Infective endocarditis CD.txt

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Author:
kavinashah
ID:
71087
Filename:
Infective endocarditis CD.txt
Updated:
2011-03-06 17:15:31
Tags:
IE CD
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Description:
IE CD
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  1. 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
  2. what are symptoms of IE?
    • if acute: high fever, rigor, embolic eg weakness due to stroke
    • indolent: malaise, fatigue, low grade persistent fever
  3. what are signs of IE?
    • vascular: mycotic aneurysm or stroke (embolus)
    • immune: haematuria, oslers, janeway, roth, splinter,
    • fever
    • anaemia
    • spleen enlarged
  4. 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
  5. 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
  6. 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
  7. how do you diagnose IE?
    • dukes criteria
    • 2 major or
    • 1 major + 3 minor or
    • 5 minor
  8. which valve is mostly affected in IE and what is exception?
    • mitral valve
    • ivdu tricuspid as inject in veins - R side heart
  9. which organisms cause acute IE?
    • staph aureus
    • ivdu (tricuspid valve)
  10. which organisms cause indolent presentation of IE? name
    • viridans strep
    • s. mutans, mitis, sanguis
  11. which organisms cause prosthetic valve IE?
    • CNS
    • staph epidermis (skin commensal)
  12. what gram stain is HACEK?
    Gram -ve
  13. name 3 culture negative organisms causing IE and 1 other cause of culture -ve
    • coxiella burnetti
    • chlamydia psittaci/trachomatis
    • brucella
    • previous anti-microbial therapy
  14. what are LOCAL complications of IE?
    • heart failure
    • conduction defect
    • pericarditis
  15. what are SYSTEMIC complications of IE?
    • spleen
    • kidney - GN
    • liver
    • vessels: mycotic aneurysm eg cerebral aneurysm
    • CNS: stroke due to embolus
  16. what does empirical Rx for IE depend on?
    presentation
  17. what is empirical Rx of IE for acute presentation?
    • flucloxacillin 2g 4-6hourly iv
    • and
    • gentamicin 1mg/kg tds iv
  18. 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
  19. what is empirical Rx of IE for penicillin allergy?
    • vancomycin 1g bd iv
    • and rifampicin 300-600mg bd PO
    • gentamicin 1mg/kg tds iv
  20. 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
  21. what is empirical Rx of IE for MRSA?
    • vancomycin 1g bd iv
    • and rifampicin 300-600mg bd PO
    • gentamicin 1mg/kg tds iv
  22. what is Rx for MSSA IE and duration
    • flucloxacillin 2g 4-6hourly iv
    • 4 weeks
  23. 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
  24. 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
  25. what does strep IE depend on?
    MIC
  26. 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
  27. 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
  28. how do you treat enterococi IE? and if pen resistance?
    • amoxicllin
    • if pen res give vancomycin
    • and
    • gentamicin
    • 4 weeks
  29. how treat HACEK IE?
    ceftriaxone
  30. what are 2 main SE of gentamicin
    • ototoxicity
    • nephrotoxicity
  31. 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
  32. what monitoring do you have to do with vancomycin?
    • nephrotoxic
    • measure levels
    • TROUGH: 10-15mg/L
  33. what are indications for surgery in IE?
    • heart failure
    • perivalvular invasive disease
    • uncontrolled infection despite max abx - pseudomonas, brucella, candida, coxiella
    • prosthetic valve
  34. 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%
  35. what is overall mortality in IE?
    20-25%
  36. what is cause of mortality in IE?
    • CNS embolic events
    • haemodynamic events
  37. what is difference in mortally in R sided IE in IVDU?
    10% mortality
  38. which patients may benefit from 6 months treatment?
    if had symptoms for more than 3 months

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