Endocarditis Flashcards
Definite criteria for Endocarditis?
2 major, 1 major + 3 minor, 5 minor
Major Criteria for IE?
- Typical microorganisms consistent with IE from 2 separate blood cultures:
Viridans streptococci, Streptococcus bovis, HACEK group, Staphylococcus
aureus; or community-acquired enterococci in the absence of a primary
focus, or microorganisms consistent with IE - Single positive blood culture for Coxiella burnetii or anti–phase 1 IgG
antibody titer ≥1:800 - Evidence of endocardial involvement
Echocardiogram positive for IE: oscillating intracardiac mass on valve or
supporting structures, in the path of regurgitant jets, or on implanted
material; abscess;or new partial dehiscence of prosthetic valve or new valvular regurgitation (worsening or changing or pre-existing murmur not sufficient)
Minor Criteria for IE
- Predisposition, predisposing heart condition, or IDU
- Fever, temperature >38°C
- Vascular phenomena, major arterial emboli, septic pulmonary infarcts,
mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and
Janeway lesions - Immunological phenomena: glomerulonephritis, Osler nodes, Roth spots,
and rheumatoid factor - Microbiological evidence: positive blood culture but does not meet a major
criterion as noted above (excludes single positive cultures for coagulase negative
staphylococci and organisms that do not cause endocarditis) or
serological evidence of active infection with organism consistent with IE
How should blood cultures be drawn for major criteria for IE?
at least 2 positive cultures of blood samples drawn >12 h apart or all 3 or a majority of ≥4 separate cultures of blood (with
first and last sample drawn at least 1 h apart)
clinical critera suggestive for surgical intervention ?
- Vegetation
Persistent vegetation after systemic embolization
Anterior mitral leaflet vegetation, particularly with size >10 mm*
≥1 Embolic events during first 2 wk of antimicrobial therapy*
Increase in vegetation size despite appropriate antimicrobial therapy*† - Valvular dysfunction
Acute aortic or mitral insufficiency with signs of ventricular failure†
Heart failure unresponsive to medical therapy† - Valve perforation or rupture†
Perivalvular extension
Valvular dehiscence, rupture, or fistula†
New heart block†‡
Large abscess or extension of abscess despite appropriate antimicrobial
therapy†
When should TEE be performed?
negative TTE with high clinical suspiscion, high initial patient risks like prosthetic heart valves, many congenital heart
diseases, previous endocarditis, new murmur, heart failure, or other stigmata of endocarditis. Candidemia,
What is possible IE?
1 Major criterion and 1 minor criterion, or 3 minor criteria
what is the inoculum effect? abx?
The effect of high bacterial densities on antimicrobial activity is called the inoculum effect in which certain groups of antimicrobials commonly used to treat IE such as β-lactams and glycopeptides (and, to a lesser extent, lipopeptides such as daptomycin) are less active against highly dense bacterial populations.Therefore, the effective minimum inhibitory concentration (MIC) at the site of infection with bacterial densities of 108 to 1011 colony-forming units
per 1 g tissue can be much higher than anticipated by in vitro susceptibility tests that use a standard inoculum (105.5 colony-forming units per milliliter).
IE IDU Bugs?
