21 - Endocarditis Flashcards by Karlo Sison

Catheter-Related Bacteremia/Sepsis
Vs
Localized Catheter site infection

Catheter-related bacteremia/sepsis
positive catheter culture

•ositive peripheral blood culture

same microorganism isolated in both 1 & 2

Localized catheter site infection
Clinically or microbiologically proved infection at the catheter exit site
(e.g., cellulitis, purulence, tunnelitis, pocket infections)
No systemic signs

How well did you know this?

Not at all

Perfectly

Trans-THORACIC echocardiogram

less invasive

QUICKER

better at
quantifying hemodynamic dysfunction

How well did you know this?

Not at all

Perfectly

Treatment for:

STREP
Veridans / Gallolyticus / Abiotrophia / Granulicatella

NVE
(native valve endocarditis)

*PCN - Intermediate Resistance**
*MIC > 0.12 , <0.5**

*Penicillin G Sodium**
*24 million** units per 24 hours
*4 WEEKS**

++PLUS++

*Gentamicin**
*3mg/kg** per 24 hours
*2 WEEKS**

How well did you know this?

Not at all

Perfectly

Indications for
LONG-TERM CATHETERS

PICC

Port-a-cath

Groshong = CLosed end

Hickman = open end

Lack of short term peripheral venous access (e.g, IV drug users)
Infusion of hyperosmolar solutions (e.g., TPNs)
Infusion of vessicant/ irritant drugs (e.g., certain chemotherapy)
Long-term IV therapy (e.g., treatment of endocarditis)
Infusion of intermittent drug therapy (e.g., chemotherapy)
Use of continuous ambulatory drug pumps (e.g., TPN)
Patient, physician or nursing preference
Geographic location (e.g., lives out in the country)

How well did you know this?

Not at all

Perfectly

Prevention** **for Infective Endocarditis

Unable to take ORAL

Prosthetic Valve or Material
previous IE
CHD

Dental procedures

*Ampicillin**
*2gm IM or IV**

1 hour before procedure

How well did you know this?

Not at all

Perfectly

Bacterial ETIOLOGY
of
CR-BSI

Coagulase Negative STAPHylococcus

All Gram Negative Bacteria

Enterococci = STAPH.Areus

Candida

How well did you know this?

Not at all

Perfectly

CR-BSI TREATMENT:

STAPHYLOCOCCUS AUREUS

RESISTANCE

Methicillin Resistant Strains

*Vancomycin**
*15mg/kg q12**

*Daptomycin**
*6-8mg/kg**

2-6 WEEKS
REMOVE LINE

How well did you know this?

Not at all

Perfectly

Treatment for:

GRAM NEGATIVE BACILLI
Infective Endocarditis

*B-Lactam_ + _AminoGlycoside**
*6 WEEKS**

REQUIRES VALVE REPLACEMENT

How well did you know this?

Not at all

Perfectly

Treatment for:

GRAM NEGATIVE BACILLI
Infective Endocarditis

*B-Lactam_ + _AminoGlycoside**
*6 WEEKS**

REQUIRES VALVE REPLACEMENT

How well did you know this?

Not at all

Perfectly

Treatment for:

STAPH Aureus
Coagulase-Negative Staphylococci

NVE
(Native Valve Endocarditis)

PCN ALLERGY

*Vancomycin**
*30mg/kg** QD
*6 WEEKS**

How well did you know this?

Not at all

Perfectly

Treatment for:

Enterococcuus
Coagulase-Negative Staphylococci

PVE** or **NVE
(Prosthetic OR native)

RESISTANT STRAINS
to PCN / Vancomycin / Gentamicin

*LINEZOLID**
*600mg** IV or ORAL q12 hr
*>** 6 Weeks

*DAPTOMYCIN**
*10-12 mg/kg per dose**
*>** 6 Weeks

How well did you know this?

Not at all

Perfectly

trans-ESOPHAGEAL echocardiogram

more SENSITIVE

cost-effective

Recommended in patients with:
PROSTHETIC Valves

Previous Cardiothoracic Surgery

COPD

MORBID OBESITY

How well did you know this?

Not at all

Perfectly

Prevention** **for Infective Endocarditis

ORAL

Prosthetic Valve or Material
previous IE
CHD

Dental procedures

*AMOXICILLIN**
*2gm**

1 hour before procedure

How well did you know this?

Not at all

Perfectly

Treatment for:

STAPH Aureus
Coagulase-Negative Staphylococci

PVE
(Prosthetic)

RESISTANT STRAINS

*PVE STAPH = 3 DRUGS** + >6 week treatment
Resistant –> vanco instead of oxacillin*

VANCOMYCIN
30mg/kg per 24hr in 2dd
> 6 WEEKS
++++
Rifampin
900mg per 24 hours
> 6 WEEKS
+++
Gentamicin
3mg/kg per 24 hours
2 WEEKS

How well did you know this?

Not at all

Perfectly

Prevention** **for Infective Endocarditis

PCN / Ampicillin Allergy
UNABLE TO TAKE ORAL

Prosthetic Valve or Material

previous IE
CHD

Dental procedures

*CLINDAMYCIN**
*600mg IM or IV**

How well did you know this?

