PCT exam 2 endocarditis

what is infective endocarditis

infection of the endocardium and heart valves

IV drug use-associated endocarditis is usually

right sided

1 multiple choice option

________ and _______ account for 80% of endocarditis

1. staph

2. strep

The main organism that causes endocarditis is

Staph aureus

What organisms are part of the HACEK group that can cause endocarditis

1. haemophilus

2. aggregatibacter

3. cardiobacterium

4. eikenella

5. kingella

What are the two pathogenesis pathways for endocarditis

1. platelet-fibrin deposition in the valvular endothelium resulting in non-bacterial thrombotic endocarditis and then adherence of bacteria

2. trauma to the mucous membranes or colonized tissue leads to bacteremia and then adherence

The final pathway of the pathogenesis of endocarditis flows how

adherence -> colonization -> mature vegetation

Acute infective endocarditis characteristics

1. highly virulent organisms

2. rapid damage to cardiac structures

3. death in days to weeks if untreated

Subacute infective endocarditis characteristics

1. less invasive organisms with lower virulence

2. damage is slow and gradual

3. occurs in those with pre-existing valvular heart disease

What are some of the clinical presentations of endocarditis

1. splinter hemorrhages

2. osler nodes

3. janeway lesions

4. roth spots

5. vascular embolic event

How does acute endocarditis present

1. hypotension

2. leukocytosis

3. septic picture

Subacute endocarditis may present how

1. fever

2. malaise

3. murmurs

4. myalgias

5. left upper quadrant pain

What neurological symptoms point to endocarditis

stroke like symptoms

Septic emboli from right sided endocarditis will most likely end up in which organ

lungs

Septic emboli from left sided endocarditis will most likely end up in which organ

brain

Which echo type is less invasive but may not give as clear of a picture

TTE

1 multiple choice option

Which echo may have greater sensitivity than the other type for IE with S. aureus

TEE

1 multiple choice option

What are the recommendations for blood tests when endocarditis is suspected

three or more blood cultures from different sites with at least 1 hour between draws

When a patient is getting better, how should blood samples be taken

2 or more samples at 24-48 hour intervals until cultures become negative

HACEK endocarditis may be ___________ in culture because it is _________

negative, slow growing

What are the major criteria of the Duke criteria

1. blood cultures possible for infective endocarditis

2. evidence of endocardial involvement

What are the minor criteria for the Duke criteria

1. predisposing factor

2. temperature over 38 C

3. vascular phenomena

4. immunologic phenomena

5. microbiologic evidence

In the duke criteria, what defines a definite diagnosis

1. two major criteria

2. one major and three minor criteria

3. fiver minor criteria

In duke criteria, what defines a possible diagnosis

1. one major and one minor criteria

2. three minor criteria

What is the greatest negative impact on short term prognosis in endocarditis

heart failure

________ sided endocarditis caused by _________ has increased mortality

left, S. aureus

What are the indications for surgery in endocarditis

1. prosthetic valve IE caused by resistant organism

2. persistent vegetation despite prolonged antibiotic treatment

3. valve dysfunction

4. abscess

What is the inoculum effect

antimicrobial activity is less active against highly dense bacterial populations

Which antibiotics are less affected by inoculum

1. fluoroquinolones

2. aminoglycosides

__________ is needed to sterilize vegetation with high bacterial densities and can be enhanced by _________

cidality, combining antimicrobials

vegetations contain many...

layers of fibrin and platelets

test for ________ with aminoglycosides in order to know if adding them is indicated

synergy

A patient who has an extensive IV drug use history was admitted with suspected endocarditis. What is the most likely etiology

staph aureus

3 multiple choice options

viridans group strep is

usually subacute and responds well to treatment

Highly susceptible to penicillin strep native valve endocarditis can be treated with

1. penicillin G

2. ceftriaxone

3. penicillin G plus gentamicin

4. ceftriaxone plus gentamicin

5. vancomycin

When would you use vanc for a patient with penicillin susceptible strep native valve endocarditis

for a patient who does not tolerate penicillin or ceftriaxone

adding gentamicin to penicillin and ceftriaxone to treat native valve penicillin sensitive strep endocarditis is not for patients with

1. abscesses

2. CrCl < 20 ml/min

when treating a patient with penicillin or ceftriaxone alone for native valve penicillin sensitive strep endocarditis, therapy should last _____. Adding gentamicin makes the treatment length _______

4 weeks, 2 weeks

It is reasonable to treat native valve endocarditis caused by penicillin resistant strains of strep with

penicillin G for 4 weeks plus gentamicin for 2 weeks

What are the reasonable alternatives to penicillin G in combo with gentamicin to treat native valve endocarditis caused by penicillin resistant strains of strep

1. ampicillin

2. ceftriaxone

A patient with a prosthetic valve strep endocarditis can be treated with

1. penicillin G for 6 weeks

2. ceftriaxone for 6 weeks

3. penicillin G for 6 weeks + gentamicin for 2 weeks

4. ceftriaxone for 6 weeks + gentamicin for 2 weeks

5. vancomycin for 4 weeks

What are the treatment options for penicillin resistant strep endocarditis with a prosthetic valve

1. penicillin G + gentamicin for 6 weeks

2. ceftriaxone + gentamicin for 6 weeks

3. vancomycin

Enterococcus endocarditis needs to be treated with

cell wall active agent + aminoglycosides

What therapy is used to treat enterococcus endocarditis with a native or prosthetic valve when the patient has a CrCl < 50ml/min

ampicillin plus ceftriaxone

What are the treatment options for enterococcus endocarditis resistant to penicillin, aminoglycosides, and vanc

1. linezolid for longer than 6 weeks

2. daptomycin for longer than 6 weeks

MSSA native valve endocarditis can be treated with

1. nafcillin or oxacillin for 6 weeks

2. cefazolin for 6 weeks

3. vancomycin for 6 weeks

MRSA native valve endocarditis can be treated with

1. vancomycin for 6 weeks

2. daptomycin for 6 weeks

MSSA prosthetic valve endocarditis can be treated with

nafcillin plus rifampin plus gentamicin for over 6 weeks

MRSA prosthetic valve endocarditis can be treated with

vancomycin plus rifampin for over 6 plus gentamicin for 2 weeks

How would you treat HACEK endocarditis with a native or prosthetic valve

1. ceftriaxone

2. ampicillin

3. ciprofloxacin

4. if native valve treat for 4 weeks

5. if prosthetic valve treat for 6 weeks

IE prophylaxis is recommended for patients who

have a prosthetic valve and are undergoing a dental procedure

A 60 year old male with a prosthetic mitral valve is scheduled for a tooth extraction next week. Which regimen would you recommend to the physician

amoxicillin 2 grams PO, 1 hour before surgery

3 multiple choice options