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Clinical 2 - Antibiotics > 6 - Infective Endocarditis > Flashcards

6 - Infective Endocarditis Flashcards

1
Q

What is the incidence of infective endocarditis ?

A
  • 2-6 cases per 100,000 population

- 1 per 1000 hospitalizations

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2
Q

Gram positive cocci in clumps = ?

A

staph

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3
Q

Gram positive cocci in chains = ?

A

strep

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4
Q

What are the most likely pathogens in a native valve endocarditis?

A

S. aureus (35%)
Strep (35%)
Enterococcus (10%)

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5
Q

What are the most likely pathogens in a prosthetic valve endocarditis ?

A 
S. epidermidis (45%)
S. aureus (20%)
Fungal (10%)
Enterococcus (10%)
GNB (10%)
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6
Q

What are the most likely pathogens in a HCA (health care associated) endocarditis?

A

S. aureus (45%)
Enterococcus (15%)
S. epidermis (15%)
Streptococcus (10%)

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7
Q

Infective Endocarditis:

70% of cases associated with what 2 bugs?

A
  • staphylococcus

- streptococcus

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8
Q

What are some risk factors for infective endocarditis?

A
  • over 60 yo
  • male
  • bacteremia (intravascular catheter, IVDU)
  • dialysis, diabetes, immunocompromised
  • poor dentation
  • prosthetic valve
  • prior infective endocarditis
  • congenital heart disease
  • valvular heart disease
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9
Q

If they are at risk for infective, endocarditis, give an example of a scenario when antimicrobial prophylaxis is important?

A

dental procedures !

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10
Q

Why is there controversy around antimicrobial prophylaxis to prevent IE ?

A

1) Bacteremia is more likely spontaneous than procedure-related.
2) Oral health hygiene is important in prevention.
3) AP with 100% compliance likely to prevent small number of cases.
4) Antimicrobial-related adverse events may exceed benefits.
5) AP should be limited to dental procedures in highest-risk patients.

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11
Q

What are the highest-risk cardiac conditions for IE ?

A
  • prosthetic heart valves (400x)
  • prior endocarditis (400x)
  • unrepaired congenital heart disease, or incompletely repaired with residual defects at prosthetic patches/devices , or completely repaired with prosthetic materials for 6 months
  • cardiac transplants with valve dysfunction (valvulopathy)
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12
Q

What types of dental procedures cause bacteremia with IE pathogens ?

A
  • procedures manipulating gingival tissue, peri-apical region of teeth, or perforation of oral mucosa (not injections, radiographs)
    ex. extractions (where the gums are cut out)

**these patients should get AP to prevent IE

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13
Q

What is the 1st line antimicrobial for AP to prevent IE?

Include dose

A

Adults:
Amoxicillin 2g 1 hr prior to procedure

Children:
Amoxicillin 50mg/kg 1 hr prior to procedure

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14
Q

What is an alternative?

Include dose

A

Cephalexin or Cefadroxil

Adults:
2g 1 hr prior to procedure

Children:
50mg/kg 1 hr prior to procedure

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15
Q

What are alternatives for Severe beta lactam allergy? (3)

Include dose

A

Azithromycin/Clarithromycin :

Adults:
500 mg 1 hr prior

Children:
15 mg/kg 1 hr prior

Clindamycin:

Adults:
600 mg 1 hr prior

Children:
20 mg/kg 1 hr prior

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16
Q

For surgery involving respiratory, GI and GU tracts, ________ IV provides IE prophylaxis for staphylococcus and streptococcus

A

Cefazolin

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17
Q

For surgery involving GI and GU tracts, adding ______ provides IE prophylaxis for enterococcus

A

Ampicillin

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18
Q

What is enterococcus covered by?

A

it is covered by penicillins, not by cephalosporins

*Cefazolin will cover Staph and Strep. If you’re worried about Enterococcus, need to add a penicillin !

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19
Q

What mortality rates are associated with IE?

