Exam 4 lecture 2 Flashcards by Matti Daniel

What is the most common pathogen with regard to bacteremia

Staph aureus (I.e the name SAB- Staph aureus bacteremia)

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blood culture significance in SAB

Blood cultures are always clinically significant regardless of number of positive blood cultures.

Repeat blood culture sets q 48-72 hrs until negative)

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Other than blood cultures, what diagnostic evaluations are performed in SAB and why?

-Echocardiograph- all patients with SAB
-TEE (transesophageal echocardiograph) performed after TTE, which is performed first (preferred for MRSA)

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What if urine cultures are positive for s. aureus

S aureus is NOT a common organism in UTIs.

Prevalence of S aureus becteriuria in pts with SAB is 8-40%.

Translocation of S aureus from blood to urine

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in patients with bacteremia, describe catheter and prosthetic device management

S aureus may colonize and infect metal, plastic surfaces. Cosnider all IV catheters and prosthetic devices to be infected in patients with SAB

attempt to remove all prosthetic devices to avoid risk of relapse.

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In management of SAB in pts with catheter and prosthetic device management, what should we do if unable to remove catheter

add rifampin, may need long term suppressive therapy

replace catheters when blood cultures negative for 48-72 hrs

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Empiric tx for SAB

vancomycin IV q 8-12 h
daptomycin 6-10 mg/kg IV q 24 h

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MSSA bacteremia tx of choice

Nafcillin
oxacillin
cefazolin

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goal target for vancomycin

400-600 AUC/MIC

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tx of MRSA vacteremia

Vanc
dapto

limited data with ceftaroline

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should we use rifampin or vanc or aminoglycosides with MSSA bacteremia

No, drug i/a, toxicity, mortality

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how long to treat uncomplicated SAB

14 days of IV therapy from first negative blood culture

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criteria for uncomplicated SAB

-Exclusion of endocarditis (negative TEE, TEE)
-No indwelling or implantable devices or prostheses (valves, prosthetic joints, grafts)
- No evidence of metastatic infection
- Patient defervesced (fever brokr, clinically improved) with 48-72 hrs after initiating IV therapy and removal of presumed focus on infection
- follow up blood cultures drawn 2-4 days after initiating IV therapy and removal of presumed focus on infection are negative

Must meet ALL criteria to be uncomplicated

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Tx duration for cpmplicated SAB?

4 wks

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Tx duration for complicated SAB with metastatic infection

6-8 weeks

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PO or IV for SAB

IV always ONLY

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highest risk streptococci organisms for bacteremia

viriduans and gallolyticus

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What to use for bacteremia due to S. pyogenes, S agalactiae, S pneumoniae

penicillin IV-> high dose amoxicillin PO

For S pneumoniae- Ceftriaxone or penicillin if susceptible

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What are the two enterococci that cause bacteremia and risk for endocarditis

E facealis
E faecium

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Tx duration for E facealis and E facium

7 days

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E faecialis bacteremia tx

Ampicillin 2 g Q4h

if allergic , vanc or dapto

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E faecium bacteremia tx

If VanA and VanB negative, vancomycin

If VanA or VanB positive (VRE)- daptomycin or linezolid

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gram negative bacteremia organsims? tx duration? treatment?

pseudomonas aeruginosa

7 days (not from first day of negative blood cultures, different from MRSA)

Piperacillin/tazobactam
carbopenem
imipenem
meropenem
Levofloxacin

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is longer duration of therapy always better for bacteremia?

no shorter duration is preferred in uncomplicated disease

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takeaway for blood cultures for S aureus bacteremia

Mandatory repeat blood cultures q48-72h until negative for S aureus, not needed for other bacteremia

empiric therapy for MRSA bacteremia

Vanc or dapto

MSSA tx of bacteremia

nafcillin, oxacillin, cefazolin

duration for uncomplicated bacteremia

7-10 days

what happens if bacteremia is left unltratedq

leads to endocarditis

Classic way to diagnose endocarditis? describe it

Duke criteria 2 major criteria, 1 major + 3 minors or 5 minor criteria= endocarditis major criteria major - microbiological (positive blood cultures) -Echocardiography and CT imaging - evidence of endocarditisnduring cardiac surgery Minor (not important for exam) -patient history (valve, heart disease, inj drug use) - clinical symptoms (fever, vascular, imaging)

endocarditis vs bacteremia tx duration

Endocarditis is invasive, takes weeks

duration of endocarditis (native valve, prosthetic valve)

4-6 wks native valve- shorter duration prosthetic valve longer duration

When are surgical interventions required for endocarditis

Persistent vegetation after systemic embolization valve > 10 mm vegetation

For high penicillin susceptible NATIVE valve endocarditis with viridians and/or S gallolyticus, what is tx

Penicillin G IV or ceftriaxone- 4 wks Pen G + Gentamycin- 4 wks Ceftriaxone + Gentamycin- 4 wks Vancomycin- 4 wks

