Endocarditis Flashcards
Endocarditis
inflammation of the endocardium (the membrane lining the chambers of the heart and covering the cusps of the heart valves )
can refer to infection of the heart valves
Endocarditis: signs and symptoms
fever chills weakness dyspnea night sweats weight loss malaise
heart murmur (new or changing) embolic phenomenon splenomegaly janeway lesions osler nodes
Endocarditis: diagnosis
modified duke criteria (major and minor)
Endocarditis: major pathogens
streptococci
staphylococci
enterococci
Endocarditis: treatment approach
high dose parenteral bactericidal antibiotics for an extended period
(microorganisms enclosed within vegetations and fibrin deposits)
surgery (valvectomy, valve replacement)
Staphylococcal Endocarditis: IVDA (pathogen, valve effected, treatment)
S. aureus
tricuspid valve (R sided infective endocarditis)
2 week course of nafcillin or oxacillin PLUS aminoglycoside
Which organism is the MC cause of infective endocarditis among those with IVDA and venous catheters?
S. aureus
Which pathogen is a prominent cause of prosthetic valve endocarditis?
Staphylococcus epidermidis
Streptococcal Endocarditis
MCC: viridans streptococci
usually subacute
penicillin G (or ceftriaxone)
Streptococcal Endocarditis: viridans streptococci
common inhabitants of human mouth and gingiva (prophylaxis for dental work)
common cause of endocarditis in NATIVE valves
Enterococcal Endocarditis
MCC: E. faecalis
normal inhabitants of human GI tract and anterior urethra
HACEK organisms
Haemophilus parainfluenzae Haemophilus aphrophilus Actinobacillus actinomycetemcomitans Cardiobacterium hominis Eikenella corrodens Kingella kingae
gram negatives
Endocarditis: HACEK
native valve, community acquired
subacute
LARGE vegetations and emboli
high dose ampicillin with gentamicin for 4 weeks
What is the drug of choice for endocarditis?
beta lactam antibiotics
Endocarditis: Empiric Drug Therapy: Native Valve
vancomycin plus ceftriaxone
Endocarditis: Empiric Drug Therapy: Prosthetic Valve
vancomycin plus gentamicin plus rifampin
Native Valve Endocarditis: viridans group streptococci: PCN susceptible
4 weeks: PCN G or ceftriaxone or vancomycin
2 weeks: PCN G or ceftriaxone PLUS gentamicin
Native Valve Endocarditis: staphylococci
oxacillin sensitive and resistant drug therapy
Gentamicin
works synergistically with other agents to shorten the duration
beyond 2 weeks increases the risk for ototoxicity and nephrotoxicity
Gentamicin: not intended for
>65 years of age children CNVIII impairment creatinine clearance <20mL/min known cardiac or extracardiac abscess infection with Abiotrophia, Granulicatella, Gemalia
Native Valve Endocarditis: viridans group streptococci: PCN resistant
PCN G (4 weeks) plus gentamicin (2 weeks)
ceftriaxone (4 weeks) plus gentamicin (2 weeks)
vancomycin (4 weeks)
Native Valve Endocarditis: staphylococci: oxacillin susceptible
6 weeks:
- nafcillin or oxacillin
- cefazolin
- vancomycin
- daptomycin
Native Valve Endocarditis: staphylococci: oxacillin resistant
6 weeks:
- vancomycin
- daptomycin
Prosthetic Valve Endocarditis: viridans group streptococci: PCN susceptible
6 weeks
PCN G or ceftriaxone
2 weeks
with or without gentamicin
6 weeks
vancomycin
Prosthetic Valve Endocarditis: viridans group streptococci: PCN resistant
6 weeks
- PCN G plus gentamicin
- ceftriaxone plus gentamicin
- vancomycin
Prosthetic Valve Endocarditis: staphylococci: oxacillin susceptible
> 6 weeks
nafcillin or oxacillin or vancomycin (may sub cefazolin if hypersensitivity)
> 6 weeks
plus rifampin
2 weeks
plus gentamicin
Prosthetic Valve Endocarditis: staphylococci: oxacillin resistant
> 6 weeks
vancomycin plus rifampin
2 weeks
plus gentamicin
Native and Prosthetic Valve Endocarditis: enterococci: susceptible
4-6 weeks
- ampicillin plus gentamicin
- PCN G plus gentamicin
6 weeks
- ampicillin plus ceftriaxone
- vancomycin plus gentamicin
Native and Prosthetic Valve Endocarditis: enterococci: resistant
gentamicin resistant: use streptomycin
penicillin resistant:
6 weeks
-ampicillin sulbactam plus gentamicin
-vancomycin plus gentamicin
resistant to PCN, aminoglycodies, vancomycin:
>6 weeks
-linezolid
-daptomycin
Endocarditis: HACEK
4 weeks
- ceftriaxone
- ampicillin or ampicillin-sulbactam
- ciprofloxacin
Endocarditis: culture negative native valve
vancomycin plus cefepime or ampicillin-sulbactam
Endocarditis: culture negative prosthetic valve
EARLY (<1 year)
6 weeks
vancomycin plus cefepime plus rifampin plus gentamicin
LATE (>1 year)
6 weeks
vancomycin plus ceftriaxone
Endocarditis: suspected Bartonella (culture negative)
6 weeks
ceftriaxone
2 weeks
plus gentamicin
6 weeks
with or without doxycycline
Endocarditis: (culture positive) Bartonella
6 weeks doxycycline
plus
2 weeks gentamicin
Daptomycin: ADE
myopathy
rhabdomyolysis
Gentamicin: ADE
nephrotoxicity
ototoxicity
neuromuscular blockade
Linezolid: ADE
thrombocytopenia
optic neuropathy
peripheral neuropathy
Rifampin: ADE
hepatotoxicity
red/orange discoloration of bodily secretions
Vancomycin: ADE
nephrotoxicity
red man syndrome
- prolong infusion time from 1 to 2 hours
- consider antihistamine prior to loading
Endocarditis Prophylaxis: indications
highest risk cardiac conditions
- prosthetic heart valve
- prior diagnosis of infective endocarditis
- cardiac transplantation with valvulopathy
- congenital heart disease
NOT RECOMMENDED
for patients who undergo GI procedure
Endocarditis Prophylaxis: procedures
any that require perforation of the oral mucosa or manipulation of the periapical region of the teeth or gingival tissue
tooth extraction
drainage of abscess
routine dental cleaning
Endocarditis Prophylaxis: first line
oral amoxicillin
30-60 minutes before procedure
Endocarditis Prophylaxis: unable to take oral meds
IM or IV ampicillin or cefazolin or ceftriaxone
Endocarditis Prophylaxis: allergic to PCN (oral)
oral cephalexin or clindamycin or azithromycin
Endocarditis Prophylaxis: allergic to PCN and unable to take oral meds
IV or IM clindamycin or cefazolin or ceftriaxone
IV vancomycin
