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University Of Michigan Medical School
University Of Michigan Medical School
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What is pathogenesis of endocarditis?
turbulent blood flow produced by valvular lesions or high P gradients (VSDs) creates endothelial injury
platelets and fibrin accumulate which causes non-bacterial thrombotic endocarditis (NBTE)
Invasion of bloodstream with a microorg that can colonize NBTE
Difficult for host defenses to eradicate once established
What are clinical manifestations of endocarditis?
1. fever (profound or low-grade)
2. anorexia/weight loss
4. night sweats
5. new/worsened heart murmur**
7. peripheral finding (sin/mucosal)
8. back pain
What are typical lab findings in endocarditis?
1. positive blood cultures (more +, quicker)
2. leukocytosis, typically w/ L shift
4. elevated sed rate
5. abnormal U/A
What are EKG findings in endocarditis?
1. sinus tachycardia (related heart failure related to valve destruction
2. bradycardias related to myocardial extension of infections into conduction system
- usually heart block of some sort
3. new arrhythmias
What are cardiac consequences of endocarditis?
2. acute myocardial infarction
3. pericarditis, hemopericardium, tamponade
4. perivalvular abscess
5. various fistulas due to erosion from one area of heart to another
What are the embolic consequences of endocarditis?
-infarction of anything
-splenic infarction and/or abscess --> protracted fever, pain which can radiate to L shoulder, diaphragmatic irritation
-septic pulmonary embolism, pneumonia
-(tricuspid to lungs looks like pneumonia)
What are the neurologic consequences of endocarditis?
-20-40% have neuro effects
new stroke in setting of fever should make you think about endocarditis in young
-risk dec rapidly with initiation of abc
- mycotic aneurysms (out pouching of bv. in brain)
What are immunologic consequences of endocarditis?
2. interstitial nephritis (cause hematuria and renal failure)- also can be caused by emboli
What are skin/eye findings of endocarditis?
2. Osler nodes (painful, immunologic) swelling in distal fingers
3. Janeway lesions (painless, septal emboli) usually see on feet, dark
-- most common -- fingers, toes, splinters in nails
5. petechiae -- in eyes, conjunctiva
6. Roth spots (retina
What is acute bacterial endocarditis (ABE)?
- rapid (1-2 wk), acute, fulminant presentation
s. aureus or other G+
can occur in otherwise normal hearts (valves)
What is subacute bacterial endocarditis (SBE)?
-more insidious course (slower, difficult dx)
- less virulent organisms like
- "SBE prophy" things we do to prevent
What is NVE?
native valve endocarditis (NVE) - treated much different from artificial
What is PVE?
prosthetic valve endocarditis
-fungus not typical but can wee with prosthetic
-IV or drug use
What are usual G+ bugs in endocarditis?
-streptococci (S. viridans)
-s. aureus (coag + --> drug use)
-coat negative staph (most common in prosthetic valve endo)
What bugs are unusual in endocarditis?
-G- (e. coli)
-HACEK (haemophilus, actinobacilus, cardiobacterium, eikenella, kingenella)
-fungal infections (IV drug, peripheral line)
-Q fever (coxiella)
What is the diagnosis with Duke Criteria?
2 major criteria
1 major and 3 minor
what is the major duke criteria for endocarditis dx?
-+ blood cultures from 2 separate cultures with typical microorganisms
- new murmur
- "veggie" on echo,
- detachment (dehiscence) of a prosthetic valve
- myocardial abscess
What is the minor Duke criteria?
fever > 38C
vascular phenomenon (emboli)
-janeway, splinter hemor, stroke, splenic infarct
- oslers nodes, roth spots, glomerulonephritis, + RF
+ blood cultures not meeting major criteria
minor echo findings (valve thickening)
What is medical rx of endocarditis?
-high dose, parenteral antibiotics tailored to sensitivity of identified org
-protracted duration (4-6 weeks)
-drug resistance problem
When do you do surgical treatment of endocarditis?
-persistent bacteremia despite max abx
- severe valvular dysfunction leading to heart failure
-myocardial abscess -- heart block/fistula
-fungal endocarditis -- usually requires surgery
What causes protracted fever?
extension of infection beyond the valves -- myocardial abscess
focal metastatic infection
drug fever (allergic rxn)
What is SBE prophylaxis?
abc during times of possible bacteremia, dental procedures or surgical procedures on infected tissue or during surgical implantation
- now controversial: abx not being, bacteremia common, may not prevent
Who do we prophylax for SBE?
-prosthetic cardiac valves
-certain congenital heart defects
-yes for high flow (VSD),
NO for low flow (ASD)
- unrepaired cyanotic CHD or repaired w/ residual defects
-congenital defects repaired w/ prosthetic material (6 mos)
- cardiac transplant recipients w/ valve abnormalities (all)
What procedures to we prophylax for SBE?
-dental that involve manipulation of gingival tissue or perforation of oral mucosa
-URT procedures if involves incision of biopsy of mucosa
-GU or GI ONLY if infection present
- procedures of infected skin, skin structures, other tissues
How do we prophylax for SBE?
-Oral: amoxicillin 1 hr prior
-clindamycin, azithromycin, or cephalexin if penicillin allergic
What occurs in nonvalvular cardiovascular device-related infections? What bugs?
biofilm -- fibrinogen/platelets/WBCs, protected enviro for microorgs
skin bugs such as
(coag - staph)
What types of nonvalvular cardiovascular devices get infected?
-ventriculo-atrial shunts (hydrocephalus)
-conduits, patches, closure devices
- dialysis catheters, central lines
How do you treat nonvalvular cardiovascular device-related infections
remove device with protracted antibiotics after
-sometimes use suppressive abx if can't remove
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