Endocarditis

Question 0

Describe pathophysiology of endocarditis

Answer 0

Infxn results from colonization of damaged valvular endothelium by circulating bacteria with specific adherence properties

Question 1

Endocarditis is more likely in…

Answer 1

2x more likely in Men

Age > 50

Question 2

Endothelial damage may result from…

Answer 2

• jet-lesions due to turbulent blood flow
• electrodes
• catheters
• repeated IV injections of solid particles in IVDA

Question 3

Which side of heart is more likely in IVDA?

Answer 3

Right

Question 4

Which side of heart is more likely in Community-associated and healthcare acquired?

Answer 4

Left

Question 5

Which side of heart is more likely to have a high mortality rate?

Answer 5

Left

Question 6

Which side of heart is frequently associated with embolic stroke?

Answer 6

Left

Question 7

Which side of heart is surgical benefits greatest in early phase of IE?

Answer 7

Left

Question 8

Which side of heart involves the aortic and mitral(bicuspid) valves?

Answer 8

Left

Question 9

Which side of heart involves the tricuspid valve?

Answer 9

Right

Question 10

Which side of heart is septic pulmonary embolism more common?

Answer 10

Right

Question 11

Which valve is rarely involved in IE?

Answer 11

Pulmonary Valve

Question 12

Which side of heart has higher IE cure rates (>85%)?

Answer 12

Right

Question 13

Which side of heart is IE surgery rarely indicated?

Answer 13

Right

Question 14

RFs of IE…

Answer 14

Prosthetic Valve/Implant
Previous IE
Congenital Heart Dz
Chronic IV
Diabetes
Healthcare related exposure
Acquired valvular dysfunction 
CHF
Mitral valve prolapse with regurgitation
IV drug abuse

Question 15

Most common pathogens in IE…

Answer 15

Staph
Strep
Enterococcus

Question 16

What is the most common pathogen in IVDA?

Answer 16

S. aureus

Question 17

S. Aureus is coagulase ___ .

Answer 17

Positive

Question 18

Coagulase ___ ______ is more common in prosthetic valve endocarditis.

Answer 18

Negative staph

also staph. aureus (coagulase positive)

Question 19

Most common IE pathogen for IVDA’s?

Answer 19

Staph. aureus

Question 20

Major criteria for diagnosis of IE?

Answer 20

Positive culture (staph, strep, enterococcus or HACEK)
TTE/TEE

Question 21

Diagnosis of Definite IE

Answer 21

2 major
1 major + 3 minor
5 minor

Question 22

Diagnosis of Possible IE

Answer 22

1 major + 1 minor

3 minor

Question 23

Tx of NATIVE valve, PCN-S strep

Answer 23

Pen G or Ceftriaxone x 4 weeks
or
Pen G or Ceftriaxone PLUS Gent x 2 weeks

If PCN allergy, use Vanc x 4 weeks

Question 24

Tx of NATIVE valve, PCN-I/R strep

Answer 24

Vanc x 4 weeks | Pen G or Ceftriaxone x4 wks PLUS Gent x2wks

Question 25

Tx of PROSTHETIC valve, PCN-S strep

Answer 25

Pen G or Ceftriaxone x6 wks +/- Gent x2 wks | Vanc x6 wks if PCN allergy

Question 26

Tx of PROSTHETIC valve, PCN-I/R strep

Answer 26

Vanc x6 wks | Pen G or Ceftriaxone PLUS Gent x6 wks

Question 27

Tx of NATIVE valve, MSSA

Answer 27

Nafcillin or oxacillin x 6 weeks | +/- Gent x3-5 days

Question 28

Tx of NATIVE valve, MSSA (w/PCN allergy)

Answer 28

Cefazolin x6 weeks (minor allergy) If Anaphylaxis to PCN, use Vanc. x6 wks

Question 29

Tx of NATIVE valve, MRSA

Answer 29

Vanc x6 weeks

Question 30

Tx of PROSTHETIC valve, MSSA

Answer 30

Nafcillin or oxacillin >6 weeks PLUS Rifampin >6 weeks PLUS Gentamicin x2 weeks

Question 31

Tx of PROSTHETIC valve, MRSA

Answer 31

Vanc >6 weeks PLUS Rifampin >6 weeks PLUS Gentamicin x2 weeks

Question 32

When do you need to use Vanc + Gent in strep?

Answer 32

Never

Question 33

When do you need to use Vanc + Gent in staph?

Answer 33

Only with PROSTHETIC valve MRSA

Question 34

Tx of NATIVE or PROSTHETIC valve, ENTEROCOCCUS (PCN, Gent, and Vanc - S)

Answer 34

``` Amp or Pen G x4-6 weeks PLUS Gent (makes it cidal) x4-6 weeks ``` Native <3months = 4 weeks, All others x6 weeks

Question 35

Tx of NATIVE or PROSTHETIC valve, ENTEROCOCCUS (PCN, Streptomycin, and Vanc - S) and (Gent -R)

Answer 35

Ampicillin or Pen G PLUS Streptomycin x4-6 weeks (Use Vanc if PCN allergy)

Question 36

Tx of NATIVE or PROSTHETIC valve, ENTEROCOCCUS (PCN - R) and (Vanc, Aminoglycoside - S)

Answer 36

Vanc PLUS Gent x6 weeks

Question 37

Tx of NATIVE or PROSTHETIC valve, ENTEROCOCCUS (PCN, Aminoglycoside, and Vanc - R) positive for Enterococcus faecium

Answer 37

Linezolid >8 weeks (monitor plts) or | Quinupristin-Dalfopristin >8 weeks

Question 38

Tx of NATIVE or PROSTHETIC valve, ENTEROCOCCUS (PCN, Aminoglycoside, and Vanc - R) positive for Enterococcus faecalis

Answer 38

Ceftriaxone PLUS Ampicillin > 8 weeks or Imipenem/cilastatin PLUS Ampicillin > 8 wks (seizures) Both make use of double beta-lactam therapy

Question 39

How to measure DUR in IE pts and other monitoring

Answer 39

Set length of tx from 1st day of negative blood culture Monitor renal fx w/Aminoglycosides >1 wk Monitor Vanc/Gent trough concentrations

Question 40

DUR for all staph IE

Answer 40

6 weeks (plus 2 weeks for Gent in prosthetic)

Question 41

When do you use Rifampin in IE?

Answer 41

Tx of PROSTHETIC IE - MSSA and MRSA