Revision Hem&Cvs

8/10/2019 Revision Hem&Cvs

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Dr. Mohammad Saad Abdul-Majid

REVISION HEM&CVS


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LECTURE

Bacteremia, sepsis, andrelated disorders


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Bacteremia

Sepsis

Severe sepsis

Septic Shock

MODS

Severity

Bacteremia + SIRS

Sepsis+CVS

dysfunction and/or

ARDS

sepsis+hypotension

despite adequate fluidresuscitation

vary from a mild

degree to completely

irreversible organ

failure

1 Dental treatment.

2 Endoscopic procedures

3 Urinary tract infections.

4 Bowel infections.

Transient (resolvespontaneously)


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Bacteremia+ Endotoxins

Monocyte/Macrophage

Alpha-TNF, interleukins, chemokines

Sepsis/ severe sepsis

Endothelial cells release nitric oxide

septic shock

MODS

Pathogenesis


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Treatment

Bacteremia

Bacteremia + SIRS

Sepsis

Severe sepsis

Septic Shock

MODS

Severity

Penicillin or Amoxicillin

IV Penicillin + GentamycinOr

IV Ceftriaxone

IV fluid

Noradrenaline

Oxygen supply


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Bacteremia

Bacteremia: GBS is the most common cause inneonates and infants.

Sources of bacteremia:

Follows the distribution of normal flora.


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SIRS NOTonly caused by infection.

Criteria: 2 or more of the following:

Temp. (High/Low) ; Breathing (fast) ; WBC(high/low) ; Heart rate (fast/slow)

Pathogenesis:

Stage I: Production of local cytokines.

Stage II: Local cytokines released into circulation.

Stage III: Systemic reaction and tissue damage.


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MODS

Primary MODS:

Due to direct insult.

Secondary MODS: Due to SIRS.


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Lack of functioning spleen:

Risk of:

pneumococcal infections

meningococcal infections H. influenzae type B infection


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Fungemia

It is most commonly seen in:

1. Immunocompromised patients

HIV positive individual : Penicillium marneffei fungemia isone of the AIDS-defining illness.

2. Patients with intravenous catheters

Corynebacterium jeikeium and Candida sp. (colonize the tipof the catheter)


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Viremia

Primary: refers to the initial spread of virus in theblood from the first site of infection.

Secondary: Primary viremia ---- Target organs ---

Replicate ---- Secondary viremia.

Secondary viremia results in:

1. Higher viral shedding.2. Higher viral loads within the bloodstream


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LECTURE

INFECTIVE ENDOCARDITIS


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Congenital heart defects

Rheumatic heart diseaseIVDU

Early Prosthetic

valves (60 Days)

Late Prosthetic

valves

High-pressure

gradients and

turbulent flow

Direct intraoperative

contamination

Endothelialization of

the sutures

(attachment sites for

bacteria)

Staphylococcus

epidermidis

Staphylococcus aureus

Drug particles

bombardment

Platelets + Fibrin = Primary sterile

Vegetation

Bacterial vegetation


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INFECTIVE ENDOCARDITIS The mitral valve is most commonly affected.

IVDU= Right sided IE (Tricuspid valve)

Staphylococcus aureuscan infect normal/abnormalheart valves.

Streptococciand enterococciinfect previously abnormalvalves.

Prophylaxis for oral procedures is directed mainly againststreptococcus sp.


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Negative cultures:

1. Prior antibiotics.

2. HACEK group (Haemophilus,Actinobacillus,

Cardiobacterium,Eikenella, andKingella),

3. Bartonel laspecies.

4. Cox iel la bu rnet i i.


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Clinical features Staphylococcusis usually associated with acute

IE.

Streptococcusis usually associated withsubacuteIE.

Fever + Murmur = Most common Splinter hemorrhage

There is a history of invasive procedure or

abnormal heart valves or IVDU.

IVDU = High grade fever.


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Cutaneous Findings

Osler nodes :

small, tender subcutaneous nodules on the pads

of the fingers or toes that last for only hours or

days.

Janeway lesions :

small hemorrhagic painless plaques on the palms

or soles.


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Duke criteria

Major criteria

1. Positive blood culture for IE

At least 2 positive cultures drawn >12 h apart.

OR

3 separate blood cultures (with first and last

drawn at least 1 h apart).

Coxiella burneti i : 1 posi t ive cul ture is enough .

2. Echocardiography: Intracardiac vegetation.


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Mino r cr i ter ia1. Underlying risk factor.

2. Fever: temperature >38C

3.Vascular phenomena: Janeway lesions

4. Immunologic phenomena: Osler nodes.

5. Microbiologic evidence: Not a common

microorganism for IE.


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Definite infective endocarditis

Two major criteria

orOne major and three minor criteria

or

Five minor criteria


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Treatment

4 weeks course of high dose antibiotics

Prosthetic valve IE:

Vancomycin + Gentamicin + Rifampicin

The rest of risk factors:

Vancomycin + Gentamicin


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Genitourinary + Gastrointestinal (Excluding

Esophageal) Procedures

High risk:Prosthetic valves

Previous IE

Cyanotic heart disease

Ampicillin + Gentamicin

Anything else

Amoxicillin or Ampicillin

Prophylaxis


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GOOD LUCK

THANK YOU

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Revision Hem&Cvs