A

15-25% mortality (40% at 5 years)

>50% for fungal
>20% for left-sided S. aureus
20% for enterococcus
10% for streptococcus
<5% for right-sided S. aureus associated with IVDU
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20
Q

What is the clinical presentation of IE?

A
  • fever (>75%)
  • leukocytosis, anemia, elevated ESR and CRP
  • malaise, anorexia, weight loss (50%)
  • regurgitant murmur in most cases, new murmur (35%)
  • new/worsening heart failure
  • skin/mucosal lesions (50%)
  • pulmonary emboli, TIA/stroke, renal failure (hematuria), splenomegaly
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21
Q

Subacute, indolent = ______

A

streptococcus

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22
Q

Acute, invasive = ________

A

S. aureus

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23
Q

What means Definite IE ?

A 
2 major criteria 
OR
1 major + 3 minor
OR
5 minor
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24
Q

What means Possible IE ?

A

1 major + 1 minor
OR
3 minor criteria

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25
Q

List Major Criteria

A
  • blood culture for IE pathogen (x 2 of 3 draws from different sites > 1 hr apart)
  • serology for Coxiella burneatii (Q fever)
  • echocardiogram for IE (vegetation, abscess)
26
Q

List Minor Criteria

A
  • predisposition, predisposing heart conditions, IVDU
  • temperature > 38 degrees C
  • vascular phenomenon (trunk, buccal, conjunctival petechia, splinter hemorrhages, Janeway lesions)
  • immunologic phenomenon (glomerular nephritis, Osler’s nodes, Roth’s spots)
  • microbiological data that does not meet major criteria
27
Q

What are Janeway lesions ?

A

little blood bursts under the skin

28
Q

What are Osler’s nodes?

A

when patients have endocarditis, there tends to be an immunologic reaction so antibodies deposit in skin

29
Q

What are Roth’s spots ?

A

hemorrhagic lesions in rent bc of emboli

30
Q

What are the principles of antimicrobial therapy for ACTUALLY TREATING infective endocarditis ??

A

1) High-dose, IV therapy for plasma concentrations that sufficiently penetrate vegetation (clot)

2) Bactericidal against high-densities of bacteria with low metabolism and stationary growth phase
(cannot use static drugs)

3) Prolonged duration to sterilize vegetation (and then over time the vegetation will be resorbed)

31
Q

List some of the streptococci species that are associated with IE ?

A

S. mitis
S. sangiunis
S. mutans
S. gallolyticus

32
Q

Why are prosthetic valve endocarditis harder to treat ?

A

biofilm

33
Q

Streptococcal IE therapy:
Pen-S:
What is the treatment for NVE ?

A

4w pen 12-18 MU/day (dosed Q4H)
or
4w Ceftriax 2 g Q24H

34
Q

Streptococcal IE therapy:
Pen-S:
What is the treatment for NVE ?
(severe B lactam allergy)

A

4w Vanco 15 mg/kg Q12H

35
Q

Streptococcal IE therapy:
Pen-S:
What is the treatment for NVE ? (uncomplicated, <5mm, no CV risks, no embolic events, treatment response)

A

2w Pen (12-18 MU/day or dosed Q4H)
+/-
Gent 3 mg/kg Q24H
(gent is being used for synergy)

OR

2w Ceftriax + Gent

36
Q

Streptococcal IE therapy:
Pen-S:
What is the treatment for PVE ?

A

6w Pen 24 MU/day or dosed Q4H
+/-
2w Gent 3mg/kg Q24H

OR

6w Ceftriax + 2w Gent

37
Q

Streptococcal IE therapy:
Pen-S:
What is the treatment for PVE ? (severe B lactam allergy)

A

6w Vanco

38
Q

Streptococcal IE therapy:
Pen-RR:
What is the treatment for NVE ?

A

4w Pen 24 MU/day or dosed Q4H
+
2w Gent 3mg/kg Q24H

OR

4w Ceftriax + 2w Gent

39
Q

Streptococcal IE therapy:
Pen-RR:
What is the treatment for NVE ?
(severe B lactam allergy)

A

4w Vanco

40
Q

Streptococcal IE therapy:
Pen-RR:
What is the treatment for PVE ?

