Endocarditis - Block 2 Flashcards
What is endocarditis?
Inflammation of the endocardium (membrane the lining of the chambers of the heart)
What are causes of endocarditis?
- Vavular endolial damage and colonization
- Platelet and fibrin deposits -> nonbacterial throbotic endocarditis (NBTE) -> pressure gradient across the affected valve
- Vegetation -> Bloodstream infection or transient bacteremia -> vegetation breaks off -> embolism
Overall heart valve destruction
IE is generally caused by _____ bacteria?
G+
What are the common pathogens of IE?
- S. aureus
- Coagulase - staph
- Viridians
- HACEK
Common pathogens seen in native valves?
MSSA >MRSA, Strep, and enterococci
Common pathogens of prosthetic valves?
<2 months post op: MRSA>MSSA
>2 months post op: Staph (MSSA>MRSA), strep, enterococci, biofilm of S. aureus
RF of IE?
- Prostetic heart valve
- Hx of IE
- IUD
- > 60YO
- Males
- Poor dental hygiene
What are the complications of IE?
- HF
- End organ damge
- Neurological damge
- Metastatic infection
- Local tissue infammation
What are clinical presentation IE?
- Fever
- Roth spots
- Osler nodes
- Murmur
- Janeway lesions
- Anemia
- Nail bed hemorrhage
- Emboli
What are the complications of emboli?
Left sided EC -> renal artery emboli -> flank pain and hematuria -> splenomegaly -> infarction of spleen, brain stroke or meningitis
Right-sided -> pulmonary embolism and abscess
Wht is splinter hemorrhage?
Hemorrhages found on nail beds due to systemic depletion of fibrinogen and platelet
What are oosler nodes?
Purplish Papules or nodules on the toesdue to embolism, immunologic phenomena or both
What are Janeway lesions?
Painless hemorrhagic plaques on palms and soles due to embolism
What are roth spots?
Retinal infarct with central pallor and surrounding hemorrhages
What are the lab presentations of IE?
ECHO -> vegetation
Elevated WBC
Anemia/thrombocytopenia -> decreased fibrin
Increase ESR and CRP
Bacteremia
What are the diagnostic tools for IE?
- Blood cultures
- ECHO
- Duke criteria
What are the major Duke criteria?
- Positive blood culture in the absence of primary focus
* Staph, strep, enterococcus, HACEK
* Persistant positive blood cultures - Evidence of endocardial
* Vegetation +
* New or worse murmur
What are the minor Duke criteria?
- Heart conditon or IVDU
- Fever
- Vascular phenomea (Janeway lesions, emboli)
- Immunologic phenomena (osler nodes, roth spots)
- Postive blood culture that is not major
What are categories of DUke criteria?
Definite: 2 major or 1 major+3 minor or 5 minor
Possible: 1 major+1 minor or 3-4 minor
Rejected: Not IE
Non pharm of IE?
Surgical repair of valves
What is difference betwen acute and subacute?
Acute: sudden presentation of S. aureus
Subacute: graudually over weeks-monhs from Strep and preexisting vavular HD
Valves affectedd by left and right IE?
Left: mitral/aortic
Right: tricuspid/pulmonary
Difference between complicated and uncomplicated IE?
Com: right sided IE
Un: left-sided, MRSA
What are the ideal properties of ABX for IE?
- High dose
- Prolonged activity
- Parenteral
- Bactericidal
When would you use empiric?
- Confirmed IE and
- Acutely ill or in HF
Use narrow when results are available
Empiric therapy for native valves?
Pathogens: staph, strep, enterococcus, HACEK
Vanc + Ceftriaxone or Gentamicin
Alt: Dapt in place of Vanc
Empiric therapy for prosthetic valves?
Pathogens: S. aueurs + biofilm, strep, enterococci
Vanc + Gentamicin + Rifampin
What is the purpose of using gentamicin in IE tx?
Provides G+ synergy coverage
Tx for staphy IE with MSSA
Native: Nafcillin or Oxacillin x 6b weeks
Prosthetic: Nafcillin or Oxacillin + rifampin for 6 wk + gentamic synergy x 2 wks
Alt: Cefazolin or vanc
Tx for staphy IE with MRSA
NVE: Vanco mono x 6 wks
PVE: Vanc + rifampin x 6wk + Gentamic for first 2 wks
Alt: Daptomycin x 6wks
Tx for Viridans IE with pen-susceptible strains
MIC ≤0.12
Native: Penicillin G x 4wk
PVE: Penicillin G or Ceftriaxone + gentamic for 6 weeks
Alt: Vancomicin (4wk for NVE, 6wk for PVE)
Tx for Viridans IE with intermediate pen-resistance strains
MIC 0.12-0.5
NVE: Penicillin for 4 wks + gentamycin firs 2 wks
PVE: Pen G or ceftriaxone + Gentamicin fro 6 wks
Alt: Vancomycin (4wk for NVE, 6wk for PVE)
Tx for Viridans IE with high pen-resistance strains
MIC >0.5
NVE: Pen G + gentamicin for 4-6wks
PVE: Pen G or ceftriaxone + Gentamicin fro 6 wks
Alt: Vancomycin (4wk for NVE, 6wk for PVE)
Tx for Enterococcus IE with pen and gen susceptible strains
E. facialis
NVE: Ampicillin or Pen G + gent for 4-6 wks
PVE: ampicillin + ceftriaxone for 6 wks
Alt: Vanc + gent x 6 wks
Tx for Enterococcus IE with pen resistant strains
E. faecalis
NVE and PVE: Vanc + gent x 6 wks
Alt: Ampicillin-sulbactam + gent for 6 wks
Tx for Enterococcus IE with VRE strains
E. faecium
NVE, PVE, Alt: Daptomycin or high-dose linezolid for 6 wks
Tx for HACEK IE
NVE and PVE: Ceftriaxone or ampicillin for 4 wks
Alt: Ciprofloxacin, levofloxacin, moxifloxacin, ampicillin or ceftriaxone
Culture negative with native valve tx?
Vancomycin + cefepime
Vancomycin + ampicillin/sulbactam
4-6wks
Culture negative with early (<1yr) prosthetic valve tx?
Vancomycin + cefipime + gent+ rifampin for 6 wks
Culture negative with late (>1yr) prosthetic valve tx?
Vancomycin + ceftriaxone for 6 wks
Who qualifies for OPAT?
- hemodynamically stable
- Competent of disease state
- Has immediate access to medical care
What do you monitor for IE tx?
- Hemodynamics
- Blood cultures for bacteremia
- TDM
- CBC and serum
- Drug tox and intolerance
- New onset diarrhea -> C diff
How often do ou follow up for IE tx?
- Follow vitals and lab QD till stable
- Blood culture Q24-72H till negative
- SS weekly
- Daptomycin (hold statin) monitor CPK
- follow up 1-3 months for 6 months
Who should get vaccines>
NVE: not recommend is successfully treated
PVE: influenza, PPSV23 and 13, Tdap, Zoster
Who shold get IE prophylaxis?
People with dental problems
Perforation/incision of oral mucosa or gingival tissue
PO prophylaxis tx?
Amoxicillin 2 g once
Alt: cephalexine 2g once
* Azithromycin or clarithromycin 500 mg once
NPO prophylaxis tx?
Ampicillin IV once
Ceftriaxone IV once
