endocarditis Flashcards
cardiac physiology
tricuspid valve - between right atrium and right ventricle - goes to lungs
mitral valve - between left atrium and ventricle - goes to body
infective endocarditis
syndrome resulting in colonization or invasion of the endocardium by various types of organisms
classification - valve location (tricuspid, mitral, pulmonic, aortic), native vs prostethic, organism
highest risk of endocaritis
presence of a prosthetic valve, previous endocarditis
staph in infective endocarditis
30-70% of cases**
usually S.aureus**
myocardial abscesses, purulent pericarditis and valve ring abscesses are more common
S. aureus - most common pathogen in IV drug users
no previous heart condition required for this
strep virdans in infective endocarditis
more common in patients with underlying cardiac abnormalities
enterococci in infective endocarditis
primarily infects abnormal heart valves
fastidious gram negative coccobacilli in infective endocarditis
HACEK - H. influ, H, parainflu, Aggregatibacter, cardiobacterium, eikenella, kingella
most adherent organism
P. aeruginosa
inoculum
may reach 10^10 GRU/gram of tissue - inoculum effect - problem in B-lactams
clinical presentation
variable and non-specific
heart murmur - may be 1st sign
embolic phenomena - vegetation dislodges and clots
lab findings
blood cultures - single most important lab test
draw at least 3 sets from different sites initially, then 2 sets q2-3 days
treatment - general considerations
primary goal: eradicate infection/sterilize vegitation
begin high dose, empiric antibiotics based on the most likely pathogens
bactericidal activity is required
determine MICs - MBCs if concerned about tolerance (MBC is 32xMIC)
duration of therapy: shortest is 2 weeks, but 4-6 weeks or longer needed depending on organism, susceptibilty, native vs prosthetic
optimize dosing based on PK/PD parameter
viridans group strep native valve endocarditis pen MIC less than 0.12***
Pen G 12-18 million units/day IV cont or in 4-6 doses x 4 weeks (may use ampicillin) OR ceftriaxone 2 g IV q24h x 4 weeks - Patients over 65 or with renal dynfxn or hearing impairment
Pen G 12-18 million units/day IV cont or in 6 doses x 2 weeks PLUS gentamicin 3 mg/kg/day IV x 2 weeks - not intended for patients with known cardiac or extracardiac abscessess of CrCl under 20; peak 3-4 and trough less than 1
Ceftriaxone 2 g IV q24 x 2 weeks PLUS gent 3 mg/kg/d IV x 2 weeks - peak 3-4 and trough less than 1
vancomycin 15 mg/kg IV q12h x 4 weeks - ONLY for patient unable to tolerate B-lactams; target trough 10-15
Viridans group strep - native valve endocarditis; pen MIC over 0.12, less than 0.5***
Penicillin G 24 million units/day IV cont or in 4-6 divided doses x 4 weeks PLUS gentamicin 3 mg/kg/day IV x 2 weeks - ampicillin 2g IV q4h is a reasonable option
Ceftriaxone 2 g IV q24h x 4 weeks PLUS gentamicin 3 mg/kg/d IV x 2 weeks
vancomycin 15 mg/kg IV q12h x 4 weeks - ONLY in patients unable to tolerate B-lactam therapy
Virdans group strep - prostetic valve endocarditic pen MIC less than 0.12***
Pen G 24 million units/day IV cont or in 4-6 divided doses x 6 weeks WITH or WITHOUT gentamicin 3 mg/kg/d IV x 2 weeks - combination therapy not superior* to monotherapy for highly susceptible strains, avoid gent if CrCl under 30, ampicillin 2 g IV q4h is a reasonable alternative
ceftriaxone 2 g IV q24h x 6 weeks WITH or WITHOUT gent 3 mg/kg/d IV x 2 weeks - combination therapy not superior* to monotherapy for highly susceptible strains, avoid gent if CrCl under 30, ampicillin 2 g IV q4h is a reasonable alternative
vancomycin 15 mg/kg q12h x 6 weeks - ONLY in patients unable to tolerate B-lactam therapy
viridans group strep - prosthetic valve endocarditis pen MIC over 0.12***
Pen G 24 millin units/day IV cont or in 4-6 divided doses x 6 weeks PLUS gent 3mg/kg/day IV x 6 weeks - ampicillin 2 g IV q24h is an alternative
ceftriaxone 2 g IV q24h x 6 weeks PLUS gent 3 mg/kg/d IV x 6 weeks
