21 - Endocarditis Flashcards
Catheter-Related Bacteremia/Sepsis
Vs
Localized Catheter site infection
Catheter-related bacteremia/sepsis
positive catheter culture
•ositive peripheral blood culture
same microorganism isolated in both 1 & 2
Localized catheter site infection
Clinically or microbiologically proved infection at the catheter exit site
(e.g., cellulitis, purulence, tunnelitis, pocket infections)
No systemic signs
Trans-THORACIC echocardiogram
less invasive
QUICKER
better at
quantifying hemodynamic dysfunction
Treatment for:
STREP
Veridans / Gallolyticus / Abiotrophia / Granulicatella
NVE
(native valve endocarditis)
- *PCN - Intermediate Resistance**
- *MIC > 0.12 , <0.5**
- *Penicillin G Sodium**
- *24 million** units per 24 hours
- *4 WEEKS**
++PLUS++
- *Gentamicin**
- *3mg/kg** per 24 hours
- *2 WEEKS**
Indications for
LONG-TERM CATHETERS
PICC
Port-a-cath
Groshong = CLosed end
Hickman = open end
- Lack of short term peripheral venous access (e.g, IV drug users)
- Infusion of hyperosmolar solutions (e.g., TPNs)
- Infusion of vessicant/ irritant drugs (e.g., certain chemotherapy)
- Long-term IV therapy (e.g., treatment of endocarditis)
- Infusion of intermittent drug therapy (e.g., chemotherapy)
- Use of continuous ambulatory drug pumps (e.g., TPN)
- Patient, physician or nursing preference
- Geographic location (e.g., lives out in the country)
Prevention** **for Infective Endocarditis
Unable to take ORAL
Prosthetic Valve or Material
previous IE
CHD
Dental procedures
- *Ampicillin**
- *2gm IM or IV**
1 hour before procedure
Bacterial ETIOLOGY
of
CR-BSI
Coagulase Negative STAPHylococcus
All Gram Negative Bacteria
Enterococci = STAPH.Areus
Candida
CR-BSI TREATMENT:
STAPHYLOCOCCUS AUREUS
RESISTANCE
Methicillin Resistant Strains
- *Vancomycin**
- *15mg/kg q12**
OR
- *Daptomycin**
- *6-8mg/kg**
2-6 WEEKS
REMOVE LINE
Treatment for:
GRAM NEGATIVE BACILLI
Infective Endocarditis
- *B-Lactam_ + _AminoGlycoside**
- *6 WEEKS**
REQUIRES VALVE REPLACEMENT
Treatment for:
GRAM NEGATIVE BACILLI
Infective Endocarditis
- *B-Lactam_ + _AminoGlycoside**
- *6 WEEKS**
REQUIRES VALVE REPLACEMENT
Treatment for:
STAPH Aureus
Coagulase-Negative Staphylococci
NVE
(Native Valve Endocarditis)
PCN ALLERGY
- *Vancomycin**
- *30mg/kg** QD
- *6 WEEKS**
Treatment for:
Enterococcuus
Coagulase-Negative Staphylococci
PVE** or **NVE
(Prosthetic OR native)
RESISTANT STRAINS
to PCN / Vancomycin / Gentamicin
- *LINEZOLID**
- *600mg** IV or ORAL q12 hr
- *>** 6 Weeks
OR
- *DAPTOMYCIN**
- *10-12 mg/kg per dose**
- *>** 6 Weeks
trans-ESOPHAGEAL echocardiogram
more SENSITIVE
cost-effective
Recommended in patients with:
PROSTHETIC Valves
Previous Cardiothoracic Surgery
COPD
MORBID OBESITY
Prevention** **for Infective Endocarditis
ORAL
Prosthetic Valve or Material
previous IE
CHD
Dental procedures
- *AMOXICILLIN**
- *2gm**
1 hour before procedure
Treatment for:
STAPH Aureus
Coagulase-Negative Staphylococci
PVE
(Prosthetic)
RESISTANT STRAINS
- *PVE STAPH = 3 DRUGS** + >6 week treatment
- Resistant –> vanco instead of oxacillin*
VANCOMYCIN
30mg/kg per 24hr in 2dd
> 6 WEEKS
++++
Rifampin
900mg per 24 hours
> 6 WEEKS
+++
Gentamicin
3mg/kg per 24 hours
2 WEEKS
Prevention** **for Infective Endocarditis
PCN / Ampicillin Allergy
UNABLE TO TAKE ORAL
Prosthetic Valve or Material