S aureus, including community-acquired oxacillin-resistant strains Coagulase-negative staphylococci β-Hemolytic streptococci Fungi Aerobic Gram-negative bacilli, including Pseudomonas aeruginosa Polymicrobial
Indwelling cardiovascular medical devices Bugs
S aureus Coagulase-negative staphylococci Fungi Aerobic Gram-negative bacilli Corynebacterium sp
Genitourinary disorders, infection,and manipulation, including pregnancy, delivery, and abortion bugs
Enterococcus sp Group B streptococci (S agalactiae) Listeria monocytogenes Aerobic Gram-negative bacilli Neisseria gonorrhoeae
Chronic skin disorders, including recurrent infections bugs
S aureus
β-Hemolytic streptococci
Poor dental health, dental procedures bugs
VGS Nutritionally variant streptococci Abiotrophia defectiva Granulicatella sp Gemella sp HACEK organisms
Alcoholism, cirrhosis bugs
Bartonella sp Aeromonas sp Listeria sp S pneumoniae β-Hemolytic streptococci
Burn bugs
S aureus
Aerobic Gram-negative bacilli, including
P aeruginosa
Fungi
Diabetes mellitus bugs
S aureus
β-Hemolytic streptococci
S pneumoniae
Early (≤1 y) prosthetic valve placement bugs
Coagulase-negative staphylococci S aureus Aerobic Gram-negative bacilli Fungi Corynebacterium sp Legionella sp
Late (>1 y) prosthetic valve placement bugs
Coagulase-negative staphylococci S aureus Viridans group streptococci Enterococcus species Fungi Corynebacterium sp
Dog or cat exposure bugs
Bartonella sp
Pasteurella sp
Capnocytophaga sp
Contact with contaminated milk or
infected farm animals bugs
Brucella sp
Coxiella burnetii
Erysipelothrix sp
Homeless, body lice bugs
Bartonella sp
AIDS bugs
Salmonella sp
S pneumoniae
S aureus
Solid organ transplantation bugs
S aureus
Aspergillus fumigatus
Enterococcus sp
Candida sp
Gastrointestinal lesions bugs
gallolyticus (bovis)
Enterococcus sp
Clostridium septicum
Pen susceptible VGS, Streptococcus gallolyticus treament regimen and pearls? TX
MIC ≤0.12 μg/mL
1. Both aqueous crystalline penicillin G and ceftriaxone are reasonable options for a 4-week treatment duration (Class IIa; Level of Evidence B).
2. A 2-week treatment regimen that includes gentamicin is reasonable in patients with uncomplicated IE,
rapid response to therapy, and no underlying renal
disease (Class IIa; Level of Evidence B).
3. Vancomycin for a 4-week treatment duration is a
reasonable alternative in patients who cannot tolerate
penicillin or ceftriaxone therapy (Class IIa;Level of Evidence B).
4. The desired trough vancomycin level should range
between 10 and 15 μg/mL (Class I; Level of Evidence C).
Relatively Penicillin-Resistant VGS and S gallolyticus (bovis) TX
- It is reasonable to administer penicillin for 4
weeks with single daily-dose gentamicin for
the first 2 weeks of therapy (Class IIa; Level of
Evidence B). - If the isolate is ceftriaxone susceptible, then ceftriaxone alone may be considered (Class IIb; Level of
Evidence C). - Vancomycin alone may be a reasonable alternative
in patients who are intolerant of β-lactam therapy
(Class IIa; Level of Evidence C).
A defectiva and Granulicatella Species and VGS With a
Penicillin MIC ≥0.5 μg/mL TX
- It is reasonable to treat patients with IE caused by
A defectiva, Granulicatella species, and VGS with
a penicillin MIC ≥0.5 μg/mL with a combination
of ampicillin or penicillin plus gentamicin as done
for enterococcal IE with infectious diseases consultation
(Class IIa; Level of Evidence C). - If vancomycin is used in patients intolerant of ampicillin or penicillin, then the addition of gentamicin is
not needed (Class III; Level of Evidence C). - Ceftriaxone combined with gentamicin may be a
reasonable alternative treatment option for VGS
isolates with a penicillin MIC ≥0.5 μg/mL that
are susceptible
Endocarditis of Prosthetic Valves or Other Prosthetic
Material Caused by VGS and S gallolyticus (bovis) TX
- Aqueous crystalline penicillin G or ceftriaxone for
6 weeks with or without gentamicin for the first 2
weeks is reasonable (Class IIa; Level of Evidence B). - It is reasonable to extend gentamicin to 6 weeks
if the MIC is >0.12 μg/mL for the infecting strain
(Class IIa; Level of Evidence C). - Vancomycin can be useful in patients intolerant of
penicillin, ceftriaxone, or gentamicin (Class IIa;
Level of Evidence B).
Streptococcus pneumoniae, , and β-Hemolytic Streptococci TX
- Four weeks of antimicrobial therapy with penicillin,
cefazolin, or ceftriaxone is reasonable for IE caused
by S pneumoniae; vancomycin can be useful for
patients intolerant of β-lactam therapy (Class IIa;
Level of Evidence C). - High-dose penicillin or a third-generation cephalosporin is reasonable in patients with IE caused
by penicillin-resistant S pneumoniae without meningitis;
if meningitis is present, then high doses of cefotaxime (or ceftriaxone) are reasonable (Class IIa; Level of Evidence C). - The addition of vancomycin and rifampin to cefotaxime (or ceftriaxone) may be considered in patientswith IE caused by S pneumoniae that are resistant to cefotaxime (MIC >2 μg/mL) (Class IIb; Level of Evidence C).
