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IPT: ID > Block 2 - Endocarditis, Bacteremia, Bone/Joint infection > Flashcards

Block 2 - Endocarditis, Bacteremia, Bone/Joint infection Flashcards

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1
Q

Pathophysiology of osteomyelitis (OM)?

A

Hematogenous, vascular insufficiency

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2
Q

Difference between acute, chronic, hematogenous, and contiguous OM?

A

Acute = Sx onset <1wk from infection

Chronic = 10 days to 1 month

Hematogenous = spread through blood

Contiguous = spread through connecting soft tissue

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3
Q

Pathophysiology of diabetic foot osteomyelitis (DFO)?

A

Starts with DFI and contiguous spread

Periosteum is compromised and bone infection

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4
Q

Risk factors of DFO?

A

Deep ulcers

Ulcer that doesnt heal after 6 wks of wound care

Ulcer >2cm

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5
Q

DFO diagnosis?

A

Probe to bone test

ESR, CRP, MRI!

Bone culture (avoid swab if can)

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6
Q

DFO bugs

A

S. aureus

CoNS

GNR and anaerobes (site specific)

Special cases = salmonella and TB

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7
Q

Main DFO treatment?

A

Source control!

Through surgery or non-surgical interventions

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8
Q

When is surgery required for DFO?

A

Gas in deeper tissue

Abscess

Necrotizing fasciitis

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9
Q

When is surgery opted out for DFO?

A

Pt doesnt want amputation

Confined to forefoot and minimal soft tissue loss

Risk > Benefit

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10
Q

Signs of beneficial response for DFO treatment?

A

Decreased ESR, CRP

Radiographic changes that suggest healing

CLEAR MARGINS!!!

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11
Q

If pt is stable with DFO, how do you treat them?

A

Culture it, then surgery

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12
Q

If pt is NOT stable with DFO, how do you treat them?

A

Anti-MRSA + Anti-Pseudomonal

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13
Q

Vertebral OM (VOM) presentation?

A

Back pain

Normal WBC

ESR, CRP elevated

+/- fever

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14
Q

NVO diagnosis?

A

MRI (takes 3-6 wks for bone destruction to show up)

Intraoperative aspiration or biopsy

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15
Q

Risk factors for NVO?

A

Age

IVDU

Indwelling catheter such as HD

Immunocompromised

Bacteremia w/ S. aureus

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16
Q

Which Abx have good bone penetration?

A

Azith
Bactrim
Clinda

Tetra

RFML

Rifampin
Fluoro
Metro
Linezolid

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17
Q

Abx and Sacral OM?

A

Do not give, they only offer transient response

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18
Q

If there is no source control for OM, what is the duration of Tx?

A

6 weeks

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19
Q

When should you suspect prosthetic joint infection (PJI)?

A

SINUS TRACT

persistent wound drainage

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20
Q

Early, delayed, and late PJI

What causes them and what is the time frame?

A

Early and delayed caused by surgery

Late is hematogenous

Early 1-3 months after implantation

Delayed is several months to 1-2 yrs

Late >2 yrs

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21
Q

How is PJI diagnosed?

A

Arthrocentesis (>65% neutro + >1700 leukocytes)

Microbiology (synovial fluid + blood)

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22
Q

PJI bugs?

A

Most common - S. aureus

Then Strep spp., GNR STDs

Least common (special) - arbovirus

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23
Q

PJI Treatment?

A

Source control

2 stage exchange is gold standard in US; 2 surgeries by removing hardware, spacers and Abx, then new hardware

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24
Q

PJI Abx treatment?

A

2-6 wks IV + (Rifampin if hardware is added)

