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PDAT6 ID > 21 - Endocarditis > Flashcards

21 - Endocarditis Flashcards

1
Q

Catheter-Related Bacteremia/Sepsis
Vs
Localized Catheter site infection

A

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

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2
Q

Trans-THORACIC echocardiogram

A

less invasive

QUICKER

better at
quantifying hemodynamic dysfunction

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3
Q

Treatment for:

STREP
Veridans / Gallolyticus / Abiotrophia / Granulicatella

NVE
(native valve endocarditis)

  • *PCN - Intermediate Resistance**
  • *MIC > 0.12 , <0.5**
A
  • *Penicillin G Sodium**
  • *24 million** units per 24 hours
  • *4 WEEKS**

++PLUS++

  • *Gentamicin**
  • *3mg/kg** per 24 hours
  • *2 WEEKS**
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4
Q

Indications for
LONG-TERM CATHETERS

PICC

Port-a-cath

Groshong = CLosed end

Hickman = open end

A
  • 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)
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5
Q

Prevention** **for Infective Endocarditis

Unable to take ORAL

Prosthetic Valve or Material
previous IE
CHD

Dental procedures

A
  • *Ampicillin**
  • *2gm IM or IV**

1 hour before procedure

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6
Q

Bacterial ETIOLOGY
of
CR-BSI

A

Coagulase Negative STAPHylococcus

All Gram Negative Bacteria

Enterococci = STAPH.Areus

Candida

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7
Q

CR-BSI TREATMENT:

STAPHYLOCOCCUS AUREUS

RESISTANCE

A

Methicillin Resistant Strains

  • *Vancomycin**
  • *15mg/kg q12**

OR

  • *Daptomycin**
  • *6-8mg/kg**

2-6 WEEKS
REMOVE LINE

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8
Q

Treatment for:

GRAM NEGATIVE BACILLI
Infective Endocarditis

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

REQUIRES VALVE REPLACEMENT

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9
Q

Treatment for:

GRAM NEGATIVE BACILLI
Infective Endocarditis

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

REQUIRES VALVE REPLACEMENT

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10
Q

Treatment for:

STAPH Aureus
Coagulase-Negative Staphylococci

NVE
(Native Valve Endocarditis)

PCN ALLERGY

A
  • *Vancomycin**
  • *30mg/kg** QD
  • *6 WEEKS**
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11
Q

Treatment for:

Enterococcuus
Coagulase-Negative Staphylococci

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

RESISTANT STRAINS
to PCN / Vancomycin / Gentamicin

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

OR

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

trans-ESOPHAGEAL echocardiogram

A

more SENSITIVE

cost-effective

Recommended in patients with:
PROSTHETIC Valves

Previous Cardiothoracic Surgery

COPD

MORBID OBESITY

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13
Q

Prevention** **for Infective Endocarditis

ORAL

Prosthetic Valve or Material
previous IE
CHD

Dental procedures

A
  • *AMOXICILLIN**
  • *2gm**

1 hour before procedure

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14
Q

Treatment for:

STAPH Aureus
Coagulase-Negative Staphylococci

PVE
(Prosthetic)

RESISTANT STRAINS

A
  • *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

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15
Q

Prevention** **for Infective Endocarditis

PCN / Ampicillin Allergy
UNABLE TO TAKE ORAL

Prosthetic Valve or Material

previous IE
CHD

Dental procedures

A
  • *CLINDAMYCIN**
  • *600mg IM or IV**
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16
Q

Risk Factors
Infective Endocarditis

A

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

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17
Q

Treatment for:

STREP
Veridans / Gallolyticus / Abiotrophia / Granulicatella

PVE
(Proshetic Valve Endocarditis)

  • *PCN SENSITIVE**
  • *MIC < 0.12**
A
  • *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**
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18
Q

When should the
Catheter be PULLED
for
CR-BSI

A

Short Term Use

Supperative Thrombophlebitis

Severe Sepsis / Endocarditis / Osteomylitis

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

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19
Q

Treatment for:

FUNGI
Infective Endocarditis

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

REQUIRES VALVE REPLACEMENT

20
Q

CR-BSI TREATMENT:

Coagulase-Nagative STAPHylococcus

A
  • *VANCOMYCIN**
  • *15mg/kg q12h**

AB LOCK

10 - 14 day treatment

20% recurrence if catheter NOT REMOVED

21
Q

DIAGNOSIS of CR-BSI

A

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

22
Q

Treatment for:

STAPH Aureus
Coagulase-Negative Staphylococci

PVE
(Prosthetic)

No resistance / Susceptible Strains

A

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

23
Q

Treatment for:

STAPH Aureus
Coagulase-Negative Staphylococci

NVE
(Native Valve Endocarditis)

No Resistance = Susceptible Strains

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

Prevention of endoluminal contamination

A

Aseptic hub handling

↓#of connections

Separate the hub from the skin

↓changes of infusion sets

↓ of catheter lumens/ ports

↓catheter manipulations

25
Q

Which patients should recieve
PROPHYLAXIS
for
Infective Endocarditis?

