Endocarditis Flashcards by Reagan Smith

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

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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

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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

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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

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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

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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

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Clinical Stigmata of Endocarditis:

Peripheral Manifestations

Osler’s nodes
Janeway lesions
Splinter hemorrhages
Petechiae
Roth spots

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Diagnosis of Endocarditis: major criteria (3)

1) microbio
2) imaging
3) surgical

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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

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Diagnosis of Endocarditis: minor criteria - clinical symptoms

fever
Vascular phenomena
Immunologic phenomena

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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

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T or F: Begin counting days for treatment duration on first day of negative blood cultures

TRUE

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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

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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

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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

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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