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Pharmacotherapy > Infective Endocarditis > Flashcards

Infective Endocarditis Flashcards

1
Q

Acute Endocarditis def (associated with what bacteria? Involve which valve? Mortality in how long?

A

Fulminating form; associated with high fevers and systemic toxicity (e.g., S. aureus, S. pyogenes, S. pneumoniae, or Neisseria gonorrhoeae) .

Mortality within days to weeks if untreated.

Generally involves aortic valve

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2
Q

Subacute Endocarditis def (associated with what bacteria? Involve which valve? Mortality in how long?

A

Indolent infection from less virulent organisms, often in pre-existing valvular disease (ex. Viridans group Streptococci, Enterococci, HACEK)

Mortality within 6-12 weeks if untreated

Generally involves mitral valve

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3
Q

Which valves are on right side?

A

Pulmonary and tricuspid valve

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4
Q

Which valves are on left side?

A

Mitral and aortic valve

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5
Q

Pathophysiology of infective endocarditis

A

Organisms adhere to fibrin-platelet clots that form at the site of damaged cardiac endothelium

Organisms activate monocytes to produce tissue factor activity (TFA) and cytokines

Coagulation pathway is activated causing further recruitment of platelets and growth of vegetation

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6
Q

S. aureus in infective endocarditis

A

Staphylococci

Most common cause of IE (rates continuing to increase)

Commonly seen with IVDA (often right-sided), DM, presence of skin disorders, or in patients with implanted cardiac devices

Highly virulent

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7
Q

S. epidermidis in infective endocarditis

A

Staphylococci

Ordinarily related to prosthetic valves or indwelling implanted cardiac devices

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8
Q

Viridans group streptococci (VGS) in infective endocarditis

A

Present in normal oral flora, skin, GI tract

Commonly in patients with underlying cardiac defects
E.g., rheumatic heart disease or mitral valve prolapse

Often community acquired infection

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9
Q

Enterococcus faecalis and Enterococcus faecium

Which one is more resistant? Found in normal flora

A

Enterococcus faecalis and Enterococcus faecium

Found in normal flora of the GI tract

Often seen in patients after patients after obstetric procedures or manipulation of genitourinary tract

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10
Q

HACEK Organisms in infective endocarditis

A

Slow growing, fastidious Gram-negative bacilli

Possible cause in culture-negative IE

Account for 5-10% of native valve endocarditis in non-IVDU patients

Haemophilus parainfluenzae OR aphrophilus
Actinobacillus actinomycetemcomitans
Cardiobacterum hominis
Eikenella corrodens
Kingella kingae
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11
Q

Clinical Presentation: Peripheral Manifestations of infective endocarditis

A 
Osler Nodes
Janeway Lesions
Splinter Hemorrhages
Petechiae
Clubbing
Roth Spots (eye exam)
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12
Q

Clinical Presentation: Lab findings

A

Anemia (normocytic, normochromic)​
Thrombocytopenia​
Leukocytosis (may be mild)​
Elevated ESR/CRP

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13
Q

Clinical Presentation: Signs

A

Fever (>38 C)
Heart/Changing/New murmur
Vascular Embolic events

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14
Q

Pathologic Criteria: Definitive IE

A

Microorganism demonstrated by culture/sample of:

  • Vegetation
  • Embolized vegetation
  • Intracardiac abscess speciness

Pathologic lesions:
-Histologic examination of vegetation or intracardiac abscess showing active IE

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15
Q

Clinical Criteria: Definitive IE

A

Modified Duke criteria:

  • 2 major criteria
  • 1 major criteria and 3 minor criteria
  • 5 minor criteria
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16
Q

Clinical Criteria: Possible IE

A

Modified Duke criteria:

  • 1 major and 1 minor criteria
  • 3 minor criteria
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17
Q

Clinical Criteria: Rejected IE

A
  • Alternative explanation for findings
  • Resolutions of symptoms with ABx < 4 days
  • No pathophysical evidence at surgery or autopsy with ABx < 4 days
  • Does not meet criteria as described
18
Q

Modified Duke Criteria: Major blood culture positive for IE

A

Typical organism from 2 blood cultures

Organisms consistent with IE from persistently positive blood culture:

  • Culture has >=2 positive drawn >12 hours apart
  • All of 3 or a majority of >4 cultures (with first and last drawn >1 apart)

Single positive blood culture for Coxiella burnetti or anti-phase IgG antibody tier >1:800

19
Q

Modified Duke Criteria: Major evidence of endocardial involved

A

ECHO positive for IE

New valvular regurgitation (worsening/changing old murmur not sufficient )

20
Q

Modified Duke Criteria: Minor

A

Predisposing heart condition or intravenous drug use

Fever >= 38.0 C (100.4 F)

Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage, Janeway lesion

Immunologic phenomena: glomerulonephritis, Osler’s nodes, Roth spots, rheumatoid factor

Positive blood culture not meeting major criterion as noted previously (Excluding single positive cultures for coagulase-negative staphylococci and organisms that do not cause endocarditis) or serologic evidence of active infection with organism consistent with infective endocarditis

21
Q

Nonpharmacologic (FYI)

Typical indications for valve replacement:

A

Hemodynamic disturbances (CHF or valve dysfunction)
Positive blood cultures after 1 week of therapy
≥ 1 embolic event during first 2 weeks of therapy
Increase in vegetation size
Prosthetic valve endocarditis
Valve dehiscence, rupture, fistula, or abscess

22
Q

Considerations when deciding therapy for Infective endocarditis

A 
Valve type (native or prosthetic)
Organism &amp; susceptibilities
Drug issues (e.g., allergy, renal function, etc.)
23
Q

What drugs should be used for synergy in infective endocarditis?

A

Aminoglycosides (typically used for GNR activity) used at low doses for GPC synergy.

24
Q

Gentamicin Dosing for Infective Endocarditis

A

1 mg/kg IV q8h - Option for ALL organisms -> REMEMBER THIS

3 mg/kg of IV q24h - Option for SOME organism

25
Q

Monitoring for Gentamicin

A

Target peak for synergy 3-5 mg/L and trough < 1 mg/L

Obtain peak 30 mins after the end of a 30 min infusion (generally after 3rd dose)

Obtain trough (generally after 3rd dose) immediately before next dose

26
Q

Penicillin MIC testing for which resistant

A

Viridans group streptococci

Utilized to guide treatment intensity
≤ 0.12 mcg/ml = sensitive

0.25 mcg/ml = relatively resistant to PCN

≥ 0.5 mcg/ml = fully resistant (uncommon)

27
Q

Treatment for VGS and Streptococcus gallolyticus (bovis) – NVE
Highly Penicillin-sensitive Treatment Options (PCN MIC ≤ 0.12)

A
  1. PCN G 12-18 mU/d IV divided q4-6h or via continuous infusion (CI) x 4 wks (preferred if > 65 yo and poor candidates for AGs)
  2. Ceftriaxone 2 g IV/IM q24h x 4 wks (emerging DOC, esp. outpatients)
  3. PCN G or ceftriaxone as above x 2 wks PLUS gentamicin 3 mg/kg IV/IM q24h (or 1 mg/kg IV q8h) x 2 wks (shortest regimen; avoid if CrCl < 20 ml/min)
  4. Vancomycin 15 mg/kg IV q12h x 4 wks (penicillin/cephalosporin allergy)
28
Q

Treatment for VGS and Streptococcus gallolyticus (bovis) – NVE
Relatively Penicillin-Resistant Treatment Options
(PCN MIC 0.25 mcg/ml)

A
  1. PCN G 24 mU/d IV divided q4-6h or via CI x 4 wks
    PLUS
  2. Gentamicin 3 mg/kg IV or IM q24h (or 1 mg/kg IV q8h) x 2 wks
  3. Ceftriaxone 2 g IV or IM q24h x 4 wks (if susceptible)
  4. Vancomycin 15 mg/kg IV q12h x 4 wks (penicillin/cephalosporin allergy)
29
Q

Treatment: VGS and Streptococcus gallolyticus (bovis) – Prosthetic Valve or Other Prosthetic Material

A
  1. PCN G 24 mU/d divided q4-6h or via CI x 6 wks
    OR
    Ceftriaxone 2 g IV/IM q24h x 6 wks
    EITHER, PLUS
    Gentamicin 3 mg/kg IV/IM q24h (or 1 mg/kg IV q8h):
    + PCN MIC ≤ 0.12: Gent x 2 wks OPTIONAL; avoid if CrCl < 20 ml/min
    + PCN MIC > 0.12: Gent x 6 wks NEEDED in combination with PCN or ceftriaxone
  2. Vancomycin 15 mg/kg IV q12h x 6 wks (severe PCN allergies)
30
Q

Treatment: Staphylococci - NVE

MSSA/MSSE

A
  1. Nafcillin or Oxacillin 12 g/d IV divided q4-6h x 6 wks (MSSA/MSSE DOC)
  2. Cefazolin 2 g IV q8h x 6 wks (PCN allergy, but tolerate cephalosporins)
31
Q

Treatment: Staphylococci - NVE

MRSA/MRSE

A

Vancomycin 15 mg/kg IV q12h x 6 wks (MRSA/MRSE DOC and for PCN/Ceph allergy)

Daptomycin ≥ 8 mg/kg IV q24h x 6 wks*

32
Q

Treatment: Staphylococci – Prosthetic Valve or Other Prosthetic Material
MSSA/MSSE

