Endocarditis Flashcards
Infective Endocarditis
Syndrome resulting in colonization or invasion of endocardium
Risk Factors
Prosthetic heart valve (highest risk)
Hx of endocarditis (highest risk)
Staphylococcus
30-70%
Most common in myocardial abscess, purulent pericarditis, valve ring
Most common in people who inject drugs
Streptococcus
10-28%
Viridians streptococcus
- Alpha-hemolytic, nontypeable
- More common in underlying cardiac abnormalities (mitral valve prolapse,
rheumatic heart disease)
Enterococci
E. faecalis, E. faecium
Attacks abnormal heart valves in older men after GU and younger women after OB
Fastidious Gram-Negative Coccobacili
5-10%
HACEK
Fungi
More common in narcotic addicts, patients after reconstructive CV surgery, patients after prolonged antibiotic therapy
Clinical Presentation
Fever
Heart murmur
Embolic phenomena
Laboratory findings
BLOOD CULTURES: draw 3 sets from different sites initially, then repeat (2 sets) every 48-72 hours
Normochromic, normocytic anemia
Leukocytosis
Increased ESR and CRP
Proteinuria, hematuria
Diagnosis
Duke criteria
2 major OR 1 major + 3 minor OR 5 minor
Major criteria
Positive blood culture
- Common organism isolated from 2 or more separate blood culture sets
- Rare organism isolated from 3 or more separate blood culture sets
Positive laboratory test
Endocardiography or CT scan
- Shows vegetation, valvular/leaflet perforation, valvular/leaflet aneurysm, abscess, intracardiac fistula
- Significant new vegetation
- New partial dehiscence of prosthetic valve
Positron emission with 18F-fluorodeoxyglucose
- Abnormal activity involving valve, aortic graft, intracardiac device
Surgical
- Evidence of IE direct inspection during cardiac surgery
Minor Criteria
Predisposition: Hx of IE, prosthetic valve, Hx of valve repair, congenital heart disease, mod/severe regurgitation or stenosis, endovascular intracardiac implantable device, hypertrophic obstructive cardiomyopathy, injection drug use
Fever > 38 C
Vascular phenomena: Arterial emboli, septic pulmonary infarct, cerebral/splenic abscess,
mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage, Janeway lesion
Immunologic phenomena: RF +, Osler node, Roth spot, glomerulonephritis
Positive blood culture not meeting major criteria
Imaging: PET/CT showing abnormal activity within 3 months of implantation of prosthetic valve, aortic graft, intracardiac device leads
Physical exam: new valvular regurgitation identified on auscultation
Treatment
Goal: eradicate infection
Takes weeks to achieve; bactericidal activity is required
Native=4 weeks
Prosthetic=6 weeks
Starting at first negative culture (Day 0)
Viridans Strep & S. gallolyticus–>NATIVE
Highly penicillin-susceptible (MIC ≤ 12)
Penicillin G 12-18 million U/day +/- gentamicin 3 mg/kg/d x 2-4 weeks
Ceftriaxone 2 g q24h +/- gentamicin 3 mg/kg/d x 2-4 weeks
Vancomycin 15 mg/kg q12h x 4 weeks
Penicillin “relatively” resistant (MIC > 12 to ≤5)
Penicillin G 24 million U/day + gentamicin 3 mg/kg/d x 2-4 weeks
Ceftriaxone 2 g q24h + gentamicin 3 mg/kg/d x 2-4 weeks
Vancomycin 15 mg/kg q12h x 4 weeks
Viridans Strep & S. gallolyticus–>PROSTHETIC
Highly penicillin-susceptible (MIC ≤ 12)
Penicillin G 24 million U/day +/- gentamicin 3 mg/kg/d x 2-6 weeks
Ceftriaxone 2 g q24h +/- gentamicin 3 mg/kg/d x 2-6 weeks
Vancomycin 15 mg/kg q12h x 6 weeks
Penicillin “relatively” resistant (MIC > 12)
Penicillin G 24 million U/day + gentamicin 3 mg/kg/d x 6 weeks
Ceftriaxone 2 g q24h + gentamicin 3 mg/kg/d x 6 weeks
Vancomycin 15 mg/kg q12h x 6 weeks
Staphylococci–>NATIVE
MSSA:
Nafcillin/Oxacillin 12 g q24h x 6 weeks
- Uncomplicated right-sided = 2 weeks
Cefazolin 2 g q8h x 6 weeks
- If allergic to penicillin
MRSA:
Vancomycin 15 mg/kg q12h x 6 weeks
Daptomycin 8 mg/kg q24h x 6 weeks
- Right sided only
Alternatives:
- Ceftaroline–>salvage therapy only
- May see daptomycin + ceftaroline
- Linezolid: Only bacteriostatic + serotonin syndrome
Staphylococci–>Prosthetic
MSSA:
Nafcillin/Oxacillin 12 g q25h x ≥ 6 weeks
- Cefazolin if allergic to penicillin
PLUS Rifampin 300 mg q8h ≥ 6 weeks
PLUS Gentamicin 3 mg/kg/d x 2 weeks
MRSA:
Vancomycin 15 mg/kg q12h x ≥ 6 weeks
PLUS Rifampin 300 mg q8h x ≥ 6 weeks
PLUS Gentamicin 3 mg/kg/d x 2 weeks
Enterococci–> NATIVE OR PROSTHETIC
HACEK–> NATIVE OR PROSTHETIC
Ceftriaxone 2 g q24h–>preferred
Native= 4 weeks
Prosthetic=6 weeks
Ampicillin +/- sulbactam 12 g q24h
Native=4 weeks
Prosthetic=6 weeks
Ciprofloxacin 500 PO q12h or 400 mg IV q12h
Native=4 weeks
Prosthetic= 6 weeks
