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Endocarditis & rheumatic fever flashcards

14 high-yield MRCP Part 1 cards from the Intellect Medicos Cardiology course. Try to answer each question before you open it — then study them properly with spaced repetition, which brings each card back just before you would forget it.

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1. What is the commonest cause of infective endocarditis, and which valve is typical in people who inject drugs?

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   Staphylococcus aureus. In people who inject drugs, the tricuspid valve.

   Why? Injected organisms reach the right heart first, so right-sided (tricuspid) disease dominates in this group.

2. Which organism is the commonest cause of early prosthetic valve endocarditis (within 60 days of surgery)?

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   Staphylococcus epidermidis (coagulase-negative staphylococcus).

   Why? It colonises skin and forms biofilm on prosthetic material, so it is introduced at the time of surgery.

3. Endocarditis caused by Streptococcus gallolyticus (formerly S. bovis) should prompt which investigation?

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   Colonoscopy — it is associated with colorectal cancer.

   Why? The organism enters the bloodstream through abnormal colonic mucosa, so bacteraemia may be the first clue to an underlying tumour.

4. Name the HACEK organisms that cause culture-negative endocarditis.

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   Haemophilus, Aggregatibacter (formerly Actinobacillus), Cardiobacterium, Eikenella, Kingella.

   Why? These are slow-growing Gram-negative organisms that may not grow in standard cultures. Other culture-negative causes: prior antibiotics, Coxiella burnetii, Bartonella, Brucella.

5. Using the modified Duke criteria, what combination confirms definite infective endocarditis?

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   2 major criteria, OR 1 major + 3 minor, OR all 5 minor criteria.

   Why? Major criteria are positive blood cultures with a typical organism and evidence of endocardial involvement (for example a vegetation on echo).

6. What is the blind (initial) antibiotic therapy for native valve endocarditis when the patient is not penicillin-allergic and MRSA is not suspected?

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   Amoxicillin, considering adding low-dose gentamicin.

   Why? Most native valve endocarditis is streptococcal or enterococcal, which amoxicillin covers. Vancomycin with low-dose gentamicin is used if penicillin-allergic, MRSA is suspected or sepsis is severe.

7. Jones criteria for rheumatic fever: list the five major criteria.

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   Joints (migratory polyarthritis), carditis, subcutaneous nodules, erythema marginatum, Sydenham chorea.

   Why? Diagnosis needs evidence of recent group A streptococcal infection plus 2 major, or 1 major and 2 minor, criteria. Minor criteria: fever, arthralgia, raised ESR/CRP, prolonged PR interval.

8. What is the first-line treatment to eradicate streptococcal infection in acute rheumatic fever?

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   Benzathine benzylpenicillin IM (single dose); oral phenoxymethylpenicillin is an alternative, azithromycin if penicillin-allergic.

   Why? Eradicating group A streptococcus stops the antigenic stimulus. Arthritis is treated with aspirin or NSAIDs, and carditis with prednisolone.

9. What is the first-line investigation in suspected infective endocarditis, and how should it be done?

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   Blood cultures: three sets from separate venepuncture sites, taken before antibiotics.

   Why? Positive cultures with a typical organism are a major Duke criterion. Taking them before antibiotics avoids culture-negative endocarditis.

10. In suspected endocarditis, which echo is done first, and when is TOE needed?

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    Transthoracic echo first. TOE if TTE is negative but suspicion stays high, with a prosthetic valve or device, or to look for complications such as abscess.

    Why? TOE is more sensitive for small vegetations, prosthetic valve infection and perivalvular abscess.

11. What is the antibiotic of choice for native valve endocarditis caused by meticillin-sensitive staphylococci?

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    IV flucloxacillin.

    Why? If penicillin-allergic or MRSA: vancomycin + rifampicin. Staphylococcal prosthetic valve endocarditis: flucloxacillin + rifampicin + low-dose gentamicin.

12. What is the treatment for endocarditis caused by fully sensitive streptococci (e.g. viridans group)?

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    IV benzylpenicillin (vancomycin + low-dose gentamicin if penicillin-allergic).

    Why? Less sensitive streptococci are treated with benzylpenicillin plus low-dose gentamicin.

13. In infective endocarditis, a new prolonged PR interval on the ECG suggests which complication?

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    An aortic root (perivalvular) abscess extending into the conduction tissue.

    Why? Perivalvular extension is a poor prognostic sign and an indication for urgent surgery. TOE is the best echo to look for it.

14. Does NICE recommend routine antibiotic prophylaxis against endocarditis for dental procedures in people at risk?

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    No. It is not recommended routinely (NICE CG64).

    Why? Evidence of benefit is lacking and antibiotics carry risks such as anaphylaxis. People having a GI or genitourinary procedure at a site of suspected infection should get antibiotics that also cover endocarditis organisms.