Cardiovascular Infections Flashcards
What are the Major criteria for Infective Endocarditis? (Duke Criteria)
- Blood culture positive for IE
a. Typical microorganisms consistent with IE from 2
separate blood cultures or persistently positive
blood cultures
1) Viridans streptococci, Streptococcus gallolyticus
(bovis), HACEK group,* Staphylococcus
aureus, community-acquired enterococci in the
absence of a primary focus - Single positive blood culture for Coxiella burnetii or anti-phase 1 IgG antibody titer ≥1:800
- Evidence of endocardial involvement
- Echocardiogram positive for IE
What are the Minor criteria for Infective Endocarditis? (Duke Criteria)
- Predisposition, predisposing heart condition, injection
drug use (IDU) - Fever, temperature >38 °C
- Vascular phenomena
a. Major arterial emboli, septic pulmonary infarcts,
mycotic aneurysm, intracranial hemorrhage,
conjunctival hemorrhages, and Janeway lesions - Immunological phenomena
a. Glomerulonephritis, Osler nodes, Roth spots,
rheumatoid factor - Microbiological evidence: positive blood culture but
does not meet major criteria (excludes single
positive culture for coagulase-negative staphylococci
and organisms that do not cause IE) or
serological evidence of active infection with organism
consistent with IE
How is Definite Infective Endocarditis defined?
a. Pathological criteria
1) Microorganisms demonstrated by culture or
histological examination of a vegetation, a
vegetation that has embolized, or an intracardiac
abscess specimen; or pathological lesions;
vegetation or intracardiac abscess confirmed by
histological examination showing active
endocarditis
b. Clinical Criteria
1) 2 major criteria, 1 major criterion and 3 minor
criteria, or 5 minor criteria
*Think of Major as 2.5 pts and minor as 1 pt. Anything more than 5 is “Definite.”
How is Possible Infective Endocarditis defined?
1 major criterion and 1 minor criterion or 3 minor criteria
*Anything more than 3 points
What are the HACEK organisms?
Haemophilus species Aggregatibacter species Cardiobacterium hominis Eikenella corrodens Kingella species
What are the implications of infective endocarditis being a high-inoculum infection?
- MIC may be higher at the site of infection may be higher than in-vitro testing shows
- Stationary growth phase means cell-wall active agents are less effective
- Bactericidal abx required, maybe in synergistic combinations, for sterilization.
Should you use higher doses of Dapto for endocarditis?
Yes: 8 mg/kg/day or higher.
When is “day 1” of therapy for endocarditis?
The first day of negative blood cultures.
*If valve removed and tests positive, or there’s an perivalvular abscess discovered during surgery, then Day 1 is after the surgery
When dosing multiple abx for IE, should they be spaced apart or given close together?
Give them close together to maximize possible synergy.
How should you treat highly-PCN susceptible VGS (or any STREP) native valve infective endocarditis?
Highly suscpetible = MIC < 0.12 mcg/ml
PCN 12-18 million units/day for 4 weeks*
OR
Rocephin 2 gram q24h for 4 weeks*
*add gent for synergy and reduce therapy to 2 weeks
OR
Vancomycin for 4 weeks (if intolerant of b-lactam)
**Rifampin not needed for strep, only for staph.
How should you treat moderately-PCN susceptible VGS (or any Strep) (MIC 0.12-0.5 mcg/ml) native valve infective endocarditis?
PCN 12-18 Million for 4 weeks and Gent (3 mg/kg/day) for 2 weeks
*If ceftriaxone susceptible, may use monotherapy 2 gram q24h for 4 weeks
Alt: Vanc 4 weeks
How should you treat PCN resistant (MIC > 0.5 mcg/ml) VGS (or any Strep) native valve infective endocarditis?
High dose PCN (24 million/day) + Gent (3 mg/kg/day) 4-6 weeks
OR
Vanc 4-6 weeks
If you are treating IE with vanc and targeting troughs for some reason, what is the trough target?
10-15
How should you treat highly-PCN susceptible VGS (or any Strep) PROSTHETIC valve infective endocarditis?
HIGH DOSE PCN for 6 weeks
OR
Rocephin 2 gram q24h for 6 weeks
+/- Gent (3 mg/kg/day) for 2 weeks
Alt: Vancomycin 4-6 weeks
How to treat VGS (or any Strep) Prosthetic Valve IE with PCN MIC > 0.12 mcg/ml? (Including fully resisant)
For 6 weeks: HIGH DOSE PCN (24 million units/day) OR Rocephin 2 grams q24h Plus Gent 3 mg/kg/day
Alt: Vanc for 4-6 weeks
Should you add Gent to Vanc for synergy in native valve staph IE?
No. It does not improve outcomes but makes AE’s worse.
Which is preferred for MSSA IE: Ancef or Nafcillin?
Nafcillin. Due to the type A beta-lactamase that staph produces, which hydrolyzes ancef at high concentrations, thus there is a high-inoculum effect against ancef.
How to treat Native valve, right sided IE in IV drug users (IDU’s) caused by Staph spp.
