Infective Endocarditis And Rheumatic Fever

Front 1

Modified Duke Criteria for Infective Endocarditis

Back 1

Definite infective endocarditis
Pathological criteria
- Microorganisms demonstrated by culture or histological examination of vegetation/abscess; or
- Pathological lesions showing active endocarditis

Clinical criteria
2 major criteria; or
1 major criterion and 3 minor criteria; or
5 minor criteria

Possible IE
1 major criterion and 1 minor criterion; or
3 minor criteria

Rejected
- Firm alternative diagnosis of IE
Resolution of IE syndrome with antibiotic therapy for 4 days
- No pathological evidence of IE at surgery or autopsy, with antibiotic therapy for 4 days; or
- Does not meet criteria for possible IE

Front 2

Major Criteria for Infective Endocarditis

Back 2

(1) Positive blood cultures (of typical pathogens) from at least two separate cultures

*Only 1 culture if coxiella

(2) Evidence of endocardial involvement by echocardiography, such as the following:
• Endocardial vegetation
• Paravalvular abscess
• New partial dehiscence of prosthetic valve
• New valvular regurgitation

Front 3

Typical Microorganisms for positive blood cultures in infective endocarditis

Back 3

Viridans streptococci

Streptococcus bovis

HACEK group,
Staphylococcus aureus

community-acquired enterococci in the absence of a primary focus

Front 4

HACEK organsisms

Back 4

Haemophilus aphrophilus

Actinobacillus actinomycetemcomitans,
Cardiobacterium hominis

Eikenella corrodens

Kingella kingae

Front 5

Minor Criteria for Infective Endocarditis

Back 5

(1) Predisposition: Predisposing heart condition or intravenous drug use

(2) Fever: Temperature >38° C

(3) Vascular phenomena: Arterial emboli, septic pulmonary infarcts, mycotic aneurysm, conjunctival hemorrhages, or Janeway lesions

(4) Immunologic phenomena: Osler’s nodes, Roth’s spots, and rheumatoid factor

(5) Microbiologic evidence: Single positive blood culture (except for coagulase-negative Staphylococcus or an organism that does not cause endocarditis)

Front 6

Other potential signs in infective endocarditis

Back 6

elevated ESR/CRP

newly diagnosed clubbing

splenomegaly

microscopic hematuria

Front 7

Indications for surgical intervention with endocarditis

Back 7

Infective endocarditis with acute heart failure
Fungal endocarditis
Periannular extension of infection
Recurrent emboli
Large mobile vegetations
Persistent bacteremia

Front 8

High risk echocardiographic features in w/u of endocarditis

Back 8

large and/or mobile vegetations

valvular insufficiency
perivalvular extension,
secondary ventricular dysfunction

Front 9

Intial Empiric Abx for Endocarditis

Back 9

Native Valve
Penicillin G 4 million units IV q4h + nafcillin 2 g IV q4h
Or
Vancomycin 15 mg/kg IV q12h
Plus
Gentamicin 1 mg/kg IV q8h

Native Valve (+ Injection Drug Use)
Vancomycin 15 mg/kg IV q12h

Prosthetic Valve
Vancomycin 15 mg/kg IV q12h
Plus
Gentamicin 1 mg/kg IV q8h

Front 10

High Risk Conditions for Bacterial Endocarditis

Back 10

- Prosthetic heart valve

- History of endocarditis

- Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits

- Completely repaired congenital heart defects with prosthesis during the first 6 months after the procedure

- Repaired congenital heart disease with residual defect at or adjacent to the site of the prosthetic device

- Cardiac valvulopathy in a transplanted heart

Front 11

Complications of Endocarditis

Back 11

CHF

AV block

Paravalular abscess

CVA

Metastatic abscess

Renal complications

Systemic Emboli

Front 12

Jones Criteria for Rheumatic Fever

Back 12

Major Manifestations
Carditis
Polyarthritis
Chorea
Erythema marginatum
Subcutaneous nodules

Minor Manifestations
Arthralgias
Fever
Increased ESR/CRP
Prolonged PR interval

Evidence of Preceding Streptococcal Infection
- Positive throat culture for group A beta-hemolytic streptococci
- positive rapid streptococcal antigen test
Elevated or rising streptococcal antibody titer

Front 13

Diagnosis of Rheumatic Fever by Jones criteria

Back 13

Evidence of antecedent streptococcal infection +:

- 2 major criteria

- 1 major & 2 minor

Front 14

Potential presentations of bacterial endocarditis in children with underlying congenital cardiac defect

Back 14

Fever without another source
New murmur or change in pre–existing murmur
New neuro deficit
New onset microscopic hematruria
Splenomegaly
Petechiae
Splinter hemorrhages
Myalgias

Front 15

Cardiac lesions with high velocity/turbulent flow that are relatively higher risk for bacterial endocarditis

Back 15

VSD
Tetrology of fallot
Aortic valvular stenosis
Single ventricles
Prosthetic valves
Postoperative systemic to pulmonary shunts

Front 16

Valsalva and HOCM

Back 16

Reduced venous return –> Decreased left ventricle size –> Increased outflow obstruction –> Augmeneted murmur

Front 17

Conditions for which antibiotic prophylaxis against IE is indicated

Back 17

Prosthetic cardiac valve/repair
Previous history of IE
Unrepaired cyanotic CHD including palliative shunts/conduits
Completely repaired CHD with prosthetic material during the 1st 6 months post procedure
Repaired CHD with residual defect in near prosthetic device
Transplant recipients with valvulopathy

Front 18

Conditions for which antibiotic prophylaxis against IE are NOT INDICATED

Back 18

ASD
VSD
PDA
MVP
Hx Kawasaki
Hypertrophic CM
CABG
Pacemaker/ICDs
Bicuspid aorta
Coarctation
Calcified AS
PS

Front 19

Antibiotics for IE prophylaxis

Back 19

1st line: Amoxicillin

Alternatives: Cefazolin, clindamycin

Front 20

Procedures for which antibiotic prophylaxis against IE is indicated

Back 20

Dental procedures involving manipulation of gingiva, periapical tooth, or perforation of oral mucosa

Incision/biopsy of respiratory mucosa

GI/GU tract procedure that otherwise requires prophylaxis or colonization/infection with enterococcus known

Procedure on infected skin/MSK tissue