previous IE
CHD
Dental procedures
- *CLINDAMYCIN**
- *600mg IM or IV**
Risk Factors
Infective Endocarditis
Heart Disease
Rheumatic / Congenital / Acquired
Patent Ductus - Mitral Valve prolapse
Prosthetic Valves
Previous Bacterial endocarditis
ways bacteria could be introduced:
Indwelling Catheters
IV DRUG USE
DENTAL / SURGICAL procedures
Treatment for:
STREP
Veridans / Gallolyticus / Abiotrophia / Granulicatella
PVE
(Proshetic Valve Endocarditis)
- *PCN SENSITIVE**
- *MIC < 0.12**
- *Penicillin G sodium**
- *24 million** units for 24 hours
- *6 WEEKS**
with or without
- *Gentamicin**
- *3mg/kg** per 24 hours in 1 dose
- *2 WEEKS**
When should the
Catheter be PULLED
for
CR-BSI
Short Term Use
Supperative Thrombophlebitis
Severe Sepsis / Endocarditis / Osteomylitis
+POS+ Blood cultures after 72 hours
& receiving ABx therapy
Treatment for:
FUNGI
Infective Endocarditis
- *Amphotericin B** +/- Flucytosine
- treatment duration is UNKNOWN*
REQUIRES VALVE REPLACEMENT
CR-BSI TREATMENT:
Coagulase-Nagative STAPHylococcus
- *VANCOMYCIN**
- *15mg/kg q12h**
AB LOCK
10 - 14 day treatment
20% recurrence if catheter NOT REMOVED
DIAGNOSIS of CR-BSI
CATHETER TIP CULTURE
> 15 CFU
has to be the TIP
+
2 Peripheral blood Cultures
Treatment for:
STAPH Aureus
Coagulase-Negative Staphylococci
PVE
(Prosthetic)
No resistance / Susceptible Strains
PVE STAPH = 3 DRUGS + >6 week treatment
Nafcillin** or **Oxacillin
12g per 24h
> 6 WEEKS
++++
Rifampin
900mg per 24 hours
> 6 WEEKS
+++
Gentamicin
3mg/kg per 24 hours
2 WEEKS
Treatment for:
STAPH Aureus
Coagulase-Negative Staphylococci
NVE
(Native Valve Endocarditis)
No Resistance = Susceptible Strains
- *Oxacillin_ or _Nafcillin**
- *12g / 24h** in 4-6 dd
- *6 WEEKS**
Prevention of endoluminal contamination
Aseptic hub handling
↓#of connections
Separate the hub from the skin
↓changes of infusion sets
↓ of catheter lumens/ ports
↓catheter manipulations
Which patients should recieve
PROPHYLAXIS
for
Infective Endocarditis?
Prosthetic Valve** OR **Material
Previous IE
infective endocarditis
CONGENITAL HEART DISEASE
palliative shunts / conduits
repaired congenital heart defects
cardiac TRANSPLANTATIOn recipients
Patient RISKS
From long-term catheter placement
Local site infection
tunnel or pocket
Catheter-related bloodstream infection = CR BSI
- Septic thrombophlebitis
- Endocarditis
•Metastatic infections
(e.g., lung abscess, brain abscess, osteomyelitis, endophthalmitis)
CR-BSI TREATMENT:
ENTEROCOCCI
&
VRE
(Vanco Resistant Enterococci)
same as Coagulase Negative STAPH
VANCOMYCIN
15mg/kg q12h
AB LOCK
10 - 14 day treatment
for isolated VRE - PULL LINE
Daptomycin - 6mg/kg/day
OR
Linezolid - 600mg q12h
CR-BSI TREATMENT:
GRAM NEGATIVE BACILLI
Piperacillin/Tazobactam
Ceftazidime or Cefipime
Imipenem or Meropenem
+/- aminoglycoside
7-14 days
REMOVE THE CATHETER
Treatment for:
STAPH Aureus
Coagulase-Negative Staphylococci
NVE
(Native Valve Endocarditis)
RESISTANT STRAINS
- *Vancomycin**
- *30mg/kg** per 24 hours in 2dd
- *6 WEEKS**
same as PCN allergic
**Pathogenesis of INFECTIVE ENDOCARDITIS (IE)**
Insult to the
Valvular or Endocardial Endothelium
allowing for
deposition of PLATELET-FIBRIN aggregates
NBTE
(Non-Bacterial Thrombotic Endocarditis) / Vegetations
acts as the:
ideal spot for BACTERIAL ADHERENCE