Then 3-6 months PO therapy

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25
Septic arthritis presentation?
Painful joint in absence of trauma Joint motion restriction Joint warmth
26
Septic arthritis pathophysiology?
Synovial membrane has bugs, pressure from effusions destroy joint cartilage and causes bone loss
27
Septic arthritis diagnosis?
Arthrocentesis (50-200WBC and Glucose <40) Microbiology
28
Treatment regimen for septic arthritis?
Depends on gram stain If gonococcal, ceftriaxone 24-48hrs then oral If not, hold empiric until we can tailor to bug for 3-4 weeks
29
Bugs for bacteremia?
CoNS HACEK Haeomphilus spp Actinobacillus spp Cardiobacterium spp Eikenella spp Kingella spp
30
G+ MSSA bacteremia, first line Abx?
CON Cefazolin Oxacillin Nafcillin x14 days
31
MRSA bacteremia, Abx?
Uncomplicated: Vanco or dapto (6mg/kg/dose) for at least 2 weeks Complicated: Same drug but for 4-6 weeks, maybe even higher dapto dose (8-10mg/kg/dose)
32
What should you rule out with gram + bacteremias?
Endocarditis
33
Bacteremia and vanco use
Just make sure MIC≤2, continue using vanco if there is clinical AND microbiological response If MIC=2, use an alternative
34
What are the alternative agents for MRSA bacteremia
High dose dapto (10mg/kg/day) + one of these agents ``` Genta Rifampin Zyvox Bactrim B-lactam (ceftaroline) ```
35
What are the CoNS?
S. epidermidis (#1 cause), S. hominis, S. lugdenesis
36
Cefazolin Oxacillin Nafcillin Which one is preferred to treat MSSA?
Cefazolin due to ADR and frequency of dosing
37
S. lugdunensis vs other CoNS in bacteremia
More virulent Treatment for minimum of 14 days
38
G+ vs G- bacteremia, which one is more "stickier" to lines and devices?
G+
39
Repeated cultures for bacteremia is typically done for (G+/G-)
G+, clearance is much faster for G- bacteremia
40
If you see HACEK, rule out...
Endocarditis
41
Empiric Tx for G- bacteremia?
Ceftriaxone, ceftazidime, cefepime Zosyn Carbapenems May do EIAD for synergy x7-14 days
42
(G+/G-) bacteremia involves step-down therapy to oral therapy? When are they used?
G- Bacteremia of urinary source (enterobacteriaceae) = Give fluoroquinolones CAP or uncomplicated bacteremia
43
What is a biofilm?
Surface-associated community of 1+ microbial species attached to each other encased in an extracellular polymeric matrix Adheres to any surface
44
What is required to diagnose a catheter related bloodstream infection (CRBI)?
Positive percutaneous blood culture or multiple catheter sites (both must be of the same organism) Sign/sx of infection
45
Common bugs for CRBI?
Staph, enterococci, GNR (E. coli, kleb.), and Yeast (candida) S. epidermidis is the most common contaminant (not true infection) and cause of CRBI
46
CRBI empiric Tx?
MRSA or Enterococcus = vanco G- = Ceftazidime, cefepime, carbapenem, B-lactam Pseudomonas = ceftazidime, cefepime, carbapenem, zosyn
47
How long do you treat CRBI?
w/o complications = 7-14 days Bacteremia or fungemia after catheter removal >72hrs = 4-6 weeks Endocarditis = 4-6 weeks
48
What bugs would cause you to remove tunneled catheters?
S. aureus or Candida
49
MS CONS + CRBI, what are you using?
Preferred: Nafcillin or oxacillin Can use: Cefazolin, Vanco, Bactrim
50
MR CONS + CRBI, what are you using?
Preferred: Vanco Can use: Dapto, Linezolid, ceftaroline
51
How long do you treat MS/MR CONS CRBI?
Depends on if catheter is removed or retained Removed = 5-7 days Retained = 7-14days
52
MSSA + CRBI, what are you using?
Preferred: Nafcillin or oxacillin Can use: cefazolin, vanco
53
MRSA + CRBI, what are you using?
Preferred: Vanco Can use: dapto, linezolid, ceftaroline, bactrim
54
How long do you treat MSSA/MRSA CRBI?
4-6 weeks unless... diabetic, immunosuppressed, catheter is retained, any prosthetic intravascular device, TEE positive for IE, bacteremia>72hrs, metastatic infection, then its 14 days
55
What to give in the following situations for CRBI Ampicillin-S Enterococcus Ampicillin -R, Vanco -S enterococcus Amp and Vanco -R enterococcus
Amp or Amp+Gent Vanco AND Gent Dapto or Zyvox x7-14days
56
How do you treat E. coli or Kleb (ESBL -) CRBI?
3rd gen ceph If ESBL+, use carbapenem x7-14 days
57
How do you treat APES CRBI? Acinetobacter P. aeruginosa Enterobacter Serratia
Acinetobacter - Unasyn or carbapenem P. aerugionsa - Ceftazidime, cefepime, carbapenem, zosyn Enterobacter/Serratia - Carbapenem x7-14 days
