Medical School – Infective Endocarditis

IE transcript Hey this is Dr K from imedicalschool. Today
we are going to talk about infective endocarditis. Just to highlight the important points anytime
you see this light bulb in this presentation it means the material is highly tested and
in the words of one of my medical school professors know that! Lets start off as usual by asking what is
infective endocarditis? Well Infective endocarditis is a microbial infection of the heart endocardium. The heart consists of three layers of tissue.
The outer most layer is the epicardium then the myocardium and finally the innermost layer
is the endocardium. The endocardium tissue covers all structures within the heart including
the valves and the chordae tendinae. Just as a refresher the valves are like parachutes
that regulate the movement of blood through the chambers of the heart while the chordate
tendinae are the cords that hold the parachute or valves open. Now that we know what infective endocarditis
is we need to understand what are the risk factors for IE. Risk factors for IE include
poor dental hygiene , intravenous drug abuse , hemodialysis , long term indeed long catheters
, diabetes mellitus, and prosthetic valves. If a patient has these risk factors and in
the appropriate clinical setting you should consider IE. Endocarditis can be caused by many different
organisms and we will focus on the most common causes of IE. Staphylococcus aureus is the
most common cause of IE. This is the reason if you have a gram positive bacteremia with
cultures that are not clearing or take a while to clear it is important to rule out infective
endocarditis as this would affect the patients duration of iv antibiotics. Coagulase negative staphylococcus IE commonly
occurs in the first few months after prosthetic valve placement. Specifically staph lugdunensis
has been known to cause significant valvular dysfunction frequently requiring valve replacement
surgery. Strep can also cause IE. Strep mutants and
sanguis have been shown to cause IE. When strep bovis causes IE it is usually seen in
the elderly and is associated with colonic lesions so these patients need a colonoscopy
in addition to treatment of their IE. HÁČEK group of organisms has also been known
to cause IE. This group consists of harmophillus, actinobacillus, cardiobacterium hominiw, eikenella,
and kingella. Other organisms that can cause IE are enterococcus,
fungi, and Coxiella burnetti. IE carries with it a significant risk for
morbidity and mortality especially if not properly recognized and treated. There are
a few clinical signs and symptoms that you should be aware of. These include fever, weight loss, fatigue,
heart failure, night sweats, heart murmur, splenomegaly, skin petechiae, conjunctival
hemorrhages, septic shock, osler nodes, splinter hemorrhages , janeway lesions. Osler nodes are painful swollen violaceous
nodules on the fleshy part of the fingers and toes. Splinter hemorrhages appear as streaks in
the nail red that appear maroon and turn black. They are due to emboli. Janeway lesions are non tender nodules in
the palms and soles. Unfortunately IE can have significant complications.
One of these complications includes Paravalvular abscess due to IE can lead to heart block
and valvular dysfunction. In addition with left sided IE there is a
very real possibility of stroke. In patients with stroke symptoms, persistent fevers, and
a heart murmur IE should be considered. Since we reviewed the common organisms that
cause IE and the clinical indicators for IE how do we diagnose IE. Well like any disease we start off with our
clinical suspicion but years of treating IE have resulted in the modified Duke’s. The modified dukes criteria include major
and minor criteria. To make a diagnosis of IE you new 2 major criteria , one major and
three Minor, or 5 minor criteria. Lets review these criteria. There are three major criteria. The first
is laboratory evidence of IE. If two blood cultures grow organisms known to cause IE
or If one blood culture is positive for Coxiella burnetti that would meet the requirement for
laboratory evidence o IE. Second major criteria is evidence of endocardium
involvement . If it is an uncomplicated case with no prosthetic valve present proceed with
a TTE. In patients who have a complicated course consistent with IE, a prosthetic valve,
or high clinical suspicion proceed
to TEE. Finally the last major criteria is new valvular regurgitation murmur. The minor criteria includes if the patient
had a prediaposing heart condition, like a untreated congenital heart defect or IVDA,
fever, or Vascular phenomenon. vascular phemoneon include septic pulmonary
infarcts, mycotic aneurysms, conjunctival hemorrhages, janeway lesions, And intracranial
hemorrhage. Mycotic aneurysms form due to full thickness
infection and formation of a vascular aneurysm of the vasculature. Immunologic phenomenon leads to glomeruli
euphoria, osler’s nodes, Roth spots, and rheumatoid factor. Finally the last minor criteria is a single
blood culture positive for an organism typical for IE or multiple cultures taken within a
short time period . Lets talk about treatment. All treatment for
IE is based on culture susceptibilities. Generally duration of therapy ranges from 2 to 6 weeks
depending on the organism and severity of IE. For gram positive organisms we must know
of the organism is susceptible to penicillins then we can use nafcillin, methicillin, penicillin,
or ampicillin plus aminoglygosides like gentamicin. If MRSA then use vancomycin plus gentamicin.
The combination of a penicillin or vancomycin with an aminoglygosides creates a synergistic
effect improving clearance of the IE. Anti coagulation has shown to increase Morbidity
and mortality in IE as there is high risk of bleeding and has not been shown to decrease
embolus events. I hope you enjoyed this video. If you did
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will see you next time.

22 thoughts on “Medical School – Infective Endocarditis

  1. Last sumer I had staph aureus IE it was the worst thing that ever happened to me and I am still suffering from it now

  2. i had IE was in great pain thought i was on my way out spent 2 months in 2 hospitals and thankfully the infection cleared up, but now i need to have my VSD closed with a 1% chance i will die on the table and less than 1% chance i will have a stroke, this scares me because i could (80%) live a full and happy infection free life without the surgery, i spoke to my surgeon about this and he thinks i really should have it, this all really sucks because i feel great.any words of comfort? IE BLOWS

  3. This was extremely informative and very interesting to watch. Thank you for taking the time to make this video! I feel like I understand IE a lot better now!

  4. I don't know that there are ECG changes associated with Endocarditis. Myocarditis, on the other hand, will exhibit changes in ST, T wave or even QRS complexes.

  5. Hi, my husband is 26 yrs. old and just had IE, which was caused by a strep bacteria, and he had open heart surgery to replace his aortic valve back in October 2014. His symptoms started after I cleaned his teeth (i'm in dental hygiene school) and he hadn't had a dental cleaning in 5-6 years. Little did we know that he had a congenital defect in his valve (his mom didn't even know). Anyways, fast forward to almost February and after never missing a single dose of IV antibiotics, doctors at a very well-known hospital in Atlanta cannot get rid of this infection. Then he ended up getting a nosocomial infection in his blood as well from the picc line. They take blood cultures almost everyday and are growing nothing in the cultures anymore, however he is STILL getting fevers of 103.7. I trust these doctors very well but the doctor told me he doesn't even know why there'd be no positive culture no but still high fevers. Have you ever heard of anything like this? 

  6. My husband had IE caused by strep. he refused to go to the doctor for weeks. he worked everyday. he almost died. he now has mesh in his ventricle and a pig valve(aortic) after open heart surgery. I would love to see a video on aftercare and protecting your gut from the super antiobiotics they give you during and after. i think he'd agree when I say it's the worst part of living your life after something of this.

  7. I had IE in 1988. I was 14 years old and got it from cutting my ankle while shaving my legs. The one thing no one mentions was vomiting. I couldn't keep anything down. I had no Janeway lesions or any other lesions. Just throwing up and a very high fever. This scares me as all the regular symptoms are what I didn't have. I have a very small VSD and also a small aortic murmur. Six weeks in the hospital and my Drs. told my parents I was as close to being dead as you can get with out actually being there. This scares me.

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