Not at all

Perfectly

Risk Factors
Infective Endocarditis

Heart Disease
Rheumatic / Congenital / Acquired
Patent Ductus - Mitral Valve prolapse

Prosthetic Valves

Previous Bacterial endocarditis

ways bacteria could be introduced:
Indwelling Catheters
IV DRUG USE
DENTAL / SURGICAL procedures

How well did you know this?

Not at all

Perfectly

Treatment for:

STREP
Veridans / Gallolyticus / Abiotrophia / Granulicatella

PVE
(Proshetic Valve Endocarditis)

*PCN SENSITIVE**
*MIC < 0.12**

*Penicillin G sodium**
*24 million** units for 24 hours
*6 WEEKS**

with or without

*Gentamicin**
*3mg/kg** per 24 hours in 1 dose
*2 WEEKS**

How well did you know this?

Not at all

Perfectly

When should the
Catheter be PULLED
for
CR-BSI

Short Term Use

Supperative Thrombophlebitis

Severe Sepsis / Endocarditis / Osteomylitis

+POS+ Blood cultures after 72 hours
& receiving ABx therapy

How well did you know this?

Not at all

Perfectly

Treatment for:

FUNGI
Infective Endocarditis

Study These Flashcards

*Amphotericin B** +/- Flucytosine
treatment duration is UNKNOWN*

REQUIRES VALVE REPLACEMENT

CR-BSI TREATMENT:

Coagulase-Nagative STAPHylococcus

Study These Flashcards

*VANCOMYCIN**
*15mg/kg q12h**

AB LOCK

10 - 14 day treatment

20% recurrence if catheter NOT REMOVED

DIAGNOSIS of CR-BSI

Study These Flashcards

CATHETER TIP CULTURE
> 15 CFU
has to be the TIP
+
2 Peripheral blood Cultures

Treatment for:

STAPH Aureus
Coagulase-Negative Staphylococci

PVE
(Prosthetic)

No resistance / Susceptible Strains

Study These Flashcards

PVE STAPH = 3 DRUGS + >6 week treatment

Nafcillin** or **Oxacillin
12g per 24h
> 6 WEEKS
++++
Rifampin
900mg per 24 hours
> 6 WEEKS
+++
Gentamicin
3mg/kg per 24 hours
2 WEEKS

Treatment for:

STAPH Aureus
Coagulase-Negative Staphylococci

NVE
(Native Valve Endocarditis)

No Resistance = Susceptible Strains

Study These Flashcards

*Oxacillin_ or _Nafcillin**
*12g / 24h** in 4-6 dd
*6 WEEKS**

Prevention of endoluminal contamination

Study These Flashcards

Aseptic hub handling

↓#of connections

Separate the hub from the skin

↓changes of infusion sets

↓ of catheter lumens/ ports

↓catheter manipulations

**Which patients should recieve _PROPHYLAXIS_** for **Infective Endocarditis?**

**_Prosthetic Valve**_ OR _**Material_** **_Previous IE_** infective endocarditis **_CONGENITAL HEART DISEASE_** **palliative shunts / conduits** **repaired** congenital heart defects cardiac **TRANSPLANTATIOn recipients**

Patient **_RISKS_** From **long-term catheter placement**

Local site infection **tunnel** or **pocket** Catheter-related bloodstream infection = **_CR BSI_** * **Septic thrombophlebitis** * **Endocarditis** •Metastatic infections (e.g.**, lung abscess, brain abscess, osteomyelitis, endophthalmitis)**

**CR-BSI TREATMENT:** **_ENTEROCOCCI_** & **VRE (Vanco Resistant Enterococci)**

*same as Coagulase Negative STAPH* **_VANCOMYCIN_** **15mg/kg q12h AB LOCK 10 - 14 day treatment** **_for isolated VRE - PULL LINE_** **_Daptomycin_** - **6mg/kg/day** OR **_Linezolid_** - **600mg q12h**

**CR-BSI TREATMENT:** **_GRAM NEGATIVE BACILLI_**

**Piperacillin/Tazobactam** **Ceftazidime** or **Cefipime** **Imipenem** or **Meropenem** +/- **aminoglycoside** **_7-14 days_** ***_REMOVE THE CATHETER_***

**Treatment for:** **_STAPH Aureus_** Coagulase-Negative Staphylococci **_NVE_** (Native Valve Endocarditis) **_RESISTANT STRAINS_**

