Endocarditis Flashcards
Risk Factors Predisposing for Infective Endocarditis
- Presence of a ___ valve (highest risk)
- Previous endocarditis (highest risk)
- Acquired valvular dysfunction
- Mitral valve prolapse with regurgitation
- IV drug use
- Congenital heart disease
- Cardiac implantable devices
- Surgically constructed systemic pulmonary shunts or conduits
- Hypertrophic cardiomyopathy
- prosthetic
Etiologic Microorganisms in Infective Endocarditis
___ (30-70% of cases)
- S. aureus – most common (also in IV drug use)
- Myocardial abscesses (with conduction disturbances), purulent pericarditis, and valve ring abscesses are more common
- Early PVE – S. aureus and coagulase-negative staphylococci
___ (10-28% of cases)
- More common in patients with underlying cardiac ___ (e.g., mitral valve prolapse, rheumatic heart disease)
- Staphylococci
- viridans Streptococci
- abnormalities
Etiologic Microorganisms in Infective Endocarditis
Enterococci (5-18% of cases)
- ___ , ___
- Affects older men after GU procedure and younger women after OB procedure
- Primarily infects ___ heart valves (capable of attacking normal heart valves, causing destruction)
Fastidious gram-negative coccobacilli (5-10% of cases)
- Part of upper respiratory tract and oropharyngeal flora
- ___ group
Fungi
- Mostly seen in those who abuse narcotics, patients after reconstructive cardiovascular surgery, patients after prolonged IV and/or antibiotic therapy
- Poor prognosis (large ___ )
- E. faecalis, E. faecium
- abnormal
- HACEK
- vegetation
Pathophysiology
- Bacterial growth in vegetation is unimpeded due to lack of host defenses.
- Inoculum may reach 10^9 to 10^10 CFU/gram of tissue
- Valvular tissue may be destroyed with ___ formation
- vegetation
Clinical Presentation
Highly variable and non specific – depends on chronicity of infection
- Fever (95%)
- Malaise
- Fatigue
- Chills
- Heart murmur
- Embolic phenomena
- Skin manifestations
- Weakness
- Dyspnea
- Night sweats
- Weight loss
Laboratory Findings
Hematologic
- Normochromic, normocytic anemia (70-90%)
- Leukocytosis (5-15%) – may be normal to slightly elevated
Increased ESR and CRP
Urinalysis
- Proteinuria
- Microscopic hematuria
Blood cultures – single most important laboratory test
- Bacteremia is ___ and low grade (< 100 CFU/ml blood)
- Draw at least ___ sets from different sites initially, then 2 sets q __ - __ days
- Culture and susceptibility testing
- continuous
- 3
- 2-3
Clinical Stigmata of Endocarditis:
Peripheral Manifestations
- Osler’s nodes
- Janeway lesions
- Splinter hemorrhages
- Petechiae
- Roth spots
Diagnosis of Endocarditis: major criteria (3)
Diagnosis of Endocarditis: major criteria (3)
1) microbio
2) imaging
3) surgical
Diagnosis of Endocarditis: minor criteria - predisposition
- Previous history of IE
- Prosthetic valve
- Previous valve repair
- Congenital heart disease
- More than mild regurgitation or stenosis of any etiology
- Endovascular intracardiac implantable electronic device
- Hypertrophic obstructive cardiomyopathy
- Injection drug use
Diagnosis of Endocarditis: minor criteria - clinical symptoms
- fever
- Vascular phenomena
- Immunologic phenomena
Treatment – General Considerations
Complete eradication of organisms takes weeks to achieve
- Shortest duration is __ weeks, but __ - __ weeks (or longer) needed depending on organism, organism susceptibility, native valve vs. prosthetic valve
- vegetation; cells may exist in a state of reduced metabolic activity and cell division; potential for ___ subpopulations
Begin ___ dose, ___ antibiotics based on the most likely pathogen(s)
Bactericidal activity is required; synergistic combinations needed for some pathogens
- 2, 4-6
- resistant
- high, empiric
T or F: Begin counting days for treatment duration on first day of negative blood cultures
TRUE
Viridans Group Streptococci and S. gallolyticus - Native Valve
Highly Penicillin Susceptible
- ___ or ___ 4 weeks
- ___ + ___ 2 weeks
- ___ + ___ 2 weeks
- ___ 4 weeks
- PCN, Ceftriaxone
- PCN, gentamicin
- ceftriaxone, gentimicin
- vanc
Viridans Group Streptococci and S. gallolyticus - Native Valve
Penicillin “Relatively” Resistant
- ___ (4 weeks) + ___ (2 weeks)
- ___ (4 weeks) + ___ (2 weeks)
- ___ (4 weeks)
- PCN, gent
- cefriaxone, gent
- vanc
Ampicillin 2 g IV q4h is reasonable
Viridans Group Streptococci and S. gallolyticus - Prosthetic Valve
Penicillin Susceptible
- ___ (6 weeks) +/- gent (2 weeks)
- ___ (6 weeks) +/- gent
- ___ (6 weeks)
- PCN
- ceftriaxone
- vanco
if S, we dont really need gent
Viridans Group Streptococci and S. gallolyticus - Prosthetic Valve
Penicillin Relatively or Fully Resistant
- ___ (6 weeks) + ___ (6 weeks)
- ___ (6 weeks) + ___ (6 weeks)
- ___ (6 weeks)
- PCN, gent
- ceftriaxone, gent
- vanc
Staphylococci – Native Valve Endocarditis
MSSA
- ___ or ___ (6 weeks)
- allergic - non-anaphylactic: ___ (6 weeks)
