Day 1- CNS and Infective Endocarditis Flashcards
What are your risk factors for IE?
What species commonly cause IE?
What’s an early vs late infection?
Valvular disease(mitral and aortic regurgitation), hemodialysis, IV drug abuse, rheumatic heart disease, prosthetic valve, previous IE, congenital heart disease, IV access, diabetes mellitus, healthcare exposure, HIV.
Staph aureus, Coag negative staph, viridans streptococci, enterococci.
Early occurs within 2 months of valve placement, Late is >12 months after prosthesis. Nosocomial is 3-60 days after hospital admission(higher mortality rate).
What is your clinical presentation of IE?
What are your laboratory findings for IE?
How can you make a definite diagnosis of IE?
Fever(most common symptom), SIRS criteria, Clubbing fingers, emboli, osler node, Janeway lesion, splinter hemorrhages and petechiae, roth spots.
Blood cultures(continuous bacteremia is a hallmark), if culture negative hold for up to 1 month for growth. Echo TEE.
2 major criteria, 1 major + 3 minor, 5 minor. Modified DUKE criteria.
What is your empiric therapy for IE?
How to treat native valve IE for strep viridians and S.gallolyticus and how is that different vs prosthetic?
How to treat Native valve methicillin sensitive CONS S.aureus and how is that different vs methicillin resistant CONS?
Nafcillin or Oxacillin, Cefazolin, Alternatives are Vanco or Dapto.
PCN G IV or Ceftriaxone +/- gentamicin, if allergy give Vanco. Prosthetic is the same except more PCN G.
Nafcillin/oxacillin or Cefazolin, Anaphylaxis is vancomycin. Vancomycin OR Daptomycin.
How to treat Prosthetic valve IE methicillin sensitive and how is that different vs methicillin resistant?
How to treat Enterococcus IE?
How to treat HACEK IE?
Nafcillin/oxacillin + Rifampin + Gentamicin. MRSA is Vanco + Rifampin + Gentamicin.
Depends on sensitivities, Ampicillin + Ceftriaxone. Could also use Amp/vanco + Gentamicin.
Ceftriaxone, ampicillin, or Cipro(6 weeks for prosthetic and 4 for normal).
How do you monitor for treatment of IE?
When do you give prophylaxis?
How high can CSF rise during a bacterial infection?
Follow up blood cultures, obtain blood cultures every 1-2 days until infection clears from blood stream, symptoms, drug toxicities, complication, dental procedures, follow up ECHO.
If they’ve had previous IE.
500 mg/dL.
What is the most up to date guidelines for meningitis?
What makes up your meninges?
What is the difference between meningitis and encephalitis?
Clinical practice guidelines for healthcare-associated ventriculitis and meningitis.
Dura mater, Arachnoid mater, Pia mater.
Meningitis infection of membranes, encephalitis is infection of the brain parenchyma.
How does ABM spread normally and what happens to the CSF in ABM?
What are signs and symptoms of meningitis?
What factors should be considered when patients have meningitis?
Typically through Hematogenous spread. Levels of protein increase and glucose levels decrease.
Abducens palsy, Subdural empyema, Increased intracranial pressure(ICP).
route of entry, age, immune status.
What are the most common ABM causes bacterially?
What is the most common cause of ABM in elderly people and infants?
When can S.aerues be present in meningitis?
Neisseria Meningitidis, Streptococcus pneumoniae, Haemophilus influenzae type B(if have vaccine no).
L.monocytogenes,S. pnuemoniae(middle age adults), N. meningitis. But L. monocytogenes is most common. Sometimes gram negatives.
Penetrating head wound.
What are your ABM bacteria in immunocompromised patients?
What are signs and symptoms of ABM?
What do you need to immediately start doing to treat severely ill ABM patients?
L. monocytogenes, Pseudomonas Aeruginosa, Myobacterium tuberculosis.
Symptoms begin in 3-5 days. Photophobia(not true for encephalitis),Nuchal Rigidity(neck stiffness also not true for encephalitis).
Begin antibiotics +/- corticosteroids immediately(even before lumbar puncture).
What is the 1st thing you do in ABM patients?
When can diagnosis be challenging for ABM?
Do we still need to do lumbar puncture if findings are not specific for meningitis?
Blood cultures. BAIL.
patients who have had an neurosurgical procedure, elderly and alcoholics, neonates and infants.
YES! Symptoms are atypical.
What are your ABM baseline tests?
When is Lumbar Puncture CI’d?
What is the ISDA recommendation for steroids for children(>2)?
Blood culture + PCR(if available), CSF analysis- Lumbar Puncture, CBC and differential, metabolic panel.
markedly increased ICP or an intracranial mass. Defer and perform CT or MRI. Lumbar puncture ok if ICP is reduced and no mass effect.
Recommended for H.influenzae type b.
What does the ISDA recommend for steroids for adults?
What are your dexamethasone concerns?
When do you give dexamethasone?
Dexamethasone for suspected pneumococcal meningitis continue if gram stain with gram positive diplococci or culture is positive for S.pnuemoniae.
Diminished inflammation may reduce vancomycin penetration so larger dose may be needed, additional rifampin may be required if dexamethasone is continued.
Before or with the 1st dose of antibiotic(if already received 1st dose there is probably no benefit).
How do you treat ABM?
What is empiric treatment for someone < 3 months?
What about 3 months-50 years?
Ceftriaxone or Cefotaxtime(S.pneumoniae and N. meningitidis). Ampicillin(L. monocy). Vancomycin(MRSA or SP).
AMpicillin + ceftriaxone or cefotaxtime.
Cefotaxime or Ceftraixone + vancomycin.
What is empiric treatment for someone >50 years old?
How often do you give Ceftriaxone?
Which organism requires the longest therapy and what takes the most?
Ceftriaxone or Cefotaxime + ampicillin + vancomycin.
Every 12 hours.
Listeria. Nieisseria and Haemophilus.
How do you prevent ABM?
Can you give the meningococcal vaccine to people in Serogroup B?
When do you want to consider chemoprophylaxis?
Conjugated pneumococcal vaccine, H. influenzae B, Quadrivalent meningococcal vaccine(A,C,Y, W135).
50% of infant cases(<1 year).
Household members, contact at daycares, directly exposed to someones oral secretions. should begin as soon as possible(after 14 days there is little benefit).
