Infective endocarditis-Table 1 Flashcards
What is endocarditis and where does it most commonly occur?
Infection of the endocardial surface of the heart, usually heart valves but can occur within septal defects or on mural endocardium
What is the most common etiology of endocarditis?
Bacterial
What is the 4th leading cause of life-threatening infectious dz syndromes?
Endocarditis
If a L or right sided emboli worse?
L side, this can potentially dislodge and go into the brain whereas a R sided would go to the lungs (PE)
What are risk factors for endocarditis?
•Male gender •Older age •Prosthetic valve •Intra‐cardiac device •Pre‐existing cardiac abnormality •Injection drug use Congenital heart abnormalities
What are the types of infective endocarditis?
Acute infective and subacute infective
What is characteristic of acute infective endocarditis?
- caused by highly virulent organisms like S. aureus
- damage to cardiac structures happens rapidly
- there are necrotizing, ulcerative, destructive lesions
What is characteristic of subacute infective endo?
Less invasive, less virulent ( step viridans or bovis), and damage to cardiac structures is slow and gradual
If it is an IV drug user, what is the culprit?
STAPH AUREUS
What are characteristics of Left sided infective endo?
- Community associated and healthcare acquired
- Embolic stroke
- High mortality
- Surgical benefits greatest in early phase of IE
What are characteristics of right sided infective endo?
IVDU
Septic pulmonary embolism common
High cure rate (>85%)
Surgery infrequently needed
What is the clinical presentation of IE?
- Fever
- Chills
- Weakness
- Dyspnea
- Sweats
- Cough
- Anorexia
- Nausea
- Vomiting
- Chest pain
- Abdominal pain
- Heart murmur – around 20-40% only
- Septic Emboli- CT lung or brain
- Skin findings
What are the skin findings in IE?
- Splinter hemorrhages under nailbeds of fingers or toes
- Petechiae - small, red painless lesions
- Osler’s nodes: red or purple, painful, subcutaneous nodules
- Janeway lesions: non-tender, red, hemorrhagic lesions; usually found on palms or soles
What is the hallmark finding of IE?
continuous bacteremia (persistently positive blood cultures) caused by bacteria shedding from the vegetation into the bloodstream
What diagnostic tests are used in IE?
•TTE (transthoracic echocardiogram) sensitivity- 58% to 63%
Test Question, cant trust this if it is negative**
•TEE (transesophageal echocardiogram) sensitivity- 90% to 100%
Way more invasive
How is IE diagnosed off the duke criteria?
2 major, 1 major + 3 minor or 5 minor
What are majors in the duke criteria?
1) blood cultures 2/2
2) evidence of vegetation on ECHO
What are the minors in the duke criteria?
- predisposed heart condition
- fever
- vascular phenomena
- immunologic phenomena
- positive blood culture that doesn’t meet major criteria
What is the main non pharm intervention for IE?
Surgery- repair or replace
Dependent on heart failure, uncontrolled infection, and prevention of embolism
What are the four general principles when choosing therapeutic agents for infective endocarditis?
1.Use high dose therapy (to get adequate concentrations within vegetation)
2.Use parenteral (IV) therapy
3.Use bactericidal therapy
4.Count days of therapy from the first day on which blood cultures change to negative.
4-6 week tx from when blood culture is negative….after you start abx wait a few days and draw labs to see if still (+)
Why should you never add gentamicin unless specifically indicated?
Increased risk of nephrotoxicity and renal dysfunction with little to no benefit
What is the drug regimen for streptococcus IE with native valves and PCN susceptibility?
4 weeks: PEN G or CTX
2 weeks: PEN G_ gent OR CTX + gent
What is the drug regimen for streptococcus IE with native valves and PCN intermediate?
4 and 2 weeks PEN G x 4 weeks PEN G + gent x 2 weeks CTX x 4 weeks CTX + gent x 2 weeks
What is the drug regimen for streptococcus IE with prosthetic valves and PCN susceptible?
6 weeks
PEN G
CTX
What is the drug regimen for streptococcus IE with prosthetic valves or native valves and PCN resistance?
6 weeks
PEN G? these are confusing
CTX
What is tx for staph IE with native valves?
6 weeks
nafcillin IV
What is tx for staph IE with prosthetic valves?
> /= 6 weeks
nafcillin
PLUS rifampin
PLUS gent x 2 weeks
What is tx for staph IE with MRSA?
Vanco
What is the tx for efaecalis IE?
Amp + gent for 4-6 weeks
What is HACEK?
H – Haemophilus parainfluenzae, H. aphrophilus, H. paraphtophilus, H. influenzae A – Actinobacillus actinomycetemcomitans C – Cardiobacterium hominis E– Eikenella corrodens K – Kingella kingae, K. denitrificans
How is HACEK IE tx with native valve?
4 weeks
CTX or AMP/sulb OR cipro
How is HACEK IE tx with prosthetic valve?
6 weeks
ceftriaxone (CTX) OR amp/sulb OR cipro
When is daptomycin used in IE?
FDA approved for the treatment of right‐ sided MSSA or MRSA endocarditis