MRSA
- ___ or ___ (6 weeks)
- nafcillin, oxacillin
- cefazolin
- vanc, dapto
Daptomycin and Staphylococcal Endocarditis
FDA-approved for ___ sided endocarditis
- Minimum of __ - __ days for uncomplicated infection; __ - __ days for complicated disease
Higher doses up to 10 mg/kg have demonstrated increased rate of
bacterial killing
- may reduce emergence of resistance
right
- 14-28
- 28-42
MRSA Alternatives in Endocarditis
___ - Reserved for salvage therapy
- Case reports suggest that ceftaroline plus daptomycin may be an option in reatment refractory ___ infections
Ceftaroline
S. aureus
MRSA Alternatives in Endocarditis
linezolid and tedizolid
both are kinda eh
- not great evidence
Staphylococci – Prosthetic Valve Endocarditis
oxacillin susceptible
___ or ___ (≥6 weeks) + ___(≥6 weeks) + ___ (2 weeks)
oxacillin resistant
___ (≥6 weeks) + ___ (≥ 6 weeks) + ___ (2 weeks)
- nafcillin, oxacillin, rifampin, gentamicin
- vanc, rifampin, gentamicin
Enterococci – Native or Prosthetic Valve
Penicillin- and Gentamicin-Susceptible
- ___ + ___ (4-6 weeks)
- ___ + ___ (4-6 weeks)
- ___ + ___ (6 weeks)
Prosthetic valve: __ weeks
- last regiment for pts with CrCl < 50
- ampicillin, gent
- PCN, gent
- ampicillin, ceftriaxone
- 6
Enterococci – Native or Prosthetic Valve
Penicillin-Susceptible & Aminoglycoside-Resistant
- ___ + ___ (6 weeks)
Penicillin-Susceptible, Streptomycin-Susceptible, Gentamicin-Resistant
- ___ + ___ (4-6 weeks)
- ___ + ___ (4-6 weeks)
- ampicillin, ceftriaxone
- ampicillin, streptomycin
- PCN, streptomycin
Enterococci – Native or Prosthetic Valve Endocarditis
Vancomycin Regimens in Patients Unable to Tolerate β-Lactam Therapy; Vancomycin and Aminoglycoside-Susceptible Strains
- ___ + ___ (6 weeks)
Intrinsic Resistance to Penicillin or β-Lactamase-Producer
- ___ + ___ (6 weeks)
- vanco, gent
Enterococci – Native or Prosthetic Valve Endocarditis
Penicillin, Aminoglycoside, and Vancomycin-Resistant
Strains
- ___ (> 6 weeks)
- ___ (> 6 weeks)
Valve replacement may be necessary for cure.
- daptomycin
- linezolid
HACEK Organisms – Native or Prosthetic Valve Endocarditis
- ___ (preferred)
- ___ +/- ___
- ___
NVE: ___ weeks
PVE: ___ weeks
- cefriaxone
- ampicillin, sulbactam
- ciprofloxacin
- 4, 6
Non-HACEK Gram-Negative Bacilli in Endocarditis
- Rare: < 2% of endocarditis cases
- Associated with IV drug use and healthcare exposure in > 50% of cases
- ___ and ___ most common organisms
- Management: Cardiac surgery and prolonged antibiotic therapy (> __ weeks), especially with left-sided valvular involvement
- Treatment determined based on culture and susceptibility results.
- Combination of β-lactam (penicillins, cephalosporins, carbapenems) plus either aminoglycoside or fluoroquinolone for 6 weeks
- E. coli, P. aeruginosa
- 6
Fungal Endocarditis
- rare
- Risk factors: cardiovascular devices (pacemakers, defibrillators, prosthetic valves);
central venous catheters - Organisms: Candida and Aspergillus species
- Mortality unacceptably high
- Combination of parenteral anti-fungal agents containing ___ plus ___ is initial treatment of choice
Duration of therapy: > __ weeks (may require life-long suppressive therapy with oral azole agent ( ___ )
- amphotericin B, flucytosine
- 6, fluconazole
Culture-Negative Endocarditis
- Inadequate microbiological techniques
- Highly fastidious bacteria or fung
- smh: Previous administration of antimicrobial agents ___ blood cultures
before
Culture-Negative Endocarditis
Native Valve Endocarditis
- ___ + ___ (4-6 weeks) - acute onset
- ___ / ___ + ___ (4-6 weeks) - subacute onset
- vanco, cefepime
- ampicillin/sulbactam, vanco
Culture-Negative Endocarditis
Prosthetic Valve Endocarditis (early, < 1 year)
- ___ (6 weeks) + ___ (2 weeks) + ___ (6 weeks) + ___ (6 weeks)
Prosthetic Valve Endocarditis (late > 1 year)
- ___ + ___ (6 weeks)
- vanc, gent, rifampin, cefepime
- vanc, ceftriaxone
Culture-Negative Endocarditis
Suspected Bartonella, Culture-Negative
- ___ (6 weeks) + ___ (2 weeks) +/- ___ (6 weeks)
Documented Bartonella, Culture-Positive
- ___ (6 weeks) + ___ (2 weeks)
- ceftriaxone, gentamicin, doxycycline
- doxycycline, gentamicin
Monitoring Parameters
fever
- Continued fever can be caused by ineffective antimicrobial therapy, emboli, infection of intravascular catheters, or drug fever
Blood cultures and susceptibilities
- should become negative within a ___
- Re-culture q __ - ___ h until cultures are negative
- week
- 24, 48
Prevention of Endocarditis
Only an extremely small number of cases of IE may be prevented by antibiotic prophylaxis for dental procedures
Most beneficial in patients with underlying cardiac conditions associated with highest risk of adverse outcome from IE
Antibiotics not recommended for patients undergoing GI or GU procedures
if they are at risk and going to dentist they should get Abx prophylaxis