58
Pathophysiology of endocarditis?
Endothelial damage to heart; deposition of platelets and fibrin Forms nonbacterial thrombotic lesion Presence of bacteremia and bacterial adherence Persistent growth of bacteria within cardiac lesion and forms infective vegetation Septic emboli to distant organs
59
Most common bug for endocarditis?
S. aureus
60
Most common bug for dental procedures that can cause endocarditis prior to S. aureus?
Viridans group Strep
61
Most common bug found in elderly population or homelessness?
S. gallolyticus
62
Bug associated w/ GI/GU surgeries?
Enterococcus spp.
63
Bug associated w/ prosthetic valve endocarditis?
CoNS
64
Which bugs may present as culture negative endocarditis?
HACEK organisms ``` Haemophilus Actinobacillus Cardiobacterium Eikenella Kingella ```
65
What are the extra-cardiac complications of endocarditis?
Kidneys Mycotic aneurysms Skin, eyes, nails
66
Diagnosis of endocarditis?
Need clinical, lab, and ECG data Modified Duke Criteria Blood cultures (at least 2)
67
TTE and TEE for Endocarditis?
TTE used initially or for someone with IVDU TEE for staph bacteremia and prosthetic heart valves; con = if used initially, they might miss early abscess formation
68
Modified Duke Criteria for endocarditis?
Major = 2 positive cultures, evidence via TTE, TEE Minor = Heart issues, IVDU, Fever >38, immunologic or microbiologic stuff Definite = 2 major OR 1 major + 3 minor OR 5 minor Possible = 1 major + 1 minor OR 3 minor Rejected = alternate diagnosis or resolution <4 days or doesnt meet criteria
69
Staph endocarditis, native valve. Oxacillin-S, Tx?
CON Cefazolin Oxacillin Nafcillin x6 weeks
70
Staph endocarditis, native valve. Oxacillin-R, Tx?
Vanco or dapto x6 weeks
71
Staph endocarditis, prosthetic valve. Oxacillin-S, Tx?
Naf or Oxacillin + Rifampin + Genta ≥6wks for the first two rx, gentamicin is for the first 2 wks only
72
Staph endocarditis, prosthetic valve. Oxacillin-R, Tx?
Vanco + Rifampin + Genta ≥6wks for the first two rx, gentamicin is for the first 2 wks only
73
Strep endocarditis, native valve. PCN strain MIC ≤0.12, Tx?
Pen G x 4wks Ceftriaxone x 4wks Pen G + Gent x2wks Ceftriaxone + Gent x2wks Vanco x4 wks
74
Strep endocarditis, native valve. PCN strain MIC 0.12-0.5, Tx?
Pen G for 4 wks + Gent for first 2 wks or Vanco x4wks
75
Strep endocarditis, native valve. PCN strain MIC≥0.5, Tx?
Amp + Gent Pen + Gent Vanco x4-6 wks
76
Strep endocarditis, prosthetic valve. PCN strain MIC≤0.12, Tx?
Pen +/- Gent Ceftriaxone +/-Gent Vanco Pen, Ceft, Van x 6 wks Gent first 2 wks
77
Strep endocarditis, prosthetic valve. PCN strain relatively or fully resistant MIC >0.12 or >0.5mcg/mL, Tx?
Pen + Gent Ceftriaxone + Gent Vanco x6 wks **almost the same as <0.12 but easier to remember
78
Enterococcal endocarditis (regardless of native or prosthetic), susceptible to PCN, gent, and vanco Tx?
Amp + Gent (4-6wks) Pen + Gent (4-6wks) Amp + ceftriaxone (6wks)
79
Enterococcal endocarditis (regardless of native or prosthetic), susceptible to PCN and vanco, but not to gent Tx?
Amp + Strep (4-6wks) Pen + Strep (4-6wks) Amp + ceftriaxone (6wks)* same as gent susceptible kind
80
Enterococcal endocarditis, unable to tolerate B-lactams, Tx?
Vanco + Gent x 6wks
81
Enterococcal endocarditis, , intrinsic or Beta lactamase producer, Tx?
Vanco + Gent Vanco + Strep x6wks
82
Enterococcal endocarditis, resistant to PCN, aminoglycosides, and vanco, Tx?
Linezolid or Dapto >6 wks
83
HACEK endocarditis Tx?
Ceftriaxone Amp Cipro 4wks for native 6 for prosthetic
84
Culture negative endocarditis, native valve Tx?
Vanco + Cefepime Vanco + Unasyn x4-6wks
85
Culture negative endocarditis, prosthetic valve Tx?
Vanco + Cefepime + Rifampin + Gent Vanco + Ceftriaxone +/- Rifampin x 6wks except with gent, its from weeks 2-6
86
Dental procedure prophylaxis, oral Tx?
Dosed 30-60 min before procedure Amox 2g
87
Dental procedure prophylaxis, unable to take oral Tx?
Dosed 30-60 min before procedure Amp, Cefazolin, ceftriaxone 1-2g
88
Dental procedure prophylaxis, allergic to PCN or ampicillin, oral Tx?
Dosed 30-60 min before procedure Cephalexin, Clinda, Clarithromycin, Azithromycin
89
Dental procedure prophylaxis, allergic to PCN or ampicillin, unable to take oral Tx?
Dosed 30-60 min before procedure Cefazolin, ceftriaxone, clinda

IPT: ID (11 decks)

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