Oxacillin Sensitive:
First line: Nafcillin 12 gram/24h for 2 weeks
If PCN allergic: Ancef
Oxacillin Resistant: Vanc (for longer than 2 weeks) or Dapto for 2 weeks (Zyvox has poor outcomes)
- Don’t add gent
- *Vanc requires longer treatment due to poor penetration into vegetation.
Oral is potentially an option: Cipro + Rifampin
How to treat Prosthetic Valve IE caused by Staph
Triple therapy!
Oxacillin Susceptible:
Nafcillin + Rifampin for at least 6 weeks
PLUS Gent (3 mg/kg) for 2 weeks (not ext interval)
*If PCN allergy, may use ancef (not preferred)
Oxacillin Resistant:
Vanc + Rifampin (300 mg q8h) for at least 6 weeks
Plus Gent (3 mg/kg/day) for 2 weeks (not ext interval)
How to treat Native OR Prosthetic Valve IE caused by enterococcus?
Ampicillin 2 gra q4h or PCN 18-30 million/24h
PLUS
Gent 3 mg/kg/day in divided doses
For 4-6 weeks (4 weeks if Native valve and symptoms < 3 months, else 6 weeks)
OR
Ampicillin PLUS high dose Rocephin (2 gram q12h) for 6 weeks. (Rec’d for CrCl < 50 ml/min) (Interesting new option!)
If can’t take b-lactams or bug is b-lactam resistant:
Vanc + Gent for 6 weeks
What if you’re treating VRE IE? (Native or prosthetic)
Daptomycin High Dose (10-12 mg/kg/day) +/- Ampcillin or Ceftaroline (combination especially if dapto is intermediate (MIC < 4 mcg/ml)
Linezolid (IV) for 6 weeks is an option, but there are risks of bonemarros suppression and neuropathy. And reports of treatment failures and resistance.
Can you treat endocarditis with PO abx?
Maybe. It would be really nice considering the length of abx treatment. The POET trial suggests non-inferiority, but not currently guideline recommended. Consider in uncomplicated right-sided IE for IDU’s (cipro + rifampin)
When there is a blood culture for a HACEK organism, without any obvious source, what does that suggest?
Infective Endocarditis is highly likely.
What if you’re treating a gram negative HACEK Endocarditis?
Susceptibility testing is difficult, so assume amp resistant. Treat with 3rd or 4th gen cephalosporin or FQ for 6 weeks.
What if you’re treating IE caused by GNR (non-HACEK)?
This is rare. b-lactam plus AG or FQ for 6 weeks.
What if you’re treating culture negative NVIE?
Duration of sypmtoms is important:
Days: Vanc + cefepime
Weeks: Vanc + Unasyn
What if you’re treating culture negative PVIE?
Time between implant date and onset of symptoms is important:
< 1 yr: Vanc + Gent + Rifampin + Cefepime!
> 1 yr: Vanc + Ceftriaxone
What if you’re treating fungal IE?
High mortality! Fungal IE is a stand-alone indication for valve surgery.
Ampho + Flucytosine for 6 weeks + surgery
THEN
Lifelong suppression with oral -azole
What is OPAT?
Outpatient Parenteral Antimicrobial Therapy
Who should get abx prophy prior to dental visits?
People with:
Prosthetic heart valves (sounds reasonable)
Previous IE (also makes sense)
Congenital heart disease
Heart transplant with cardiac vulvolopathy
What dental procedures warrant prophylaxis?
Only for the highest risk patients:
- Manipulation of gingival tissue
- Biopsies
- Suture removal
- Placement of orthodontic bands.
Give amoxicillin 2 grams once 30-60 min before procedure.
What is a CIED?
Cardiovascular implantable electronic device
How do you treat a superficial /incisional CIED infection?
7-10 days of oral anti-staph abx. Don’t remove any hardware.
How do you treat an actual CIED infection (not superficial), including pocket infection?
- Remove all hardware.
- Empiric Vanc
- Blood cultures negative?
-Pocket infection? 10-14 days
-Lead/generator infection? 7-10 days. - Blood cultures positive?
-TEE, if vegetation, treat IE
-If no vegetation:
Staph? 2-4 weeks
Non-staph? 2 weeks
What about LVAD infections (don’t focus on this)?
Either Pump/cannula infections OR driveline infections.
Either pocket (in the abdominal cavity), or IE (probably accompanied by bacteremia).
Second gen “continuous flow” devices have lower incidence of infections. Third gen is implanted in pericardial cavity. No pocket needed.
Mostly Staph, Enterococcus, or Pseudomonas.
Target Staph and pseudomonas empirically.
How to treat Native Valve IE caused by Staph?
MSSA? 6 weeks of nafcillin preferred. Alt = ancef
MRSA? 6 weeks of Vanc or Dapto (at least 8 mg/kg/day)
When should gent be given in divided doses when used as synergy for IE?
When native valve VSG and PCN resistant (MIC > 0.5 mcg/ml)
When Prosthetic Valve with Staph.
When Enterococcus
Do you need Gent for IE if it’s caused by non-VGS?
You don’t need it for Strep pyogenes (GAS) or Strep Pneumo. But you should use it for Groups B, C, F and G.
When do you keep gent for the full time rather than just the first 2 weeks in IE?
If NVIE with fully resistant VGS or Enterococcus spp.
If treating Enterococcus spp.