Diagnosis of
Infective Endocarditis
Clinical Presentations:
embolic phenomenom / OSLER nodes / janeway lesions
splenomegaly
- *BLOOD CULTURES**
- *Continuous BACTEREMIA**
- *3 Sets** @different SITES & TIMES = 1-2sets/day until negative
ECHOCARDIOGRAM
Trans-thorasic vs Trans-esophageal
Treatment for:
Enterococcuus
Coagulase-Negative Staphylococci
PVE** or **NVE
(Prosthetic OR native)
NO RESISTANCE
to PCN / Vancomycin / Gentamicin
- *AMPICILLIN**
- *2g** every 4hrs
- *4-6 WEEKS**
for PCN allergy:
Vancomycin + Gentamycin
Etiologic Agents in
Infective Endocarditis
- *STAPHYLOCOCCI**
- *Positive > negative**
Streptococci
Veridans > other
Enterococci
Gram-Negative
Fungi
Etc
Treatment for:
STREP
Veridans / Gallolyticus / Abiotrophia / Granulicatella
NVE
(native valve endocarditis)
PCN ALLERGY
- *Vancomycin**
- *30mg/kg** per 24 hours in 2divdoses
- *4 WEEKS**
for
PVE –> 6 Week treatment
Septic thrombophlebitis
Evidence of venous THROMBUS of the vein
with indwelling catheter & positve blood cultures
with clinical manifestations of sepsis
CR-BSI TREATMENT:
CANDIDA
- *14 DAYS**
- *REMOVE THE CATHETER**
CASPOFUNGIN
AMPHOTERICIN B
FLUCONAZOLE
SITUATIONS
where patients should receive
PROPHYLAXIS
Infective Endocarditis
all DENTAL procedures that involve manipulation of :
gingival tissue**or**periapical region of teeth**or**perforation of oral mucosa
_no longer recommended for
NON-DENTAL PROCEDURES_
in the absence of active enfection
Prevention** **for Infective Endocarditis
ORAL
PCN / Ampicilin ALLERGY
Prosthetic Valve or Material
previous IE
CHD
Dental procedures
- *Clindamycin**
- *600mg**
OR
- *Azithromycin** or Clarithromycin
- *500mg**
1 hour before procedure
Infusate-related bacteremia
presense of the
- *same pathogen in BLOOD & INFUSATE**
- without ID of alternative sites of infection*
Mouth Bacteria
H-A-C-E-K
Haemophilus
Aggregatibacter
Cardiobacterium
Eikenella
Kingella
Treatment for:
HACEK
Haemophilus / Aggregatibacter / Cardiobacterium / Eikenella-Kingella
Responsible for 5-10% of community aquired NVE
- *CEFTRIAXONE**
- *2g** per 24hours IV or IM 1 dose
4 WEEKS
Treatment for:
STREP
Veridans / Gallolyticus / Abiotrophia / Granulicatella
NVE
(native valve endocarditis)
- *PCN SENSITIVE**
- *MIC < 0.12**
- *Penicillin G sodium**
- *12-18** million units / 24 hours
- *4 WEEKS**
OR
Penicillin** + **Gentamicin
same + 3mg/kg / 24 hours
2 WEEKS
RISK FACTORS
for
CR-BSI
Catheter related Bloodstream Infections
Cutaneous** vs **Subcutaneous Ports
↑# of LUMENS
- *LENGTH of TIME in place**
- *>3 days**
Poor sterile insertion technique
Insertion Site
TPN Used
Treatment for:
STREP
Veridans / Gallolyticus / Abiotrophia / Granulicatella
PVE
(Proshetic Valve Endocarditis)
- *PCN Resistant**
- *MIC > 0.12**
Same as PCN resistant, but PLUS gentamicin is 6 WEEKS (not 2)
- *Penicillin G sodium**
- *24 million** units for 24 hours
- *6 WEEKS**
++PLUS++
- *Gentamicin**
- *3mg/kg** per 24 hours in 1 Dose
- *6 WEEKS**
Treatment for:
HACEK
Haemophilus / Aggregatibacter / Cardiobacterium / Eikenella-Kingella
Responsible for 5-10% of community aquired NVE
- *CEFTRIAXONE**
- *2g** per 24hours IV or IM 1 dose
4 WEEKS
CR-BSI TREATMENT:
STAPHYLOCOCCUS AUREUS
no resistance
- *Nafcillin** or Oxacillin
- *1-2 gm IVPB q4-6hr**
2-6 WEEKS
REMOVE LINE