When are each tx for native valve highly pen susceptible viridians/gallolyticus used?

pen G or ceftriaxone- Preferred in pts > 65 yrs or with renal dysfunction. Pen G + Gentamycin- not in pts with cardiac abscess or crcl<20

WHat is the MIC of highly pen susceptible

MIC< or = 0.12

tx for penicillin relatively resistant NATIVE valve endocarditis with viridians strep and/or gallolyticus

Pen G IV 4 wks + Gent IV 2 wks Ceftriaxone 4 wks + Gent 2 wks Vanc 4 wks (only if unable to tolerate B lactam therapy)

What is another option for pen G + Gent in pen relatively resistant native valve endocarditis

Ampicillin IV q 4h

MIC for pen relatively resistant MIC

MIC>0.12 to < 0.5

Tx of pen susceptible prosthetic valve endocarditis for viridians/gallolyticus

Pen G 6 wks+/- gentamycin 2 wks Ceftriaxone 6 wks +/- gent 2 wks Vancomycin 6 wks NOTICE how much longer prosthetic are than native

Alternative for prosthetic valve endocarditis pen susceptible viridians/gallolyticus

AVOID gentamycin if Crcl<30 Instead of ceftriaxone- ampicillin 2 g IV is reasonable alternative

For prosthetic valve endocarditis with pen resistant strep viridians/ gallolyticus, what are tx options

Pen G + gent- 6 wks (ampicillin is alternative) Ceftriaxone + Gent- 6 wks Vanc - 6 wks (if unable to tolerate B lactam therapy)

for oxacillin susceptible strains (MSSA), native valve endocarditis, what is tx of choice

nafcillin or oxacillin 6 wks (2 wks for uncomplicated right sided) For pen allergic- cefazolin - 6 wks

Tx of oxacillin resistant (MRSA) native valve endocarditis

Vancomycin 6 wks daptomycin 6 wks

fda approved drug for right sided endocarditis

daptomycin

MRSA alternative in endocarditis

ceftaroline if failed vanc or dapto (salvage therapy)

tx for prosthetic valve endocarditis for MSSA

nafcillin or oxacillin (6 wks) + rifampin (6 wks) + gentamycin (2 wks)

What to use for immediate type HS rxn to b lactams in prosthetic valve endocarditis in MSSA (oxicillin susceptible)? Non immediate?

Vanc Non immediate- cefazolin

What to use to treat MRSA prosthetic valve endocarditis

Vanc (6 wks) + Rifampin (6 wks) + Gentamicin (2 wks)

how to treat e faecalis, e faecium native/prosthetic valve endocarditis if they are pen and gent susceptible

Ampicillin + Gent (4-6 wks) Pen + Gent- 4-6 wks Ampicilin + ceftriaxone - 6 wks 4 wks for native 6 wks for prosthetic

e faecalis, e faecium native/prosthetic valve endocarditis if they are pen and gent susceptible, what to use if CRCL< 50? > 50

> 50- pen + gent Amp + ceftriaxone if < 50

e faecalis, e faecium native/prosthetic valve endocarditis if they are pen susceptible and aminoglycoside resistant

Ampicillin + Ceftriaxone 6 wks

e faecalis, e faecium native/prosthetic valve endocarditis if they are pen susceptible, streptomycin susceptible, gent resistant

Ampicillin + streptomycin 4-6 wks pen + Streptomycin 4-6 wks

e faecalis, e faecium native/prosthetic valve endocarditis if they are unable to tolerate B lactam, but are vanc and aminoglycoside susceptible

Vanc + Gentamycin 6 wks Same if intrinisc resistance to penicillin or B lactamase producer

e faecalis, e faecium native/prosthetic valve endocarditis if they are Vancomycin resistant (VRE), pen and aminoglycoside resistant

Daptomycin > 6 wks linezolid > 6 wks Valve replacement may be necessary

What are HACEK Organisms? How to tx native of prosthetic valve endocarditis

Ceftriaxone- 4-6 wks (preferred) Ampicillin +/- sulbactam Ciprofloxacin 4-6 wks HACEK- gram negative in oral flora

what are some non hacek gram negative organisms that cause endocarditis? tx?

Rare- < 2 % of endocarditis cases E coli and Pseudomonas aeruginosa Combination of B lactams (penicillins, cephalosporins and carbapenems + aminoglycosides or fluoroquinolones for 6 wks)

what is culture negative endocarditis? what to treat?

imaging shows endocarditis, but culture is negative cover for staph aureus, strep, aerobic gram negative bacilli (pseudomonas)

tx regimen for culture negative endocarditis

Vanc + Cefepime - 4-6 wks for acute (days onset) Ampicillin/sulbactam + Vanc- 4-6 wks for subacute (weeks onset)

monitoring parameters for endocarditis

fever, blood cultures (blood cultures should beome negative within a week)

do patient cases on lecture march 12

Exam 4 lecture 2 Flashcards

(61 cards)