A

Nafcillin/oxacillin 12 g/d IV divided q4h x ≥ 6 wks + rifampin 300 mg q8h x ≥ 6 wks + gentamicin 1 mg/kg IV q8h x 2 wks (cefazolin may sub for naf/oxa)

33
Q

Treatment: Staphylococci – Prosthetic Valve or Other Prosthetic Material
MRSA/MRSE

A

Vancomycin 15 mg/kg IV q12 x ≥ 6 wks + rifampin x ≥ 6 wks + gentamicin 1 mg/kg q8h x 2 wks (also used with severe PCN/Ceph allergy)

34
Q

Treatment: Enterococci - NVE or PVE/Other Prosthetic Material
Treatment Options: PCN (S) and Gent (S)

A 
1. PCN G  18-30 mU/d divided q4h or via CI x 4-6 wks 
OR
Ampicillin 12 g/d divided q4h x 4-6 wks
EITHER, PLUS 
Gentamicin 1 mg/kg IV/IM q8h x 4-6 wks
  1. PCN G OR Ampicillin dosed as above x 6 wks
    EITHER, PLUS
    Ceftriaxone 2 g IV q12h x 6 wks (Recommended for pts w/ CrCl<50 ml/min or who develop CrCl<50ml/min on gent)
35
Q

Treatment: Enterococci - NVE or PVE/Other Prosthetic Material
Treatment Options: PCN (S) and Gent (R)

A

Ampicillin 12 g/d divided q4h x 6 wks

36
Q

FYI: Alternative treatment: Enterococci - NVE or PVE/Other Prosthetic Material
PCN (S), Gent (R), Streptomycin (S)

A

PCN G 18-30 mU/d divided q4h or via CI x 4-6 wks
OR
Ampicillin 12 g/d divided q4h x 4-6 wks
EITHER, PLUS
Streptomycin 7.5 mg/kg IV/IM q12h x 4-6 wks

37
Q

Treatment: Enterococci NVE or PVE/Other Prosthetic Material

Unable to tolerate β-Lactams or PCN (R)

A

Vancomycin 15 mg/kg IV q12 x 6 wks
PLUS
Gentamicin 1 mg/kg IV/IM q8h x 6 wks

38
Q

Treatment: EnterococciNVE or PVE/Other Prosthetic Material

Treatment Options: PCN (R), Gent (R), and Vanc (R)

A
  1. Linezolid 600 mg IV/PO q12h x >6 wks

2. Daptomycin 10-12 mg/kg IV q24h x >6 wks

39
Q

Treatment: HACEK Organisms - Native or Prosthetic Valve

A
  1. Ceftriaxone 2 g IV/IM q24h x 4 wks (may use other 3rd-4th gen. cephalosporin)

FYI: -Ampicillin 2 g IV q4h x 4 wks (only use if organism is susceptible)

-Ciprofloxacin 400 mg IV q12h or 500 mg PO q12h x 4 wks (may use if unable to tolerate option 1 or 2)

40
Q

Monitoring for efficacy for infective endocarditis

A

Symptom-based
Resolution of s/sxs over time (VS, CHF MPs, emboli MPs)
Vegetation size usually decreases over months

Microbiologic eradication
Check a set of blood cultures q24h until negative and 2-3d later
Follow-up blood culture 4-8 wks after treatment to verify absence of relapse

Laboratory
Serial ESR (q2-4 wks), CBC, SCr
Serum drug concentration monitoring (vancomycin, AGs)
Repeat echocardiogram at completion of therapy

41
Q

FYI Monitoring for safety for infective endocarditis

A

Oxacillin/Nafcillin 12 g/d
Hypersensitivity reactions, baseline and periodic LFTs for hepatic effects and dosing, sx c/w hepatic disturbances, CBC

Ampicillin/penicillin (high-dose)
Hypersensitivity reactions, SCr for dosing, CBC

Ceftriaxone
Hypersensitivity reactions, stool output, CBC

Cefazolin
Hypersensitivity MPs, SCr for dosing, CBC

Rifampin
LFTs, warn of effects on body secretions, sx c/w GI disturbances, CBC
Possible drug interactions

42
Q

FYI: Prevention of IE (mostly for dental)

A

Amoxicillin 2 grams PO 30-60 min pre-procedure

Penicillin Allergy:
Clindamycin 600 mg PO 30-60 min pre-procedure
Cephalexin 2 grams PO 30-60 min pre-procedure
Azithromycin or clarithromycin 500 mg 30-60 min pre-procedure

NPO:
Ampicillin 2 grams IV or IM 30-60 min pre-procedure
Cefazolin 1 gram IV or IM 30-60 min pre-procedure
Ceftriaxone 1 gram IV or IM 30-60 min pre-procedure
Clindamycin 600 mg IV 30-60 min pre-procedure

Pharmacotherapy (27 decks)

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