IE Flashcards
when does IE occur?
when bacteria or fungi enters the bloodstream and attaches to the inner lining of the heart (endocardium)
risk factors of IE
presence of prosthetic heart valve
intravenous drug users
structural heart disease
persistant bacteremia
poor dental hygiene
colon cancer or IBD (s.gallolyticus)
most common pathogens of IE
gram positive cocci»» gram negative
IVDU
higher risk for poly microbial IE
prosthetic valve IE
coagulase negative staphococci (CoNS)
IVDU microorganisms
s. aureus
CoNS
Group A & B streptococcus
fungi
early (<1 yr ) post prosthetic valve replacement
CoNs
S.aureus
aerobic neg bacilli
corynebacterium spp.
late (> 1yr) post prosthetic valve replacement
CoNS
s.aureus
viridans group streptococcus
enterococcus spp.
corynebacterium spp
poor dental health , post dental procedures
viridian’s group streptococci
nutritionally variant streptococci
HACEK organisms
Acute IE clinical presentation
rapid onset
high grade fever **
new cardiac murmur
myalgia
systemic emboli
subacute IE clinical presentation
gradual onset
low grade fever**
anemia
weight los
vascular manifestations
peripheral manifestations
Less virulent pathogens (VGS)
right sided IE
tricuspid and pulmonary valve
IVDUs
Septic Pulmonary emboli**
NO peripheral emboli and immunological vascular phenomena
Left sided IE
Mitral and aortic ( majority of IE cases)
Peripheral emboli or neurological features**
Staphylococcus aureus
most common cause of IE
IVDUs is typically involves triceps/ right sided IE
coagulase negative staphylococcus
typically causes PVE
most CoNS are methicillin resistant
staph lugdunenis= hyper virulent species
Native valve IE
s.aureus or CoNS
methicillin susceptible
cefazolin IV 2 gram q8h
or
Nafcillin/ oxacillin IV 2 g q4H
duration 6 weeks
only use Vanco for severe b lactam intolerance
Native valve IE
s.aureus or CoNS
methicillin resistant
Vancomycin IV
alternative= daptomycin IV
duration= 6 weeks
prosthetic valve IE
s.aureus or CoNS
methicillin susceptible
Nafcillin/oxacillin IV 2 gram q4h
plus
rifampin PO/IV 300 mg q8h (900 mg/day)
plus
gentamicin IV 1mg/kg q8h
alternative; cefazolin IV gram q8h
duration: 6 weeks , gentamicin: only first two weeks
Prosthetic valve IE
s.aureus or CoNS
methicillin resistant
vancomycin IV
plus
rifampin PO/IV 300 mg q8h (900 mg/day)
plus
gentamicin IV 1mg/kg q8h
alternative: daptomycin IV
duration: 6 weeks , gentamicin: only first two weeks
Native valve IE
virdiadans Group strep or strep. gallolyticus
highly penicillin susceptible
aqueous PCN G IV 18 mill units/day
or
ceftriaxone IV 2 g q24
plus/ or minus
gentamicin IV 3mg/kg q24hr
preferred regimen= without gentamicin synergy
duration: 4 weeks
Native valve IE
virdiadans Group strep or strep. gallolyticus
PCN relatively or fully resistant
cerftriaxone IV 2 g q24h
plus/minus
gentamicin IV 3 mg/kg q24h
or
vancomycin
altenative:PCN G plus gentamicin
duration: 4 weeks
prosthetic valve IE
virdiadans Group strep or strep. gallolyticus
highly penicillin susceptible
aqueous PCN G IV 18 mill units/day
or
ceftriaxone IV 2 g q24
plus/ or minus
gentamicin IV 3mg/kg q24hr
gentamicin does NOT improve cure rates vs. blactams
duration 6 weeks
prosthetic valve IE
virdiadans Group strep or strep. gallolyticus
PCN relatively or fully resistant
cerftriaxone IV 2 g q24h
plus
gentamicin IV 3 mg/kg q24h
or
vancomycin
altenative:PCN G plus gentamicin
PCN G 24 mill units /day plus gentamicin synergy alternative
native and prosthetic valve
enterococci (ampicillin suseptible)
double beta lactam regimen
- ampicillin IV 2 gram q2h
plus
-ceftriaxone IV 2 g q12h
duration: 6 weeks (for both
native and prosthetic valve
enterococci (ampicillin resistant or beta lactam intolerance/allergy)
vancomycin IV
plus
gentamicin IV 1mg/kg q8h
Gentamycin for ENTIRE treatment course
duration: 6 weeks (NVE), >= 6 weeks (PVE)
native and prosthetic valve
enterococci (ampicillin and vancomycin resistant)
daptomycn 10-12 mg/kg q24hr
drug of choice
drug of choice for streptococci
pen G
drug of choice for MSSA
Nafcillin/oxacillin or cefazolin
drug of choice for MRSA
vancomycin
stepwise approach for streptococcus
- penicillin look at MIC
- ceftriaxone
- vancomycin
stepwise approach for staphylococcus
- oxacillin/ceftazolin
- vancomycin
- daptomycin
when to use gentamicin synergy
s.aureus PVE
enterococci
PCN resistant strep (nv/PVE)
general rule for duration of therapy
loneger for PVE
Native and prosthetic valve
HACEK organisms (gram neg)
certtriaxone (preferred)
ampicillin/sulbactam
ciprofloxacin PO 500 mg q12 h (intolerance to beta lac)
4weeks NV
6weeks PVE
indication for IE prophylaxis indication
- dental procedures
-pts at risk for iE development and high risk of for poor IE outcomes
when is duration of therapy counted for?
first day of a negative blood culture
obtain at least two blood cx every 24-48 hrs under cleared
if operative heart valve is are positive, when do you start counting # of treatment days
start counting # of treatment days from valve surgery
if operative heart valve is are negative, when do you count treatment days
count # of treatment days administered before surgery into overall duration
Major Criteria
evidence of endocardial involvement
ECHO positive for IE**
Single blood cx for coxiella burnetii**
2 or more separate blood culture or
3 or a majority of >4= separate blood cx for typical microorganism consistent w IE:
- viridian’s Group strep
-s.gallolyticus
-HACEK organism
-s. aureus**
-community acquired enterococci
Minor criteria
predisposition, predisposing heart disease, or IVDU
fever
Vascular phenomena
Immunological phenomena
positive blood cx that does not met major criterion
what type of antibiotics is needed to sterilize vegetation with high bacterial densities
bactericidal antibiotics
why is prolonged therapy needed for IE
to ensure complete eradication
required since vegetations have high bacterial densities + slower antibiotic bactericidal activity
solution for antimicrobial considerations
prolonged, parenteral**, high dose, bactericidal antibiotic therapy
