IE Flashcards by Nagine Bruno

when does IE occur?

when bacteria or fungi enters the bloodstream and attaches to the inner lining of the heart (endocardium)

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risk factors of IE

presence of prosthetic heart valve

intravenous drug users

structural heart disease

persistant bacteremia

poor dental hygiene

colon cancer or IBD (s.gallolyticus)

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most common pathogens of IE

gram positive cocci»» gram negative

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IVDU

higher risk for poly microbial IE

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prosthetic valve IE

coagulase negative staphococci (CoNS)

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IVDU microorganisms

s. aureus
CoNS
Group A & B streptococcus
fungi

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early (<1 yr ) post prosthetic valve replacement

CoNs
S.aureus
aerobic neg bacilli
corynebacterium spp.

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late (> 1yr) post prosthetic valve replacement

CoNS
s.aureus
viridans group streptococcus
enterococcus spp.
corynebacterium spp

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poor dental health , post dental procedures

viridian’s group streptococci
nutritionally variant streptococci
HACEK organisms

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Acute IE clinical presentation

rapid onset
high grade fever **
new cardiac murmur
myalgia
systemic emboli

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subacute IE clinical presentation

gradual onset
low grade fever**
anemia
weight los
vascular manifestations
peripheral manifestations

Less virulent pathogens (VGS)

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right sided IE

tricuspid and pulmonary valve
IVDUs
Septic Pulmonary emboli**

NO peripheral emboli and immunological vascular phenomena

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Left sided IE

Mitral and aortic ( majority of IE cases)
Peripheral emboli or neurological features**

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Staphylococcus aureus

most common cause of IE
IVDUs is typically involves triceps/ right sided IE

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coagulase negative staphylococcus

typically causes PVE
most CoNS are methicillin resistant
staph lugdunenis= hyper virulent species

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Native valve IE
s.aureus or CoNS
methicillin susceptible

cefazolin IV 2 gram q8h
or
Nafcillin/ oxacillin IV 2 g q4H

duration 6 weeks

only use Vanco for severe b lactam intolerance

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Native valve IE
s.aureus or CoNS
methicillin resistant

Vancomycin IV

alternative= daptomycin IV

duration= 6 weeks

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prosthetic valve IE
s.aureus or CoNS
methicillin susceptible

Nafcillin/oxacillin IV 2 gram q4h
plus
rifampin PO/IV 300 mg q8h (900 mg/day)
plus
gentamicin IV 1mg/kg q8h

alternative; cefazolin IV gram q8h

duration: 6 weeks , gentamicin: only first two weeks

Prosthetic valve IE
s.aureus or CoNS
methicillin resistant

vancomycin IV
plus
rifampin PO/IV 300 mg q8h (900 mg/day)
plus
gentamicin IV 1mg/kg q8h

alternative: daptomycin IV

duration: 6 weeks , gentamicin: only first two weeks

Native valve IE
virdiadans Group strep or strep. gallolyticus
highly penicillin susceptible

aqueous PCN G IV 18 mill units/day
or
ceftriaxone IV 2 g q24
plus/ or minus
gentamicin IV 3mg/kg q24hr

preferred regimen= without gentamicin synergy

duration: 4 weeks

Native valve IE
virdiadans Group strep or strep. gallolyticus
PCN relatively or fully resistant

cerftriaxone IV 2 g q24h
plus/minus
gentamicin IV 3 mg/kg q24h

or
vancomycin

altenative:PCN G plus gentamicin

duration: 4 weeks

prosthetic valve IE
virdiadans Group strep or strep. gallolyticus
highly penicillin susceptible

aqueous PCN G IV 18 mill units/day
or
ceftriaxone IV 2 g q24
plus/ or minus
gentamicin IV 3mg/kg q24hr

gentamicin does NOT improve cure rates vs. blactams

duration 6 weeks

prosthetic valve IE
virdiadans Group strep or strep. gallolyticus
PCN relatively or fully resistant

cerftriaxone IV 2 g q24h
plus
gentamicin IV 3 mg/kg q24h

or
vancomycin

altenative:PCN G plus gentamicin

PCN G 24 mill units /day plus gentamicin synergy alternative

native and prosthetic valve
enterococci (ampicillin suseptible)

double beta lactam regimen
- ampicillin IV 2 gram q2h
plus
-ceftriaxone IV 2 g q12h

duration: 6 weeks (for both

native and prosthetic valve enterococci (ampicillin resistant or beta lactam intolerance/allergy)

vancomycin IV plus gentamicin IV 1mg/kg q8h Gentamycin for ENTIRE treatment course duration: 6 weeks (NVE), >= 6 weeks (PVE)

native and prosthetic valve enterococci (ampicillin and vancomycin resistant)

daptomycn 10-12 mg/kg q24hr drug of choice

drug of choice for streptococci

pen G

drug of choice for MSSA

Nafcillin/oxacillin or cefazolin

drug of choice for MRSA

vancomycin

stepwise approach for streptococcus

1. penicillin look at MIC 2. ceftriaxone 3. vancomycin

stepwise approach for staphylococcus

1. oxacillin/ceftazolin 2. vancomycin 3. daptomycin

when to use gentamicin synergy

s.aureus PVE enterococci PCN resistant strep (nv/PVE)

general rule for duration of therapy

loneger for PVE

Native and prosthetic valve HACEK organisms (gram neg)

certtriaxone (preferred) ampicillin/sulbactam ciprofloxacin PO 500 mg q12 h (intolerance to beta lac) 4weeks NV 6weeks PVE

indication for IE prophylaxis indication

- dental procedures -pts at risk for iE development and high risk of for poor IE outcomes

when is duration of therapy counted for?

first day of a negative blood culture obtain at least two blood cx every 24-48 hrs under cleared

if operative heart valve is are positive, when do you start counting # of treatment days

start counting # of treatment days from valve surgery

if operative heart valve is are negative, when do you count treatment days

count # of treatment days administered before surgery into overall duration

Major Criteria

evidence of endocardial involvement ECHO positive for IE** Single blood cx for coxiella burnetii** 2 or more separate blood culture or 3 or a majority of >4= separate blood cx for typical microorganism consistent w IE: - viridian's Group strep -s.gallolyticus -HACEK organism -s. aureus** -community acquired enterococci

Minor criteria

predisposition, predisposing heart disease, or IVDU fever Vascular phenomena Immunological phenomena positive blood cx that does not met major criterion

what type of antibiotics is needed to sterilize vegetation with high bacterial densities

bactericidal antibiotics

why is prolonged therapy needed for IE

to ensure complete eradication required since vegetations have high bacterial densities + slower antibiotic bactericidal activity

solution for antimicrobial considerations

prolonged, parenteral**, high dose, bactericidal antibiotic therapy