Vanc 15 mg/kg q12h x 6 weeks - ONLY in patients unable to tolerate B-lactam therapy
staphylococci - native valve endocarditis - oxacillin susceptible***
nafcillin or oxacillin 12 g/24 h in 4-6 divided doses x 6 weeks - for complicated right-sided IE; 2 weeks for uncomplicated right-sided IE
for pen-allergic: cefazolin 2 g IV q8h x 6 weeks - consider skin testing, avoid in patients with anaphylactoid reactions
staphylococci - native valve endocarditis - oxacillin resistant***
vancomycin 15 mg/kg q12h x 6 weeks - target trough 10-20
daptomycin 8+ mg/kg/dose q24h x 6 weeks - limited data regarding efficacy, FDA-approved for right-sided IE only
staphylococci - prosthetic valve endocarditis - oxacillin-susceptible ***
Nafcillin or oxacillin 12 g/24h in 6 divided doses x 6+ weeks PLUS rifampin 300 mg IV/PO q8h x 6+ weeks PLUS gent 3 mg/kg/day IV in 2-3 doses x 2 weeks - vanc in patients with immediate-type hypersensitivity reactions to B-lactams; cefazolin may be used in patients with non-immediate type hypersensitivity reactions
staphylococci - prosthetic valve endocarditis oxacillin resistant strains***
Vanc 15 mg/kg q12h x 6+ weeks PLUS rifampin 300 mg IV/PO q8h x 6+ weeks PLUS gent 3 mg/kg/day IV in 2-3 doses x 2 weeks - target trough 10-20
enterococci - native or prosthetic valve endocarditis - pen and gent susc, able to tolerate B-lactams ***
Ampicillin 2 g IV q4h x 4-6 weeks PLUS gentamicin 3 mg/kg/d in 2-3 divided doses x 4-6 weeks - NVE: 4 weeks if sxs of illness less than 3 months, 6 weeks if symptoms over 3 months, prosthetic valve: 6 weeks, recommended in patients with CrCl over 50, target peaks 3-4 and troughs under 1
Penicillin 18-30 million units/24 h IV cont or in 6 doses x 4-6 weeks PLUS gent 3mg/kg/d in 2-3 doses x 4-6 weeks - NVE: 4 weeks if sxs of illness less than 3 months, 6 weeks if symptoms over 3 months, prosthetic valve: 6 weeks, recommended in patients with CrCl over 50, target peaks 3-4 and troughs under 1
Ampicillin 2 g q4h x 6 weeks PLUS ceftriaxone 2 g q12h x 6 weeks - for patients with CrCl under 50 or who develop CrCl under 50 on gent
enterococci - native or prosthetic endocarditis - pen susc and AG resistant ***
ampicillin 2 g IV q4h x 6 weeks PLUS ceftriaxone 2 g IV q12h x 6 weeks - normal or impaired renal function, when lab is unable to provide rapid results of streptomycin serum conc
Enterococci - native or prosthetic valve endocarditis - pen susc, streptomycin susc, gent-resistant ***
ampicillin 2 g IV q4h x 4-6 weeks PLUS streptomycin 15 mg/kg/d IV in 2 divided doses x 4-6 weeks - only for patients if rapid measurement of streptomycin conc is available, adjust streptomcycin dose to obtain peaks of 20-35 and troughs less than 10
penicillin 18-30 million unites/24 h either cont or in 6 doses x 4-6 weeks PLUS streptomycin 15 mg/kg/d IV in 2 divided doses x 4-6 weeks - only for patients if rapid measurement of streptomycin conc is available, adjust streptomcycin dose to obtain peaks of 20-35 and troughs less than 10
Enterococci - native or prosthetic valve endocarditis - vanc regimens in patients unable to tolerate B-lactam therapy; vanc and AG susc ***
vanc 15 mg/kg IV q12h x 6 weeks PLUS gent 3 mg/kg/d IV in 3 divided doses x 6 weeks - vanc target troughs 10-20 and gent target peaks 3-4 and troughs under 1
Enterococci - native or prosthetic valve endocarditis - intrinsic resistant to pen or B-lactamase producer ***
vanc 15 mg/kg IV q12h x 6 weeks PLUS gent 3 mg/kg/d IV in 3 divided doses x 6 weeks - if B-lactamase producing straing and able to tolerate B-lactam, Amp-sulbactam 3 g IV q6h plus gent may be used
Enterococci - native or prosthetic valve endocarditis -penicillin, AG, and vanc resistant strains
daptomycin 10-12 mg/kg q24h x over 6 weeks - monitor CPK
linezolid 600 mg IV or PO q12h x over 6 weeks - concern for severe bone marrow suppression (thrombocytopenia (over 2 weeks)), neuropathy and drug interactions