- Six weeks of therapy is reasonable for PVE caused
by S pneumoniae (Class IIa; Level of Evidence C).
Streptococcus pyogenes TX
- For IE caused by S pyogenes, 4 to 6 weeks of therapy
with aqueous crystalline penicillin G or ceftriaxone
is reasonable; vancomycin is reasonable only in
patients intolerant of β-lactam therapy (Class IIa;
Level of Evidence C).
Groups B, C, F, and G TX?
For IE caused by group B, C, or G streptococci, the
addition of gentamicin to aqueous crystalline penicillin
G or ceftriaxone for at least the first 2 weeks of
a 4- to 6-week treatment course may be considered
(Class IIb; Level of Evidence C).
Therapy for NVE Caused by Staphylococci - Oxa susceptible TX
Complicated right/left sided: Nacfillin or oxacillin: 12 g/24 h IV in 4–6 equally divided doses x 6 weeks
Uncomplicated rigtht side: 2 weeks
Therapy for NVE Caused by Staphylococci - Oxa susceptible pen allergic TX
Cefazolin/Vancomycin 6 g/24 h IV in 3 equally divided doses
Therapy for NVE Caused by Staphylococci - Oxa resistant TX
Vancomycin 30 mg/kg per 24 h IV in 2 equally divided
doses with trough 10-20 (Ic) OR Daptomycin ≥8 mg/kg/dose 2b
IE Caused by CoNS/staphylococci in the Presence of
Prosthetic Valves or Other Prosthetic Material TX
These are usually methicillin resistant, especially within 1 year of surgery
1. Vancomycin and rifampin are recommended for a
minimum of 6 weeks, with the use of gentamicin limited
to the first 2 weeks of therapy (Class I; Level of
Evidence B). Vancomycin 30 mg/kg 24 h in 2 equally divided doses; Rifampin: 900 mg per 24 h IV or orally in 3 equally divided doses; Gentamycin 3 mg/kg per 24 h IV or IM in 2 or 3 equally divided doses
2. If CoNS are resistant to gentamicin, then an aminoglycoside to which they are susceptible may be considered (Class IIb; Level of Evidence C).
3. If CoNS are resistant to all aminoglycosides, then
substitution with a fluoroquinolone may be considered
if the isolate is susceptible to a fluoroquinolone
(Class IIb; Level of Evidence C).
4. Organisms recovered from surgical specimens or blood from patients who have had a bacteriological relapse should be carefully retested for complete antibiotic susceptibility profiles (Class I; Level of Evidence C).
5. If oxacillin susceptible, use Naficillin/Oxacillin 12g/24hr; Can use cefazolin/Vancomycin
6. Staph Aureus
Enterococci bugs typically in IE?
E faecalis causes ≈97% of cases of IE; E faecium, ≈1%
to 2%; and other species, ≈1%.Usually, Facealis is amp sensitive; faceium is amp resistant
Enterococci therapy regimens?
- Ampicillin/pen g + gentamycin for CrCl>50ml/min
- NVE with illness<3 months - 4 weeks
- NVE with illness>3 months/prosthetic - 6 weeks
- Gentamycin peak serum 3-4 ug/ml and trough <1ug/ml - Double B-lactam: ampicillin + Ceftriaxone for CrCl<50ml/min for 6 weeks
Treatment duration for enterococci IE
- Ampicillin sodium 2 g IV every 4 h Native valve: 4-wk therapy recommended for patients with symptoms of illness <3 mo; 6-wk therapy recommended for native valve symptoms >3 mo or Pen G
What if the patient is gentamycin resistant enterococcal IE or can’t take gentamycin?
Try streptomycin with serum peak concentration of 20-35ug/ml with trough concentration<10ug/ml
What if the patient is penicillin-resistant enterococcal IE or can’t take penicillin?
Vancomycin + gentamycin
what if enterococcal IE is resistant to penicillin, aminoglycosides and vancomycin?
