Endovascular Infections Flashcards
What are the Class I indications for TEE in the work up of infective endocarditis?
- TTE Non-diagnostic
- IE complications suspected
- Intracardiac lead present
- In patients being considered for any early change to oral abx therapy (baseline TEE with repeat 1-3 days prior to completing abx)
What are the HACEK organisms?
Hemophilus Aggregatibacter Cardiobacterium Eikenella Kingella
What are the major criteria for infective endocarditis?
- Microbiological Evidence
2. Endocardial Involvement
What are the microbiological major modified Duke criteria for IE?
- Typical organisms: S. aureus, viridans groups strep, S. gallolyticus, enterococcus, HACEK in 2 cultures > 12 hours apart or > or = 3 cultures > 1 hour apart.
OR - 1 blood culture demonstrating Coxiella
OR 3. Coxiella anti-phase 1 IgG > or = 1:800
What are the modified Duke criteria for endocardial involvement?
- Oscillating valvular/prosthetic mass
- Valvular abscess
- Dehiscence of prosthetic valve
- New valvular regurgitation
What are the minor modified Duke criteria?
- Predisposition
- Fever > 38 C
- Vascular Phenomenon
- Immunological Phenomenon
- Microbiological evidence (+ blood culture not meeting a major criterion)
What are the predisposing features included in the minor criterion of the Duke criteria?
Heart defect
Prosthetic valve
IVDU
What are the vascular phenomenon of the modified Duke criteria (6)?
Arterial emboli Septic pulmonary infarcts Mycotic aneurysm IC hemorrhage Conjunctival hemorrhage Janeway lesions
What are the immunological criteria of the modified Duke criteria (4)?
Glomerulonephritis
Osler nodes
Roth spots
+ Rheumatoid factor
What are the modified Duke criteria requirements for definitive and possible IE?
Definite:
- Positive vegetation culture or histopathology
- 2 major criteria OR 1 major and 3 minor OR 5 minor criteria
Possible:
1 major + 3 minor OR 3 minor
What is the treatment for MSSA prosthetic valve endocarditis?
Cloxacillin OR cefazolin
PLUS:
Rifampin & Gentamycin
How is a HACEK group endocarditis treated?
Ceftriaxone
How is an MRSA or CNST native valve IE treated? What about prosthetic valve?
Native Valve: Vancomycin
Prosthetic Valve: Vancomycin + rifampin + gentamycin
How is Enterococcus faecalis endocarditis treated?
Ampicillin PLUS:
Gentamycin OR ceftriaxone
How is Enterococcus faecium IE treated?
Vancomycin + Gentamycin
What is the duration of treatment for IE?
4-6 weeks
Longer for increasing beta-lactam resistance, S. aureus and prosthetic valves.
In which patients can you consider step down to oral therapy for treatment of infective endocarditis?
In patients with left-sided IE caused by Streptococcus, E. faecalis, S. aureus or CNST deemed stable by a multidisciplinary team.
MUST receive a TEE before switching AND be able to have frequent/appropriate follow up AND a follow up TEE needs to be done 1-3 days before d/c antibiotic therapy.
What are the Class I indications for “early surgical intervention” in infective endocarditis (5)?
- Valve dysfunction with signs or symptoms of heart failure despite optimal medical therapy.
- Left-sided IE caused by S. aureus, fungi or highly resistant organisms.
- Heart block, annular/aortic root abscess, destructive penetrating lesions.
- Persistent bacteremia or fever > 5 d after starting appropriate abx.
- Complete removal of implantable electronic cardiac device systems with definite endocarditis.
What are the Class I indications for delayed surgery in infective endocarditis (2)?
- Prosthetic Valves: relapsing infection (new fevers, bacteremia after a complete course of appropriate abx and interval sterile blood culture, without other source/portal for infection).
- In patients with recurrent endocarditis in the setting of continued IVDU, consultation w/addiction medicine is recommended before repeat surgical intervention is considered.
What are the Class II EARLY surgical indications for infective endocarditis?
- Reasonable in those with recurrent a boil and persistent vegetation’s despite an appropriate course of antimicrobial therapy.
- In those with native L-sided valvular endocarditis with mobile vegetation > 10 mm with or without emboli phenomenon, especially when anterior MV leaflet.
- For patients who have had a minor emboli stroke (no extensive deficits) without ICH in patients with an indication for iE surgery.
What is the Class II indication for delayed surgery (> 4 weeks) in infective endocarditis?
In patients who are hemodynamically stable after a major ischemic or hemorrhagic stroke.
Which are the patients that need infective endocarditis prophylaxis in the setting of specific procedures?
- Prosthetic Cardiac Valves (including TAVI)
- Prosthetic Cardiac Material (annuloplasty ring, chord, clips)
- Previous IE
- Congenital HD if:
- cyanotic heart disease, un-repaired
- CHD post-repair within 6 months
- CHD post-repair with residual defect - Cardiac Transplant Recipients with valve regurgitation attributable to structurally abnormal valve.
In what types of procedures is prophylaxis required for infective endocarditis?
- Dental procedures involving gingival manipulation, manipulation of the peri-apical tissue and perforation of oral mucosa.
- Respiratory tract procedures with transaction of respiratory mucosa, such as tonsillectomy, adenoidectomy
NOT FOR GU/GI, Gyne
What are the guidelines for duration of secondary prophylaxis in patients with history of rheumatic fever?
- RF w/carditis & residual valvular disease - 10 years or until patient is 40 (whichever later)
- RF w/carditis w/o residual VHD - 10 years or until 21 (whichever longer)
- RF w/o carditis - 5 years or until 12 (whichever is longer)
What are the possible regimens for IE prophylaxis?
Amoxicillin 2g PO x 1 OR ampicillin 2g IV/IM OR cefazolin/CTX 1 g IV/IM
If Pen allergy:
Cephalexin 2 g PO OR clindamycin 600 mg PO/IM/IV OR azithromycin 500 mg PO OR cefazolin/CTX 1g IV/IM
When do you give IE prophylaxis (timing) prior to a procedure?
Within 30-60 minutes
How would you treat Lyme disease with cardiac involvement?
Ceftriaxone 14-21 days