A

6w Pen 24 MU/day or dosed Q4H
+
Gent 3/mg/kgk Q24H

OR

6w Ceftriax + Gent

41
Q

Streptococcal IE therapy:
Pen-RR:
What is the treatment for PVE ?
(severe B lactam allergy)

A

6w Vanco

42
Q

Streptococcal IE therapy:
Pen-R:
What is the treatment for NVE ?

A 
4-6w Pen 18-30 MU/day or dosed Q4H 
\+ 
Gent 3 mg/kg/day in 2-3 doses
OR
4-6 weeks Ceftriax + Gent
43
Q

Streptococcal IE therapy:
Pen-R:
What is the treatment for NVE ?
(severe B lactam allergy)

A

4-6 weeks vanco

44
Q

Streptococcal IE therapy:
Pen-R:
What is the treatment for PVE ?

A

6w Pen 24 MU/day or dosed Q4H
+
Gent 3 mg/kg/day in 2-3 doses

OR

6w Ceftriax + Gent

45
Q

Streptococcal IE therapy:
Pen-R:
What is the treatment for PVE ?
(severe B lactam allergy)

A

6 weeks Vanco

46
Q

How is IE different in patients with history of IVDU ?

A
  • Often without pre-existing valvular disease
  • Tricuspid valve in > 50% of cases
  • S. aureus in 60-80% of cases
  • Response favourable for S. aureus but poor for GNB and fungal infections
47
Q

Endocarditis in IVDU will mainly be on the ____ side

A

RIGHT

48
Q

Endocarditis in non-IVDU will mainly be on the _____ side

A

LEFT

49
Q

Staphylococcal IE Therapy:

What is the treatment for MSSA or MSSE? (NVE)

A

6w Cloxacillin 2g Q24H

OR

2w Clox (uncomplicated tricuspid associated with IVDU)

50
Q

Staphylococcal IE Therapy:
What is the treatment for MSSA or MSSE? (NVE)

for Severe B lactam allergy

A

6w Vanco 15 mg/kg q12h

6w Dapto > 8 mg/kg q24h

51
Q

Staphylococcal IE Therapy:

What is the treatment for MSSA or MSSE? (PVE)

A 
> 6 weeks Clox 
\+ 
Rifampin 300 mg PO q8h
\+
2w Gent 3 mg/kg/day in 2-3 doses
52
Q

Staphylococcal IE Therapy:

What is the treatment for MRSA or MRSE? (NVE)

A

6 w Vanco 15 mg/kg q12h

53
Q

Staphylococcal IE Therapy:
What is the treatment for MRSA or MRSE? (NVE)

*Alternative

A

6w Dapto

54
Q

Staphylococcal IE Therapy:

What is the treatment for MRSA or MRSE? (PVE)

A 
>6 weeks Vanco
\+
Rifampin 300 mg PO q8h
\+
2w Gent 3 mg/kg/day in 2-3 doses
55
Q

Gent is for synergy against ______

A

Strep

56
Q

Rifampin is for synergy against ______

A

Staph

57
Q

***These 6 week time frames are from the time you get a negative blood culture back.

So if you start them on this regimen, then 1 week in, you get negative blood culture, you will have ___ weeks total of treatment

A

7

58
Q

Expected response for treating IE?

A

clinical improvement within 3-7 days

59
Q

When should we repeat blood cultures ?

A

Every 2 days, for microbial response by:

  • 2 days for streptococci and HACEK infections
  • 3 days for B lactase against S. aureus
  • 5 days for Vanco against S. aureus (Vanco is a slow killer)
60
Q

____% of cases require surgery

A

25-30

61
Q

If removed valve tissue is culture negative, what is the duration of antimicrobial therapy ?

A

complete full course of effective antimicrobial therapy including preoperative therapy

62
Q

If perivalvular abscess or removed valve tissue is culture positive, what is the duration of antimicrobial therapy?

A

re-initiate and complete full course of antimicrobial therapy after surgery

Clinical 2 - Antibiotics (14 decks)

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