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Pharm II > Endocarditis > Flashcards

Endocarditis Flashcards

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1
Q

Sx of endocarditis

A 
Fever
Chills
Weakness
Dyspnea
Night sweats
Weight loss and/or malaise
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2
Q

Signs of endocarditis

A 
Fever
Heart murmur (new or changing)
Embolic phenomenon
Splenomegaly
-Osler nodes
-Janeway lesions
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3
Q

RFs of endocarditis

A 
Structural heart dz
IV drug use
Prosthetic heart valves
Prior hx of endocarditis
Chronic IV access
DM
MVP with regurg
Chronic heart failure
Congenital heart dz
25% of IE cases do not have RFs
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4
Q

Diagnostic testing

A 
Three sets of blood cultures
-Separate sites
-Over at least 1-hour period
-Prior to initiation of empiric tx
- Most reliable test
WBC: nl or only slightly elevated
Transthoracic echocardiography (TTE)
-Type of echo (u/s)
-Non-invasive
-Performed in all cases
Transesophageal echo (TEE)
-Type of echo test
-View the heart's valves and chambers
-Improves sensitivity of diagnostic criteria
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5
Q

Duke Criteria

A

3 categories:
Definite
Possible
Rejected

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6
Q

Modified Duke Criteria

A

2 major criteria OR
1 major and 3 minor criteria OR
5 minor criteria

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7
Q

Possible IE- Duke

A

1 major and 1 minor criteria OR

3 minor criteria

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8
Q

Rejected IE- Duke

A

Firm alternative dx OR
Resolution of manifestations with therapy for less than or equal to 4 days
OR
No pathologic evidence at surgery or autopsy after ab

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9
Q

Usual bacteria

A

S. aureus
S. viridians
S. bovis
Enterococcus

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10
Q

What is HACEK, and what does it stand for?

A 
Slow-growing fastidious organisms that may need 3 weeks to grow out of blood cultures
Haemophilus
Aggregatibacter
Cardiobacterium haminis
Eikenella
Kingella kingae
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11
Q

What is the incidence of the bacteria from most common to least common?

A 
Staph
-IV drug users
-Incidence increasing in hospital-acquired infections
Strep
Enterococci
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12
Q

Goals of therapy

A

Eradicate infection

Definitively treat sequelae of destructive intra-cardiac and extra-cardiac lesions

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13
Q

How often should blood cultures be obtained?

A

Q24-48h until blood stream infection is cleared

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14
Q

Clinical pearls for abx therapy

A

Abx regimens should be administered at the same time or temporally close to maximize synergistic killing
Make sure MICs are good

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15
Q

Abx therapy goals

A

Tx tailored to appropriate organism(s) isolated from blood cultures
Empiric tx
Bactericidal agents
High serum concentration(s) necessary to penetrate avascular vegetation
Infectious disease consult
Parenteral route necessary
Adequate dose
Initiate appropriate empirical abx timely
Duration: 4-6 wks

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16
Q

Beta lactam MOA

A

Inhibits bacterial wall synthesis

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17
Q

SEs of beta lactams

A

Anaphylaxis
Hives
Pseudomembranous colitis
Seizures

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18
Q

Examples of beta lactams

A

Pen G
Nafcillin/Oxacillin
Ampicillin/sulbactam

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19
Q

Indication for beta lactams

A

Strep
Enterococcus
S. aureus

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20
Q

Type 1 Ig-E mediated rxns

A 
Anaphylaxis
Urticaria
Stevens-Johnson
Angioedema
Bronchospasm
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21
Q

Cephalosporin MOA

A

Inhibits bacterial cell wall synthesis

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22
Q

SEs of cephalosporins

A

Skin rash
Diarrhea
Leukopenia

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23
Q

Aminoglycosides MOA

A

Interferes with bacterial protein synthesis by binding to 30s and 50s ribosomal subunits

