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Year 3 - Clinical > 6 - Endocarditis > Flashcards

6 - Endocarditis Flashcards

1
Q

Where is endocarditis the most common?

A
  • Mitral valve (need some damage to the valve that causes it to repair, giving a predisposition to endocarditis)
  • Second most common is tricuspid (most common in IVDU)
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2
Q

Risk factors for endocarditis?

A
  • Over 60 y/o
  • Male
  • Intravascular catheter, chronic hemodialysis, IVDU
  • Oral hygiene/ dental pathology
  • Immunocompromised
  • Prosthetic valve
  • Prior infective endocarditis
  • Congenital or valvular heart disease
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3
Q

Signs and symptoms of endocarditis?

A
  • Fever (can be low grade)
  • New or worsening murmur
  • Hematuria (RBCs in the urine)
  • Vascular embolic events, splenomegaly, skin/ mucosal lesions
  • Malaise, anorexia, weight loss
  • Lab signs = leukocytosis, anemia, elevated ESR and CRP
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4
Q

What are the common pathogens for subacute, indolent endocarditis?

A
  • Viridans strep
  • HACEK (Haemophilus, aggregatibacter, cardiobacterium, eikenella, kingella)
  • S. epidermidis
  • Enterococcus
  • Strep gallolyticus
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5
Q

What are the common pathogens of acute, invasive endocarditis?

A
  • Group A, B, C, and G strep

- Staph aureus

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6
Q

What is the most likely pathogen of PVE w/in 2 months of surgery?

A

CoNS and staph aureus

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7
Q

What is the most likely pathogen of endocarditis w/ a negative blood culture?

A

Zoonotic (coxiella burnetiid, bartonella, brucella)

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8
Q

Complications of endocarditis?

A
  • Embolization including stroke
  • New or worsening heart failure
  • Intracardiac abscess
  • Arrhythmias
  • Mortality rate 15-25% (40% at 5 years)
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9
Q

What causes the majority of complications of endocarditis?

A
  • Poor prognosis in prosthetic valves
  • Advanced age
  • Co-morbidities
  • Heart failure
  • Embolic events
  • Fungal, gram neg, and left-sided staph aureus endocarditis
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10
Q

What is required w/ gram neg and fungal endocarditis?

A

Valve replacement b/c these infections are very hard to treat w/ antibiotics

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11
Q

What are the “major” Duke’s criteria for diagnosis of endocarditis?

A
  • Positive IE blood culture of staph aureus, viridans strep, S. gallolyticus, community-acquired enterococcus, or HACEK (2 draws > 12 h apart or 3 draws > 1 h apart)
  • Positive zoonotic serology
  • Echocardiogram for vegetation, pseudoaneurysm, or abscess
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12
Q

Which streptococci are associated w/ endocarditis?

A
  • 75% viridans group strep (comes from the mouth); 15-20% pyogenic strep
  • From viridans group (from most to least common) - S. mitis, S. sanguinis, S. gallolyticus, and S. mutans
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13
Q

What are the principles of endocarditis antibiotic therapy?

A
  • High-dose IV therapy for plasma concentrations that penetrate the vegetation
  • Bactericidal against high density bacteria w/ low metabolic, stationary growth phase
  • Duration that sterilizes the vegetation
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14
Q

Antimicrobial options for NVE caused by Viridans group strep, S. gallolyticus (Pen-S, MIC < 0.1)

A
  • 4 w penicillin 12-18 MU/d CI or dosed q4h
  • 4 w ceftriaxone 2g q24h
  • [4 w vanco 15 mg/kg q12h] for allergy
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15
Q

Antimicrobial options for uncomplicated NVE caused by Viridans group strep, S. gallolyticus (Pen-S, MIC < 0.1)? What is considered uncomplicated NVE?

