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Pharm II > Endocarditis > Flashcards

Endocarditis Flashcards

1
Q

Sx of endocarditis

A 
Fever
Chills
Weakness
Dyspnea
Night sweats
Weight loss and/or malaise
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2
Q

Signs of endocarditis

A 
Fever
Heart murmur (new or changing)
Embolic phenomenon
Splenomegaly
-Osler nodes
-Janeway lesions
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3
Q

RFs of endocarditis

A 
Structural heart dz
IV drug use
Prosthetic heart valves
Prior hx of endocarditis
Chronic IV access
DM
MVP with regurg
Chronic heart failure
Congenital heart dz
25% of IE cases do not have RFs
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4
Q

Diagnostic testing

A 
Three sets of blood cultures
-Separate sites
-Over at least 1-hour period
-Prior to initiation of empiric tx
- Most reliable test
WBC: nl or only slightly elevated
Transthoracic echocardiography (TTE)
-Type of echo (u/s)
-Non-invasive
-Performed in all cases
Transesophageal echo (TEE)
-Type of echo test
-View the heart's valves and chambers
-Improves sensitivity of diagnostic criteria
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5
Q

Duke Criteria

A

3 categories:
Definite
Possible
Rejected

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6
Q

Modified Duke Criteria

A

2 major criteria OR
1 major and 3 minor criteria OR
5 minor criteria

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7
Q

Possible IE- Duke

A

1 major and 1 minor criteria OR

3 minor criteria

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8
Q

Rejected IE- Duke

A

Firm alternative dx OR
Resolution of manifestations with therapy for less than or equal to 4 days
OR
No pathologic evidence at surgery or autopsy after ab

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9
Q

Usual bacteria

A

S. aureus
S. viridians
S. bovis
Enterococcus

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10
Q

What is HACEK, and what does it stand for?

A 
Slow-growing fastidious organisms that may need 3 weeks to grow out of blood cultures
Haemophilus
Aggregatibacter
Cardiobacterium haminis
Eikenella
Kingella kingae
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11
Q

What is the incidence of the bacteria from most common to least common?

A 
Staph
-IV drug users
-Incidence increasing in hospital-acquired infections
Strep
Enterococci
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12
Q

Goals of therapy

A

Eradicate infection

Definitively treat sequelae of destructive intra-cardiac and extra-cardiac lesions

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13
Q

How often should blood cultures be obtained?

A

Q24-48h until blood stream infection is cleared

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14
Q

Clinical pearls for abx therapy

A

Abx regimens should be administered at the same time or temporally close to maximize synergistic killing
Make sure MICs are good

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15
Q

Abx therapy goals

A

Tx tailored to appropriate organism(s) isolated from blood cultures
Empiric tx
Bactericidal agents
High serum concentration(s) necessary to penetrate avascular vegetation
Infectious disease consult
Parenteral route necessary
Adequate dose
Initiate appropriate empirical abx timely
Duration: 4-6 wks

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16
Q

Beta lactam MOA

A

Inhibits bacterial wall synthesis

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17
Q

SEs of beta lactams

A

Anaphylaxis
Hives
Pseudomembranous colitis
Seizures

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18
Q

Examples of beta lactams

A

Pen G
Nafcillin/Oxacillin
Ampicillin/sulbactam

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19
Q

Indication for beta lactams

A

Strep
Enterococcus
S. aureus

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20
Q

Type 1 Ig-E mediated rxns

A 
Anaphylaxis
Urticaria
Stevens-Johnson
Angioedema
Bronchospasm
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21
Q

Cephalosporin MOA

A

Inhibits bacterial cell wall synthesis

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22
Q

SEs of cephalosporins

A

Skin rash
Diarrhea
Leukopenia

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23
Q

Aminoglycosides MOA

A

Interferes with bacterial protein synthesis by binding to 30s and 50s ribosomal subunits

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24
Q

SEs of aminoglycosides

A 
Nephrotoxic
Ototoxic
Ataxia
Confusion
C. difficile-associated diarrhea
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25
Q

Examples of aminoglycosides

A

Gentamicin
Tobramycin
Amikacin
Combined with additional abx

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26
Q

Vancomycin MOA

A

Inhibits bacterial cell wall synthesis

Bactericidal

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27
Q

SEs of vancomycin

A

Nephrotoxicity

Red Man syndrome

28
Q

Monitoring for vanc

A

Goal trough for IE (15-20 mg/dL)

29
Q

Indication for Vanc

A

Gram + (including Methicillin resistant)

30
Q

What is the first line agent for strep?

A

Pen G

31
Q

What is the 2nd line agent for strep?

A

Ceftriaxone + Gentamicin

32
Q

What is the agent for PCN and ceph allergy?

A

Vanc

33
Q

Pen G dose for strep

A

12-18 million units (24 million heart valves) over 24h

3-4 million units IV q4h

34
Q

Duration of Pen G for strep

A

4 wk

35
Q

Ceftriaxone + Gentamicin dose for strep

A

2 gms IV/IM q24h/3mg/kg IV q24h

36
Q

Vanc dose for strep

A

30 mg/kg IV q24h in 2 equally divided does

Goal trough 15-20 mcg/mL

37
Q

Pearls in tx of strep IE

A

Bacteriologic cure rates greater than or equal to 98% may be anticipated in pts who complete 4 wks of therapy
Ampicillin is an alternative to PCN
Addition of Gentamicin to PCN exerts a synergistic effect
-2 wk regimen of PCN or ceftriaxone + gentamicin resulted in similar cure rates as monotherapy

38
Q

Duration of staph tx

A

6 wks, except Gentamicin, which is 3-5 days

39
Q

What is 1st line tx for staph?

