CLABSI and Endocarditis Flashcards
CLABSI
Bacteremia or fungemia with presence of intravascular device and > 1 positive blood culture + clinical sxs of infection + no other apparent source of BSI identified
Peripheral Catheters
For short-term use (< 7 days)
Low risk of infection
Peripherally Inserted Central Catheter (PICC)
Central venous catheter
For longer term use
Moderate risk of infection
Central Line
Central venous catheter
For longer term use
High risk of infection
Most Common Cause of CLABSI
Contamination entering system at catheter/administration set junction
Most Common Pathogen Causing CLABSI
MRSA
Diagnosis of CLABSI
Obtain blood cultures before first dose of antibiotic from peripheral vein (use two different peripheral vein sites - two vials per blood draw, one aerobic and one anaerobic)
Cath tip culture
If same organism growing from peripheral blood culture and cath tip culture and no other source of BSI identified → likely device-associated bacteremia
Considerations for Empiric Therapy of CLABSI
IV therapy preferred initially
Bacteriocidal antibiotic preferred
Empiric therapy should contain broad gram-positive cocci coverage (including MRSA)
Empiric Therapy for Critically Ill Patients in ICU
In critically ill patients in ICU with femoral or other central catheter: add empiric coverage for GNR and Candida
Example: Vanco + Cefepime + Micafungin
Directed Therapy CLABSI - MRSA
Vancomycin
Directed Therapy CLABSI - MSSA
Cefazolin or Oxacillin
Directed Therapy CLABSI - Pseudomonas
Zosyn, Cefepime, Meropenem
Directed Therapy CLABSI - E. coli, Klebsiella
Beta-lactam preferred, if susceptible Ceftriaxone
Directed Therapy CLABSI - Candida (except glabrata or krusei)
Fluconazole
Directed Therapy CLABSI - Candida glabrata, krusei
Micafungin
Duration of Therapy CLABSI
7-14 days
Other Management of CLABSI
- Source control - remove infected line
- Repeat blood cultures to document sterilization - if repeat cultures continue to be positive, duration should be extended to 4-6 weeks
- Evaluation of metastatic complication - endocarditis, endophthalmitis
Common Pathogens Associated with Endocarditis
Mostly gram-positive cocci - S. aureus most common
Risk Factors for Endocarditis
>60 yo
Male
IVDU
Poor dentition
Classic Symptoms of Endocarditis (Uncommon)
Septic emboli breakoff and go into small vessels (at ends of extremities and in eyes):
Splinter hemorrhages (under fingernail)
Osler node (pad of fingertip)
Roth spots (eye)
Janeway lesions (palms and soles of feet)
Treatment/Management Strategy for Endocarditis
- Initiate appropriate IV antibiotic therapy
- Repeat blood cultures until document sterilization - clock duration starts from first date of negative blood culture
- Obtain source control
- Evaluate for surgical intervention
Directed Therapy Native Valve Endocarditis - MSSA
Oxacillin/Nafcillin or Cefazolin
Directed Therapy Native Valve Endocarditis - MRSA
Vancomycin or Daptomycin
Directed Therapy Native Valve Endocarditis - Strep
Penicillin G or Ampicillin +/- Gentamicin for synergy
Directed Therapy Native Valve Endocarditis - Enterococcus
Ampicillin + Gentamicin for synergy (ampicillin alone is NOT cidal against Enterococcus)
Treatment Duration of Native Valve Endocarditis
4 weeks (Strep)
6 weeks (MSSA, MRSA, Enterococcus)
Treatment/Management Strategy for Prosthetic Valve Endocarditis
Patients will likely need surgery + prolonged course of IV antibiotics (combination antibiotic therapy recommended)
Addition of rifampin - should NOT be used monotherapy because resistance develops rapidly
Monitor for antiobiotic adverse effects because patients are typically on maximal doses and long durations
Directed Therapy Prosthetic Valve Endocarditis - MSSA
Oxacillin/Nafcillin PLUS
Rifampin IV/PO PLUS
Gentamicin for synergy
Directed Therapy Prosthetic Valve Endocarditis - MRSA
Vancomycin PLUS
Rifampin IV/PO PLUS
Gentamicin for synergy
Treatment Duration for Prosthetic Valve Endocarditis
At least 6 weeks (everything EXCEPT gentamycin)
Gentamicin - ONLY for 2 weeks
