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REVISION HEM&CVS

Dr. Mohammad Saad Abdul-Majid

LECTURE

Bacteremia, sepsis, and


related disorders

1 Dental treatment.
2 Endoscopic procedures
3 Urinary tract infections.
4 Bowel infections.

Bacteremia + SIRS

Bacteremia
Sepsis

Sepsis+CVS
dysfunction and/or
ARDS

Severe sepsis

sepsis+hypotension
despite adequate fluid
resuscitation

Septic Shock

vary from a mild


degree to completely
irreversible organ
failure

Transient (resolve
spontaneously)

MODS

Severity

Bacteremia+ Endotoxins

Pathogenesis
Monocyte/Macrophage

Alpha-TNF, interleukins, chemokines

Sepsis/ severe sepsis

Endothelial cells release nitric oxide

septic shock
MODS

Treatment
Bacteremia
Penicillin or Amoxicillin

Bacteremia + SIRS
IV Penicillin + Gentamycin
Or
IV Ceftriaxone

Sepsis
Severe sepsis

IV fluid
Noradrenaline
Oxygen supply

Septic Shock
MODS

Severity

Bacteremia
Bacteremia: GBS is the most common cause in

neonates and infants.

Sources of bacteremia:
Follows the distribution of normal flora.

SIRS
NOT only 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.

MODS
Primary MODS:

Due to direct insult.


Secondary MODS:
Due to SIRS.

Lack of functioning spleen:


Risk of:
pneumococcal infections
meningococcal infections
H. influenzae type B infection

Fungemia
It is most commonly seen in:

1. Immunocompromised patients
HIV positive individual : Penicillium marneffei fungemia is
one of the AIDS-defining illness.

2. Patients with intravenous catheters


Corynebacterium jeikeium and Candida sp. (colonize the tip
of the catheter)

Viremia
Primary: refers to the initial spread of virus in the

blood from the first site of infection.


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

Replicate ---- Secondary viremia.


Secondary viremia results in:
1.
2.

Higher viral shedding.


Higher viral loads within the bloodstream

LECTURE

INFECTIVE ENDOCARDITIS

Congenital heart defects

Early Prosthetic
valves (60 Days)

Late Prosthetic
valves

Direct intraoperative
contamination

Endothelialization of
the sutures
(attachment sites for
bacteria)

Staphylococcus
epidermidis

Rheumatic heart disease

High-pressure
gradients and
turbulent flow

IVDU

Drug particles
bombardment

Platelets + Fibrin = Primary sterile


Vegetation

Staphylococcus aureus

Bacterial vegetation

INFECTIVE ENDOCARDITIS
The mitral valve is most commonly affected.
IVDU= Right sided IE (Tricuspid valve)
Staphylococcus aureus can infect normal/abnormal

heart valves.
Streptococci and enterococci infect previously abnormal

valves.
Prophylaxis for oral procedures is directed mainly against
streptococcus sp.

Negative cultures:
Prior antibiotics.
2. HACEK group (Haemophilus, Actinobacillus,
Cardiobacterium, Eikenella, and Kingella),
3. Bartonella species.
4. Coxiella burnetii.
1.

Clinical features
Staphylococcus is usually associated with acute

IE.
Streptococcus is usually associated with
subacute IE.
Fever + Murmur = Most common
Splinter hemorrhage
There is a history of invasive procedure or

abnormal heart valves or IVDU.


IVDU = High grade fever.

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.

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 burnetii: 1 positive culture is enough.
2. Echocardiography: Intracardiac vegetation.

Minor criteria
1. 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.

Definite infective endocarditis

Two major criteria


or
One major and three minor criteria
or
Five minor criteria

Treatment
4 weeks course of high dose antibiotics
Prosthetic valve IE:
Vancomycin + Gentamicin + Rifampicin
The rest of risk factors:
Vancomycin + Gentamicin

Genitourinary + Gastrointestinal (Excluding


Esophageal) Procedures

High risk:
Prosthetic valves
Previous IE
Cyanotic heart disease

Anything else

Amoxicillin or Ampicillin

Ampicillin + Gentamicin

Prophylaxis

THANK YOU

GOOD LUCK

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