, janeway, roth, splinter,
- fever
- anaemia
- spleen enlarged
-
what is the main Ix needed?
- 3 sets of blood cultures in first 24 hours
- from separate venepunctures
- incubate for at least 3 weeks, tell lab
-
name the major criteria in dukes
- 1. evidence of infection: => 2 +blood cultures or serology for coxiella burnetti
- 2. evidence of endocardial involvement: new murmur or echo see veg
-
name 5 minor criteria groups in dukes
- 1. predisposing factors: IVDU, prosthetic valve, previous IE, valvular damage
- 2. vascular phenomena: embolus or mycotic aneurysm
- 3. immune/vacsulitis: osler, roth, GN, Rh F
- 4. fever
- 5. single positive blood culture or serology showing active infection
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how do you diagnose IE?
- dukes criteria
- 2 major or
- 1 major + 3 minor or
- 5 minor
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which valve is mostly affected in IE and what is exception?
- mitral valve
- ivdu tricuspid as inject in veins - R side heart
-
which organisms cause acute IE?
- staph aureus
- ivdu (tricuspid valve)
-
which organisms cause indolent presentation of IE? name
- viridans strep
- s. mutans, mitis, sanguis
-
which organisms cause prosthetic valve IE?
- CNS
- staph epidermis (skin commensal)
-
what gram stain is HACEK?
Gram -ve
-
name 3 culture negative organisms causing IE and 1 other cause of culture -ve
- coxiella burnetti
- chlamydia psittaci/trachomatis
- brucella
- previous anti-microbial therapy
-
what are LOCAL complications of IE?
- heart failure
- conduction defect
- pericarditis
-
what are SYSTEMIC complications of IE?
- spleen
- kidney - GN
- liver
- vessels: mycotic aneurysm eg cerebral aneurysm
- CNS: stroke due to embolus
-
what does empirical Rx for IE depend on?
presentation
-
what is empirical Rx of IE for acute presentation?
- flucloxacillin 2g 4-6hourly iv
- and
- gentamicin 1mg/kg tds iv
-
what is empirical Rx of IE for indolent presentation?
- penicillin 1.2g 4hrly iv or amoxicillin 2g 6hrly iv (will cover enterococcus)
- and
- gentamicin 1mg/kg tds iv
-
what is empirical Rx of IE for penicillin allergy?
- vancomycin 1g bd iv
- and rifampicin 300-600mg bd PO
- gentamicin 1mg/kg tds iv
-
what is empirical Rx of IE for intra cardiac prosthesis?
- vancomycin 1g bd iv
- and rifampicin 300-600mg bd PO
- gentamicin 1mg/kg tds iv
-
what is empirical Rx of IE for MRSA?
- vancomycin 1g bd iv
- and rifampicin 300-600mg bd PO
- gentamicin 1mg/kg tds iv
-
what is Rx for MSSA IE and duration
- flucloxacillin 2g 4-6hourly iv
- 4 weeks
-
what is Rx for MRSA or pen allergy IE and duration?
- vancomycin 1g bd iv and
- rifampicin 300-600mg bd / gentamicin 1mg/kg tds / sodium fusidate 500mg tds PO
- 4 weeks
-
what is Rx for intracardiac prosthesis IE and duration? think about biofilms!!
- same as MRSA but can use fluclox or vanc
- need 6 weeks at least
-
what does strep IE depend on?
MIC
-
if MIC <0.1 and no abscess or extra cardiac focus then how treat strep IE? and duration
- penicillin 1.2g 4hourly iv
- and gentamicin 1mg/kg tds
- 2 weeks
-
if MIC 0.1-0.5 how treat strep IE?
- penicillin 1.2g 4hourly iv
- and gentamicin 1mg/kg tds
- 2 weeks
- and further 2 weeks of penicillin 1.2g 4hrly iv
- so in total 4 week Rx
- OR: 4 weeks of penicillin 2.4g 4hrly for 4 weeks
-
how do you treat enterococi IE? and if pen resistance?
- amoxicllin
- if pen res give vancomycin
- and
- gentamicin
- 4 weeks
-
how treat HACEK IE?
ceftriaxone
-
what are 2 main SE of gentamicin
- ototoxicity
- nephrotoxicity
-
how do you monitor someone on gentamicin think of 2 main aspects
- monitor renal function
- monitor gentamicin levels - start with 3rd dose
- TROUGH: just before dose - keep < 1mg/L
- PEAK: 1 hr after dose - keep 3-5mg/L
- measure twice weekly if stable
-
what monitoring do you have to do with vancomycin?
- nephrotoxic
- measure levels
- TROUGH: 10-15mg/L
-
what are indications for surgery in IE?
- heart failure
- perivalvular invasive disease
- uncontrolled infection despite max abx - pseudomonas, brucella, candida, coxiella
- prosthetic valve
-
rank order of mortality: staph, G-ve rods, strep, candida from best to worst and give average%
- strep 4-16%
- staph 25-47%
- G-ve rod and candida > 50%
-
what is overall mortality in IE?
20-25%
-
what is cause of mortality in IE?
- CNS embolic events
- haemodynamic events
-
what is difference in mortally in R sided IE in IVDU?
10% mortality
-
which patients may benefit from 6 months treatment?
if had symptoms for more than 3 months
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