A

Nafcillin/Oxacillin (MSSA)

40
Q

What is 2nd line tx for staph?

A

Cefazolin (PCN allergy)

41
Q

What is the synergy tx for staph?

A

Gentamicin

42
Q

What is the Oxacillin-resistant tx for staph?

A

Vanc

43
Q

Nafcillin/Oxacillin dose for staph

A

2 gms IV q4h

44
Q

Cefazolin dose for staph

A

2 gms IV q8h

45
Q

Gentamicin dose for staph

A

3 mg/kg IV q24h dose then “Rx to dose”

46
Q

Vanc dose for staph

A

30 mg/kg per 24h IV in 2 equally divided doses then “Rx to dose”

47
Q

What is the main tx for staphylococci prosthetic valve?

A

Nafcillin/Oxacillin +
Rifampin +
Gentamicin

48
Q

What is the duration for both txs for staphylococci prosthetic valves?

A

Greater than or equal to 6 wks

49
Q

What is the tx for oxacillin-resistant organisms for staphylococci prosthetic valves?

A

Vanc +
Rifampin +
Gentamicin

50
Q

Nafcillin/Oxacillin + Rifampin + Gentamicin doses for staphylococci prosthetic valve

A

2 gms IV q4h
900 mg per 24h IV/PO in 3 equally divided doses
3 mg/kg per 24h in 2 or 3 equally divided doses x 2 wks

51
Q

Vanc + Rifampin + Gentamicin doses for staphylococci prosthetic valve

A

30 mg/kg 24h in 2 equally divided doses
900 mg per 24h IV/PO in 3 equally divided doses
3 mg/kg per 24h in 2 or 3 equally divided doses x2 wks

52
Q

Pearls in tx of staphylococci IE

A

S. aureus primarily involves L side of the heart
IV drug abuse is associated with the right side of the heart
Only 3–5 days of combo therapy with Gentamicin

53
Q

PCN desensitization

A

Should be considered when sub-optimal response to cephalosporin or vanc
Very small doses administered and orally or IV and are gradually increased in stepwise manner until a full therapeutic dose is reached
Occurs in hospital setting
Completed in 4-12 hrs
Pts remain on PCN continuously for the duration of therapy

54
Q

Vanc intolerance

A

TMP-SMX, doxy or minocycline (either with or without rifampin) and linezolid are alternatives
Rifampin resistance develops quickly when used as monotherapy

55
Q

What regimens are prescribed for IE due to enterococcus?

A

(Ampicillin + Ceftriaxone)

[Ampicillin or Pen G] + Streptomycin

56
Q

Dosing of ampicillin + ceftriaxone for enterococcus

A

2 g IV q4h

2 g IV q12h

57
Q

Dosing of (ampicillin or Pen G) + streptomycin

A

2 g IV q4h
18-30 million units/24 hr continuously or in 6 equally divided doses
15 mg/kg IBW per 24h IV in BID doses

58
Q

Pearls in enterococcus tx

A

Enterococcus resistance to PCN, ampicillin and vanc exist
Must add synergistic effect of Gentamicin
<3 mos of sx require 4 wks therapy
>3 mos of sx require 6 wks of therapy

59
Q

What is 1st line tx in IE due to HACEK?

A

Ceftriaxone

60
Q

What is 2nd line tx in IE due to HACEK?

A

Ampicillin/sulbactam

61
Q

Ceftriaxone dose for HACEK

A

2 gms IV/IM q24h

62
Q

Ampicillin-sulbactam dose for HACEK

A

3 gms IV q6h

63
Q

Regimen for Pseudomonas

A

Tobramycin +

PIP-TZ or Ceftazadime or Cefepime

64
Q

Tobramycin +

PIP-TZ or Ceftazidime or Cefepime doses for Pseudomonas

A

8 mg/kg per day IV/IM in once daily doses
(Peak levels: 15-20 mcg/mL)
(Trough less than or equal to 2 mcg/mL)

65
Q

Guidelines Daptomycin

A 
Vanc resistant if MICs are >4 ug/mL
Coverage
-MRSA/MSSA (alt. to Vanc)
--Dose 8-10 mg/kg IV daily
-Small studies of VRE IE tx with daptomycin
--Conclusion difficult to define success rate
--Combo with ampicillin or ceftaroline
--Dose 10-12 mg/kg IV daily
66
Q

Prophylaxis for bacterial endocarditis

A

Prophylactic regimen targeted against likely organism

  • Strep viridians: oral, resp., esophageal
  • Enterococcus: genitourinary, GI
  • S. aureus: infected skin, mucosal surfaces
67
Q

Prophylaxis doses for dental, oral, resp., esophageal

A

Amoxicillin 2 g PO 1 h before procedure OR
Ampicillin 2 g IM/IV 30 min before procedure
PCN allergic:
Clindamycin- 600 mg PO 1 hr before procedure OR 600 mg IV 30 min before
Cephalexin OR Cefadroxil 2 g PO 1 hr before
Cefazolin 1 gm IM/IV 30 min before procedure
Azithromycin or Clarithromycin 500 mg PO 1 hr before

Pharm II (8 decks)

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