Endocarditis 1- MJ Flashcards
_________ refers to infection of the heart valves by various microorganisms
Endocarditis
The following are signs/symptoms of what?
- Sxs
- Fever, chills, weakness, dyspnea, night sweats, weight loss, and/or malaise
- Signs
- fever
- heart murmur
- embolic phenomenon
- splenomegaly
- Osler’s nodes (painful), Janeway’s lesions
Infective Endocarditis
What is the name of the criteria used to dx endocarditis?
Duke Criteria
(major= blood culture + for infective endocarditis, evidence of endocardial involvement
minor= risk factors, fever, conjunctival hemorrhages, janeways lesions, etc)
What 3 groups of organisms cause a majority of infective endocarditis cases?
Streptococci (9-38%)
Staphylococci (30-70%)
Enterococci
Which specific staphylococci is the MC
Staph aureus
(coagulase positive)
What is the tx approach for infective endocarditis (IE)?
- isolate pathogen (blood culture from 2 dif sites)
- Determine antimicrobial susceptibilities
- High dose IV bactericidal abx for extended period
4. Surgery (valvectomy/valve replacement)- important adjunct in tx of NVE and PVE
(NVE= native valve, PVE= prosthetic valve)
Why has Staphylococcal endocarditis become more prevalent?
b/c of increased IVDA
(also from more frequent use of peripheral/central venous catheters)
What is the most common organism causing infective endocarditis among those with IVDA and persons with venous catheters
S. aureus
What coagulase-negative staphylococci are prominent causes of PVE?
usually Staphylococcus epidermidis
What valve is most frequently infected in a IVDA patient?
Tricuspid valve (right sided IE)
–> caused by S. aureus
How do you tx an IVDA pt w/ staphylococcus endocarditis?
2 week course of:
Nafcillin or oxacillin + Aminoglycoside
What is an especially common cause of endocarditis involving native valves? Is this generally acute or subacute?
Strep viridans (common inhabitants of mouth/gingiva)
subacute
________ are normal inhabitants of the human GI tract and, occasionally, of the anterior urethra
Enterococci
(the cause of enterococcal endocarditis)
How do you tx infective endocarditis caused by the HACEK group of organisms?
(HACEK= H. flu, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae)
High-dose ampicillin + gentamicin x4 weeks
- What native valve does the HACEK group most commonly infect?
- Is this considered community or hospital acquired IE?
- Subacute or acute?
- Native Valve
- Community-acquired
- Subacute (w/ lg vegetations and emboli)
What is the group of drugs that remain the drug of choice for endocarditis?
β-Lactam antibiotics
Which β-Lactam antibiotic is the drug of choice for IE caused by strep?
Penicillin G (or ceftriaxone)
(this is not the only med used to tx this, just the specific B-lactam)
Which β-Lactam antibiotic is the drug of choice for IE caused by staph?
Nafcillin
(this is not the only med used to tx this, just the specific B-lactam)
Which β-Lactam antibiotic is the drug of choice for IE caused by enterococci?
Ampicillin
(this is not the only med used to tx this, just the specific B-lactam)
Which group of microbes causes large vegetations and emboli?
HACEK group
- Haemophilus parainfluenzae, Haemophilus aphrophilus,
- Actinobacillus actinomycetemcomitans,
- Cardiobacterium hominis,
- Eikenella corrodens,
- Kingella kingae
Empiric therapy for IE should cover what 3 groups of bacteria?
- Staphylococci (methicillin-susceptible and resistant)
- streptococci
- enterococci
What is empiric drug therapy for Native Valve infective endocarditis?
Vancomycin + Ceftriaxone
What is empiric drug therapy for Prosthetic Valve infective endocarditis?
Vancomycin + Gentamicin + Rifampin
Example test question:
Someone has prosthtic valve Endocarditis caused by strep viridans and is allergic to PCN- what are you going to order and for how long? (it is sensitive to penicillin)
(she said to not memorize the chart but then said this was a sample test question so IDK)
Vancomycin x6 weeks
What are the 2 major adverse drug rxns of Daptomycin and what are the monitoring parameters?
ADEs:
- Myopathy- monitor creatinine phosphokinase weekly
- Rhabdomyolysis- monitor for signs/sxs of mm. pain
What are the 3 major ADEs of Gentamicin?
ADEs:
- Nephrotoxicity
- Ototoxicity
- neuromuscular blockade
What are the 3 major ADEs of linezolid and how do you monitor?
ADEs:
- Thrombocytopenia
- optic neuropathy
- peripheral neuropathy
Monitoring:
- platelet counts at baseline and weekly
- visual changes
WHat is the 1 major ADE of Rifampin and how do you monitor?
Hepatotoxicity
monitor baseline liver function tests, and then at least every 2-4 wks during therapy
What are the 2 major ADEs of Vancomycin?
- Nephrotoxicity
- Red Man Syndrome
Daptomycin- when is more frequent monitoring warrented?
In patients w/ renal dysfunction or receiving concomitant therapy w/ HMG-CoA reductase inhibitors (statins)
When should Daptomycin be discontinued?
If symptomatic and CPK >5x upper limit of normal (ULN) or if CPK > 10x ULN
If taking Gentamicin, you should avoid concomitant use of what?
- of other nephrotoxic agents such as diuretics, nonsteroidal anti-inflammatory drugs, and radiocontrast media
T/F: you should avoid rapid IV administration of Gentamicin?
True
ADEs of Linezolid:
Thrombocytopenia is MC in >___ weeks of prolonged therapy
>2 weeks
ADEs of Linezolid:
Visual symptoms are MC after >___ days of prolonged therapy
28
Which medication might cause red or orange discoloration of bodily secretions (urine, sweat, tears)?
Rifampin
ADE of Vancomycin:
How is red man syndrome managed?
Red man syndrome may be managed by prolonging the infusion time from 1-2 hours
Administration of antihistimine prior to loading or maintenacne doses also be considered
Although there is controversy over antimicrobial prophylaxis of infective endocarditis (what to give and when), everyone agrees on what makes a patient “high risk”.
What makes a person high risk?
- Presence of prosthetic heart valve
- prior dx of infective endocarditis
- cardiac transplantation w/ subsequent valulopathy
- congenital heart disease
For patients w/ high risk underlying cardiac conditions, What types of procedures should be given antimicrobial prophylaxis for infective endocarditis?
any that require perforation of the oral mucosa or manipulation of the periapical region of the teeth of gingival tissue
What is the MC drug prescribed for prophylaxis of infective endocarditis?
Which drug do dentists really like to give for prophylaxis?
MC- Oral amoxicillin
Dentists- oral Clindamycin
Infective endocarditis prophylaxis for dental procedures should be recommended only for patients with what?
underlying cardiac conditions associated with the highest risk
Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergoe which 2 types of procedures?
genitourinary or GI tract procedure
According to UpToDate, when is prophylaxis not recommended?
- Common valvular lesions for which antimicrobial prophylaxis is NOT recommended include:
- bicuspid aortic valve
- acquired aortic or mitral valve disease (including mitral valve prolapse with regurgitation)
- hypertrophic cardiomyopathy with latent or resting obstruction
T/F: the following are examples of dental procedures where IE prophylaxis is recommended:
Tooth extractions, drainage of dental abscess, routine dental cleaning
True
Clinical Pearl:
Initiation of ________ for tx of native valve infective S. aureus is optional.Why?
Routine use of _________ for tx of native valve endocarditis should be avoided
gentamicin
recent literature reports increased risk of nephrotoxicity when combining gentamicin w/ vanco or antistaphylococcal agents in comparison to daptomycin monotherapy