A
  • <5 mm, no CV risks or embolic events, good tx response
  • 2 w penicillin 12-18 MU/d CI or q4h + gentamicin 3 mg/kg q24h
  • 2 w ceftriaxone 2g q24h + gentamicin 3 mg/kg q24h
  • [4 w vanco 15 mg/kg q12h] for allergy
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16
Q

Antimicrobial options for PVE caused by Viridans group strep, S. gallolyticus (Pen-S, MIC < 0.1)

A
  • 6 w penicillin 24 MU/d CI or dosed q4h + 2 w gentamicin 3 mg/kg q24h
  • 6 w ceftriaxone 2g q24h + 2 w gentamicin 3 mg/kg q24h
  • [6 vanco 15 mg/kg q12h] for allergy
17
Q

Antimicrobial options for NVE caused by Viridans group strep, S. gallolyticus (Pen-RR, MIC 0.1-0.5)

A
  • 4 w penicillin 24 MU/d CI ro dosed q4h + 2 w gentamicin 3 mg/kg q24h
  • 4 w ceftriaxone 2g q24h + 2 w gentamicin 3 mg/kg q24h
  • [4 w vanco 15 mg/kg q12h] for allergy
18
Q

Antimicrobial options for PVE caused by Viridans group strep, S. gallolyticus (Pen-RR, MIC 0.1-0.5)

A
  • 6 w penicillin 24 MU/d CI or dosed q4h + 6 w gentamicin 3 mg/kg q24h
  • 6 w ceftriaxone 2g q24h + 6 w gentamicin 3 mg/kg q24h
  • [6 w vanco 15 mg/kg q12h] for allergy
19
Q

How is endocarditis different in IVDU?

A
  • Less pre-existing valvular disease
  • Tricuspid valve in > 50%
  • Staph aureus in 60-80% of cases
  • Good tx response for staph aureus, poor for gram neg or fungal
20
Q

Antimicrobial options for NVE caused by MSSA CoNS?

A
  • 6 w cloxacillin 2g q24h
  • 2 w cloxacillin 2g q24h (for uncomplicated tricuspid associated w/ IVDU)
  • [6 w cefazolin 2g q8h] for minor reaction to beta lactam
  • [6 w vanco 15 mg/kg q12h] for hypersensitivity reaction to beta lactam
  • [6 w dapto > 8 mg/kg q24h] very last resort if vanco not working
21
Q

Antimicrobial options for PVE caused by MSSA CoNS?

A
  • At least 6 w cloxacillin 2g q24h + rifampin 300 mg po q8h + 2 w gentamicin 3 mg/kg/day in 2-3 doses
22
Q

Antimicrobial options for NVE caused by MRSA CoNS?

A
  • 6 w vanco 15 mg/kg q12h

- [6 w dapto > 8 mg/kg q24h]

23
Q

Antimicrobial options for PVE caused by MRSA CoNS?

A
  • At least 6 weeks vanco 15 mg/kg q12h + rifampin 300 mg po q8h + 2 w gentamicin 3 mg/kg/day in 2-3 doses
  • Only use aminoglycoside if organism is susceptible
24
Q

What is the expected tx response for endocarditis?

A
  • Clinical improvement w/in 3-7 days
  • Repeat blood cultures every 2 days
    • Negative by day 2 by strep & HACEK; by day 3 for beta lactams against staph aureus; by day 5 for vanco against staph aureus
  • Durations of therapy from time of negative blood culture
25
Q

What are the challenges in treating endocarditis w/ antibiotics?

A
  • Penetrate vegetation
  • Activity against high-density, low metabolic bacteria
  • Biofilm, particularly in PVE
  • Antimicrobial resistance
26
Q

What is the duration of antimicrobial therapy w/ surgery?

A
  • If valve tissue is culture negative, complete recommended therapy including that administered pre- and post-surgery
  • If peri-valvular abscess or valve tissue is culture positive, re-initiate and complete recommended antimicrobial post-surgery
27
Q

When is antimicrobial prophylaxis for endocarditis recommended?

A
  • For high risk cardiac conditions (prosthetic valves, prior endocarditis, unrepaired congenital heart disease, incompletely repaired congenital heart disease w/ residual defects at prosthetic patches/ devices, completely repaired congenital heart disease w/ prosthetic materials for 6 months, and cardiac transplants w/ valve dysfunction)
  • Dental procedures causing bacteremia w/ IE pathogens (procedures manipulating gingival tissue, peri-apical region of teeth, or perforation of oral mucosa)
28
Q

What antimicrobials are used for endocarditis prophylaxis?

A
  • Best option = amoxicillin 2g (adults) or 50 mg/kg (children) 1h prior to surgery
  • Alternatives = cephalexin/ cefadroxil, azithro/ clarithro, or clinda (allergy)
29
Q

Why is azithromycin not the best option for prophylaxis?

A

Has a very long t1/2, which means it stays in the body for a long time and can cause resistance

30
Q

Resistance to macrolides = cross resistance to _____

A

Clindamycin

Year 3 - Clinical (30 decks)

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