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24
Q

SEs of aminoglycosides

A 
Nephrotoxic
Ototoxic
Ataxia
Confusion
C. difficile-associated diarrhea
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25
Examples of aminoglycosides
Gentamicin Tobramycin Amikacin Combined with additional abx
26
Vancomycin MOA
Inhibits bacterial cell wall synthesis | Bactericidal
27
SEs of vancomycin
Nephrotoxicity | Red Man syndrome
28
Monitoring for vanc
Goal trough for IE (15-20 mg/dL)
29
Indication for Vanc
Gram + (including Methicillin resistant)
30
What is the first line agent for strep?
Pen G
31
What is the 2nd line agent for strep?
Ceftriaxone + Gentamicin
32
What is the agent for PCN and ceph allergy?
Vanc
33
Pen G dose for strep
12-18 million units (24 million heart valves) over 24h | 3-4 million units IV q4h
34
Duration of Pen G for strep
4 wk
35
Ceftriaxone + Gentamicin dose for strep
2 gms IV/IM q24h/3mg/kg IV q24h
36
Vanc dose for strep
30 mg/kg IV q24h in 2 equally divided does | Goal trough 15-20 mcg/mL
37
Pearls in tx of strep IE
Bacteriologic cure rates greater than or equal to 98% may be anticipated in pts who complete 4 wks of therapy Ampicillin is an alternative to PCN Addition of Gentamicin to PCN exerts a synergistic effect -2 wk regimen of PCN or ceftriaxone + gentamicin resulted in similar cure rates as monotherapy
38
Duration of staph tx
6 wks, except Gentamicin, which is 3-5 days
39
What is 1st line tx for staph?
Nafcillin/Oxacillin (MSSA)
40
What is 2nd line tx for staph?
Cefazolin (PCN allergy)
41
What is the synergy tx for staph?
Gentamicin
42
What is the Oxacillin-resistant tx for staph?
Vanc
43
Nafcillin/Oxacillin dose for staph
2 gms IV q4h
44
Cefazolin dose for staph
2 gms IV q8h
45
Gentamicin dose for staph
3 mg/kg IV q24h dose then "Rx to dose"
46
Vanc dose for staph
30 mg/kg per 24h IV in 2 equally divided doses then "Rx to dose"
47
What is the main tx for staphylococci prosthetic valve?
Nafcillin/Oxacillin + Rifampin + Gentamicin
48
What is the duration for both txs for staphylococci prosthetic valves?
Greater than or equal to 6 wks
49
What is the tx for oxacillin-resistant organisms for staphylococci prosthetic valves?
Vanc + Rifampin + Gentamicin
50
Nafcillin/Oxacillin + Rifampin + Gentamicin doses for staphylococci prosthetic valve
2 gms IV q4h 900 mg per 24h IV/PO in 3 equally divided doses 3 mg/kg per 24h in 2 or 3 equally divided doses x 2 wks
51
Vanc + Rifampin + Gentamicin doses for staphylococci prosthetic valve
30 mg/kg 24h in 2 equally divided doses 900 mg per 24h IV/PO in 3 equally divided doses 3 mg/kg per 24h in 2 or 3 equally divided doses x2 wks
52
Pearls in tx of staphylococci IE
S. aureus primarily involves L side of the heart IV drug abuse is associated with the right side of the heart Only 3--5 days of combo therapy with Gentamicin
53
PCN desensitization
Should be considered when sub-optimal response to cephalosporin or vanc Very small doses administered and orally or IV and are gradually increased in stepwise manner until a full therapeutic dose is reached Occurs in hospital setting Completed in 4-12 hrs Pts remain on PCN continuously for the duration of therapy
54
Vanc intolerance
TMP-SMX, doxy or minocycline (either with or without rifampin) and linezolid are alternatives Rifampin resistance develops quickly when used as monotherapy
55
What regimens are prescribed for IE due to enterococcus?
(Ampicillin + Ceftriaxone) | [Ampicillin or Pen G] + Streptomycin
56
Dosing of ampicillin + ceftriaxone for enterococcus
2 g IV q4h | 2 g IV q12h
57
Dosing of (ampicillin or Pen G) + streptomycin
2 g IV q4h 18-30 million units/24 hr continuously or in 6 equally divided doses 15 mg/kg IBW per 24h IV in BID doses
58
Pearls in enterococcus tx
Enterococcus resistance to PCN, ampicillin and vanc exist Must add synergistic effect of Gentamicin <3 mos of sx require 4 wks therapy >3 mos of sx require 6 wks of therapy
59
What is 1st line tx in IE due to HACEK?
Ceftriaxone
60
What is 2nd line tx in IE due to HACEK?
Ampicillin/sulbactam
61
Ceftriaxone dose for HACEK
2 gms IV/IM q24h
62
Ampicillin-sulbactam dose for HACEK
3 gms IV q6h
63
Regimen for Pseudomonas
Tobramycin + | PIP-TZ or Ceftazadime or Cefepime
64
Tobramycin + | PIP-TZ or Ceftazidime or Cefepime doses for Pseudomonas
8 mg/kg per day IV/IM in once daily doses (Peak levels: 15-20 mcg/mL) (Trough less than or equal to 2 mcg/mL)
65
Guidelines Daptomycin
``` Vanc resistant if MICs are >4 ug/mL Coverage -MRSA/MSSA (alt. to Vanc) --Dose 8-10 mg/kg IV daily -Small studies of VRE IE tx with daptomycin --Conclusion difficult to define success rate --Combo with ampicillin or ceftaroline --Dose 10-12 mg/kg IV daily ```
66
Prophylaxis for bacterial endocarditis
Prophylactic regimen targeted against likely organism - Strep viridians: oral, resp., esophageal - Enterococcus: genitourinary, GI - S. aureus: infected skin, mucosal surfaces
67
Prophylaxis doses for dental, oral, resp., esophageal
Amoxicillin 2 g PO 1 h before procedure OR Ampicillin 2 g IM/IV 30 min before procedure PCN allergic: Clindamycin- 600 mg PO 1 hr before procedure OR 600 mg IV 30 min before Cephalexin OR Cefadroxil 2 g PO 1 hr before Cefazolin 1 gm IM/IV 30 min before procedure Azithromycin or Clarithromycin 500 mg PO 1 hr before

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