* *_Vancomycin_** * *30mg/kg** per 24 hours in **2dd** * *6 WEEKS** same as PCN allergic

``` **Pathogenesis of INFECTIVE ENDOCARDITIS (IE)** ```

Insult to the **Valvular** or **Endocardial Endothelium** allowing for **deposition** of **_PLATELET-FIBRIN_** aggregates **_NBTE_** **(Non-Bacterial Thrombotic Endocarditis)** **/ Vegetations** acts as the: ideal spot for **BACTERIAL ADHERENCE**

**Diagnosis of Infective Endocarditis**

Clinical Presentations: **embolic phenomenom / OSLER nodes / janeway lesions splenomegaly** * *_BLOOD CULTURES_** * *Continuous BACTEREMIA** * *3 Sets** @different **SITES &** **TIMES = 1-2sets/day until negative** **_ECHOCARDIOGRAM_** Trans-thorasic vs Trans-esophageal

**Treatment for:** **_Enterococcuus_** Coagulase-Negative Staphylococci **_PVE**_ or _**NVE_** (Prosthetic OR native) ***_NO RESISTANCE_*** to **PCN / Vancomycin / Gentamicin**

* *_AMPICILLIN_** * *2g** every **4hrs** * *4-6 WEEKS** for PCN allergy: **Vancomycin + Gentamycin**

**Etiologic Agents in** Infective Endocarditis

* *_STAPHYLOCOCCI_** * *Positive \> negative** **_Streptococci_** Veridans \> other **Enterococci** **Gram-Negative** **Fungi** **Etc**

**Treatment for:** **_STREP_** Veridans / Gallolyticus / Abiotrophia / Granulicatella **_NVE_** (native valve endocarditis) **_PCN ALLERGY_**

* *_Vancomycin_** * *30mg/kg** per **24 hours** in 2divdoses * *4 WEEKS** for **PVE --\> 6 Week treatment**

**_Septic thrombophlebitis_**

Evidence of **_venous THROMBUS_** of the **vein** with indwelling catheter & positve blood cultures with **clinical manifestations of sepsis**

**CR-BSI TREATMENT:** **_CANDIDA_**

* *_14 DAYS_** * *_REMOVE THE CATHETER_** **CASPOFUNGIN** **AMPHOTERICIN B** **FLUCONAZOLE**

**_SITUATIONS_** **where patients should receive _PROPHYLAXIS_** **Infective Endocarditis**

all **DENTAL procedures** that involve **manipulation of : _gingival tissue**_or_**periapical region of teeth**_or_**perforation of oral mucosa_** **_*no longer recommended for NON-DENTAL PROCEDURES*_** in the absence of active enfection

**_Prevention**_ _**for Infective Endocarditis_** **ORAL PCN / Ampicilin ALLERGY** Prosthetic Valve or Material previous IE CHD Dental procedures

* *_Clindamycin_** * *600mg** **OR** * *_Azithromycin_** or **_Clarithromycin_** * *500mg** 1 hour before procedure

**_Infusate-related bacteremia_**

presense of the * *same pathogen in BLOOD & INFUSATE** * **_without ID of alternative sites of infection_***

**Mouth Bacteria**

**_H-A-C-E-K_** **Haemophilus** **Aggregatibacter** **Cardiobacterium** **Eikenella** **Kingella**

**Treatment for:** **_HACEK_** Haemophilus / Aggregatibacter / Cardiobacterium / Eikenella-Kingella Responsible for 5-10% of community aquired NVE

* *_CEFTRIAXONE_** * *2g** per **24hours** IV or IM **1 dose** ## Footnote **4 WEEKS**

**Treatment for:** **_STREP_** Veridans / Gallolyticus / Abiotrophia / Granulicatella **_NVE_** (native valve endocarditis) * *_PCN SENSITIVE_** * *MIC \< 0.12**

* *_Penicillin G sodium_** * *12-18** million units / **24** hours * *4 WEEKS** OR **_Penicillin**_ + _**Gentamicin_** same + **3mg/kg** / 24 hours **2 WEEKS**

**_RISK FACTORS_** for **CR-BSI** Catheter related Bloodstream Infections

**_Cutaneous**_ vs _**Subcutaneous Ports_** ↑**# of LUMENS** * *LENGTH of TIME in place** * *_\>3 days_** *Poor sterile insertion technique* **Insertion Site** **TPN Used**

**Treatment for:** **_STREP_** Veridans / Gallolyticus / Abiotrophia / Granulicatella **_PVE_** (Proshetic Valve Endocarditis) * *_PCN Resistant_** * *MIC \> 0.12**

*Same as PCN resistant, but PLUS gentamicin is 6 WEEKS (not 2)* * *_Penicillin G sodium_** * *24 million** units for 24 hours * *6 WEEKS** ++PLUS++ * *_Gentamicin_** * *3mg/kg** per 24 hours in 1 Dose * *6 WEEKS**

**Treatment for:** **_HACEK_** Haemophilus / Aggregatibacter / Cardiobacterium / Eikenella-Kingella Responsible for 5-10% of community aquired NVE

* *_CEFTRIAXONE_** * *2g** per **24hours** IV or IM **1 dose** ## Footnote **4 WEEKS**

**CR-BSI TREATMENT:** **_STAPHYLOCOCCUS AUREUS_** ***no resistance***

* *_Nafcillin_** or **_Oxacillin_** * *1-2 gm IVPB q4-6hr** ## Footnote **2-6 WEEKS** **_REMOVE LINE_**

21 - Endocarditis Flashcards

(46 cards)