Linezolid 600mg IV/oral q12 hours or daptomycin 10-12mg/kg per dose for >6 weeks
HACEK IE tx?
Unless growth is adequate in vitro to obtain susceptibility testing results, HACEK microorganisms are
considered ampicillin resistant, and penicillin and
ampicillin should not be used for the treatment of
patients with IE (Class III; Level of Evidence C).
2. Ceftriaxone is reasonable for treatment of HACEK
IE (Class IIa; Level of Evidence B).
3. The duration of therapy for HACEK NVE of 4
weeks is reasonable (Class IIa; Level of Evidence
B); for HACEK PVE, the duration of therapy of 6
weeks is reasonable (Class IIa; Level of Evidence C).
4. Gentamicin is not recommended because of its
nephrotoxicity risks (Class III; Level of Evidence C).
5. A fluoroquinolone (ciprofloxacin, levofloxacin, or
moxifloxacin) may be considered an alternative
agent for patients unable to tolerate ceftriaxone (or
other third- or fourth-generation cephalosporins)
(Class IIb; Level of Evidence C). Ciprofloxacin 1000mg/24 hours PO or 800mg/24h IV in 2 doses
6. Ampicillin-sulbactam may be considered a treatment
option for HACEK IE (Class IIb; Level of
Evidence C).
Non-HACEK gram negative bacilli TX?
- Cardiac surgery is reasonable in combination with
prolonged courses of combined antibiotic therapy
for most patients with IE caused by non-HACEK
Gram-negative aerobic bacilli, particularly P aeruginosa
(Class IIb; Level of Evidence B). - Combination antibiotic therapy with a β-lactam
(penicillins, cephalosporins, or carbapenems) and
either an aminoglycoside or fluoroquinolone for 6
weeks is reasonable (Class IIa; Level of Evidence C).
Fungal IE TX?
A 2-phase treatment of fungal IE has evolved. The initial
or induction phase consists of control of infection. Treatment includes a combination of a parenteral antifungal agent, usually an amphotericin B–containing product, and valve surgery. Valve surgery should be done in most cases of fungal IE. In addition,
patients who were treated with combination therapy including amphotericin B and flucytosine had reduced mortality compared with those who received antifungal monotherapy.
Antifungal therapy usually is given for >6 weeks. After
completion of this initial therapy, long-term (lifelong) suppressive therapy with an oral azole is reasonable
Early valve surgery in left sided ?
- Heart Failure
- Fungi or highly resistant organisms (VRE/MDR GNB)
- heart block/abscess/destructive penetrating lesions
- manifested by persistent bacteremia or fever lasting >5–7 days
- recurrent emboli and persistent or enlarging
vegetations despite appropriate antibiotic therapy - severe valve regurgitation + mobile vegetations >10 mm or PVE and mobile vegetations>10mm
- Early surgery may be considered in patients with
mobile vegetations >10 mm, particularly when
involving the anterior leaflet of the mitral valve and
associated with other relative indications for surgery
Early valve surgery for right sided IE?
Surgical intervention is reasonable for patients with the following complications: right heart failure secondary to severe tricuspid regurgitation with poor response to medical therapy, sustained infection caused by difficult-to-treat organisms (ie, fungi, multidrug resistant bacteria) or lack of response to appropriate antimicrobial therapy, and tricuspid valve vegetations that are ≥20 mm in diameter and recurrent pulmonary embolism despite antimicrobial therapy. Valve repair rather than replacement should be performed when feasible.
Valve Surgery in Patients With Prior Emboli/
Hemorrhage/Stroke
- Valve surgery may be considered in IE patients with
stroke or subclinical cerebral emboli and residual
vegetation without delay if intracranial hemorrhage
has been excluded by imaging studies and neurological
damage is not severe (ie, coma) (Class IIb; Level
of Evidence B). - In patients with major ischemic stroke or intracranial
hemorrhage, it is reasonable to delay valve
surgery for at least 4 weeks (Class IIa; Level of
Evidence B).
When do you anticoagulate in mechanical valve IE?
The general advice is to discontinue all forms of anticoagulation in patients with mechanical valve IE who have experienced a CNS embolic event for at least 2 weeks. Initiation of aspirin or other antiplatelet agents as
adjunctive therapy in IE is not recommended
