CLABSI and Endocarditis

Question 1

CLABSI

Answer 1

Bacteremia or fungemia with presence of intravascular device and > 1 positive blood culture + clinical sxs of infection + no other apparent source of BSI identified

Question 2

Peripheral Catheters

Answer 2

For short-term use (< 7 days)
Low risk of infection

Question 3

Peripherally Inserted Central Catheter (PICC)

Answer 3

Central venous catheter
For longer term use
Moderate risk of infection

Question 4

Central Line

Answer 4

Central venous catheter
For longer term use
High risk of infection

Question 5

Most Common Cause of CLABSI

Answer 5

Contamination entering system at catheter/administration set junction

Question 6

Most Common Pathogen Causing CLABSI

Answer 6

MRSA

Question 7

Diagnosis of CLABSI

Answer 7

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

Question 8

Considerations for Empiric Therapy of CLABSI

Answer 8

IV therapy preferred initially

Bacteriocidal antibiotic preferred

Empiric therapy should contain broad gram-positive cocci coverage (including MRSA)

Question 9

Empiric Therapy for Critically Ill Patients in ICU

Answer 9

In critically ill patients in ICU with femoral or other central catheter: add empiric coverage for GNR and Candida

Example: Vanco + Cefepime + Micafungin

Question 10

Directed Therapy CLABSI - MRSA

Answer 10

Vancomycin

Question 11

Directed Therapy CLABSI - MSSA

Answer 11

Cefazolin or Oxacillin

Question 12

Directed Therapy CLABSI - Pseudomonas

Answer 12

Zosyn, Cefepime, Meropenem

Question 13

Directed Therapy CLABSI - E. coli, Klebsiella

Answer 13

Beta-lactam preferred, if susceptible Ceftriaxone

Question 14

Directed Therapy CLABSI - Candida (except glabrata or krusei)

Answer 14

Fluconazole

Question 15

Directed Therapy CLABSI - Candida glabrata, krusei

Answer 15

Micafungin

Question 16

Duration of Therapy CLABSI

Answer 16

7-14 days

Question 17

Other Management of CLABSI

Answer 17

1. Source control - remove infected line
2. Repeat blood cultures to document sterilization - if repeat cultures continue to be positive, duration should be extended to 4-6 weeks
3. Evaluation of metastatic complication - endocarditis, endophthalmitis

Question 18

Common Pathogens Associated with Endocarditis

Answer 18

Mostly gram-positive cocci - S. aureus most common

Question 19

Risk Factors for Endocarditis

Answer 19

>60 yo

Male

IVDU

Poor dentition

Question 20

Classic Symptoms of Endocarditis (Uncommon)

Answer 20

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)

Question 21

Treatment/Management Strategy for Endocarditis

Answer 21

1. Initiate appropriate IV antibiotic therapy
2. Repeat blood cultures until document sterilization - clock duration starts from first date of negative blood culture
3. Obtain source control
4. Evaluate for surgical intervention

Question 22

Directed Therapy Native Valve Endocarditis - MSSA

Answer 22

Oxacillin/Nafcillin or Cefazolin

Question 23

Directed Therapy Native Valve Endocarditis - MRSA

Answer 23

Vancomycin or Daptomycin

Question 24

Directed Therapy Native Valve Endocarditis - Strep

Answer 24

Penicillin G or Ampicillin +/- Gentamicin for synergy

Question 25

Directed Therapy Native Valve Endocarditis - Enterococcus

Answer 25

Ampicillin + Gentamicin for synergy (ampicillin alone is NOT cidal against Enterococcus)

Question 26

Treatment Duration of Native Valve Endocarditis

Answer 26

4 weeks (Strep) 6 weeks (MSSA, MRSA, Enterococcus)

Question 27

Treatment/Management Strategy for Prosthetic Valve Endocarditis

Answer 27

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

Question 28

Directed Therapy Prosthetic Valve Endocarditis - MSSA

Answer 28

Oxacillin/Nafcillin PLUS Rifampin IV/PO PLUS Gentamicin for synergy

Question 29

Directed Therapy Prosthetic Valve Endocarditis - MRSA

Answer 29

Vancomycin PLUS Rifampin IV/PO PLUS Gentamicin for synergy

Question 30

Treatment Duration for Prosthetic Valve Endocarditis

Answer 30

At least 6 weeks (everything EXCEPT gentamycin) Gentamicin - ONLY for 2 weeks