A

Prosthetic Valve** OR **Material

Previous IE
infective endocarditis

CONGENITAL HEART DISEASE
palliative shunts / conduits
repaired congenital heart defects
cardiac TRANSPLANTATIOn recipients

26
Q

Patient RISKS
From long-term catheter placement

A

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)

27
Q

CR-BSI TREATMENT:

ENTEROCOCCI
&
VRE
(Vanco Resistant Enterococci)

A

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

28
Q

CR-BSI TREATMENT:

GRAM NEGATIVE BACILLI

A

Piperacillin/Tazobactam

Ceftazidime or Cefipime

Imipenem or Meropenem
+/- aminoglycoside

7-14 days

REMOVE THE CATHETER

29
Q

Treatment for:

STAPH Aureus
Coagulase-Negative Staphylococci

NVE
(Native Valve Endocarditis)

RESISTANT STRAINS

A
  • *Vancomycin**
  • *30mg/kg** per 24 hours in 2dd
  • *6 WEEKS**

same as PCN allergic

30
Q 
**Pathogenesis of
INFECTIVE ENDOCARDITIS (IE)**
A

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

31
Q

Diagnosis of
Infective Endocarditis

A

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

32
Q

Treatment for:

Enterococcuus
Coagulase-Negative Staphylococci

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

NO RESISTANCE
to PCN / Vancomycin / Gentamicin

A
  • *AMPICILLIN**
  • *2g** every 4hrs
  • *4-6 WEEKS**

for PCN allergy:
Vancomycin + Gentamycin

33
Q

Etiologic Agents in

​Infective Endocarditis

A
  • *STAPHYLOCOCCI**
  • *Positive > negative**

Streptococci
Veridans > other

Enterococci

Gram-Negative

Fungi

Etc

34
Q

Treatment for:

STREP
Veridans / Gallolyticus / Abiotrophia / Granulicatella

NVE
(native valve endocarditis)

PCN ALLERGY

A
  • *Vancomycin**
  • *30mg/kg** per 24 hours in 2divdoses
  • *4 WEEKS**

for
PVE –> 6 Week treatment

35
Q

Septic thrombophlebitis

A

Evidence of venous THROMBUS of the vein
with indwelling catheter & positve blood cultures
with clinical manifestations of sepsis

36
Q

CR-BSI TREATMENT:

CANDIDA

A
  • *14 DAYS**
  • *REMOVE THE CATHETER**

CASPOFUNGIN

AMPHOTERICIN B

FLUCONAZOLE

37
Q

SITUATIONS
where patients should receive
PROPHYLAXIS
Infective Endocarditis

A

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

38
Q

Prevention** **for Infective Endocarditis

ORAL
PCN / Ampicilin ALLERGY

Prosthetic Valve or Material
previous IE
CHD

Dental procedures

A
  • *Clindamycin**
  • *600mg**

OR

  • *Azithromycin** or Clarithromycin
  • *500mg**

1 hour before procedure

39
Q

Infusate-related bacteremia

A

presense of the

  • *same pathogen in BLOOD & INFUSATE**
  • without ID of alternative sites of infection*
40
Q

Mouth Bacteria

A

H-A-C-E-K

Haemophilus

Aggregatibacter

Cardiobacterium

Eikenella

Kingella

41
Q

Treatment for:

HACEK
Haemophilus / Aggregatibacter / Cardiobacterium / Eikenella-Kingella

Responsible for 5-10% of community aquired NVE

A
  • *CEFTRIAXONE**
  • *2g** per 24hours IV or IM 1 dose

4 WEEKS

42
Q

Treatment for:

STREP
Veridans / Gallolyticus / Abiotrophia / Granulicatella

NVE
(native valve endocarditis)

  • *PCN SENSITIVE**
  • *MIC < 0.12**
A
  • *Penicillin G sodium**
  • *12-18** million units / 24 hours
  • *4 WEEKS**

OR

Penicillin** + **Gentamicin
same + 3mg/kg / 24 hours
2 WEEKS

43
Q

RISK FACTORS
for
CR-BSI
Catheter related Bloodstream Infections

A

Cutaneous** vs **Subcutaneous Ports

↑# of LUMENS

  • *LENGTH of TIME in place**
  • *>3 days**

Poor sterile insertion technique

Insertion Site

TPN Used

44
Q

Treatment for:

STREP
Veridans / Gallolyticus / Abiotrophia / Granulicatella

PVE
(Proshetic Valve Endocarditis)

  • *PCN Resistant**
  • *MIC > 0.12**
A

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**
45
Q

Treatment for:

HACEK
Haemophilus / Aggregatibacter / Cardiobacterium / Eikenella-Kingella

Responsible for 5-10% of community aquired NVE

A
  • *CEFTRIAXONE**
  • *2g** per 24hours IV or IM 1 dose

4 WEEKS

46
Q

CR-BSI TREATMENT:

STAPHYLOCOCCUS AUREUS

no resistance

A
  • *Nafcillin** or Oxacillin
  • *1-2 gm IVPB q4-6hr**

2-6 WEEKS

REMOVE LINE

PDAT6 ID (31 decks)

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