Pharmacotherapy: Infective Endocarditis

Infective endocarditis

An infection of the endocardial surface of the heart.

valves

The _______ in the heart is most prone to infection.

bacteremia

What condition is a large risk factor for contracting infective endocarditis?

6 weeks

Acute IE is classified as lasting for a few days up to _________.

s.aureus

What is the most common causitive agent of acute IE?

3 months

Subacute IE lasts anywhere from 6 weeks up to ________.

3 months

Chronic IE lasts longer than ________ and is more commonly seen in patients with prior valve disease and low-grade symptoms.

mitral, aortic

Which valves are most commonly involved in IE?

hemodialysis, IV drug use, dental procedures

What are some risk factors for contracting bacteremia/IE?

spreading to other organ systems

What is the most concerning complication of IE?

new mumur, fever

What are two of the most common signs of IE?

positive

Endocarditis is largely caused by gram-________ bugs.

strep, s.aureus

The two most common bugs in native endocarditis.

staph epidermidis, staph lugdunensis

The two most common bugs in prosthetic endocarditis.

2, 1, 3, 5

In order to be diagnosed with IE, a patient must have ___ major, ___ major + ____ minor, or ____ minor complications.

positive blood culture with common IE organism, vegetation on heart valve

What are the 2 main major criteria for IE?

TEE (better than TTE)

How can we visualize a vegetation on the heart?

heart conditions, IV drug use, fever, vascular phenomena, immunologic phenomena, microbiological evidence

What are some minor criteria for diagnosing IE?

bactericidal

(Bacteriostatic/Bactericidal) antibiotics are preferred in the treatment of IE.

Ceftriaxone

The workhorse of most IE regimens due to its gram-positive coverage.

strep, all negatives

What bugs does Ceftriaxone reliably cover?

Ceftriaxone

What is the preferred agent in strep viridans or strep bovis endocarditis?

penicillin

What other agent can be used besides Ceftriaxone for strep coverage?

Gentamicin

This agent may also be added to Ceftriaxone regimens for added efficacy, although it is seen less often in practice now.

vanc 30mg/kg

How can we treat strep IE if the patient has a penicillin allergy? List the dose as well.

4 weeks

How long is strep-induced IE usually treated?

more

Enterococcus, unlike strep, requires (more/less) coverage.

Ceftriaxone + Ampicillin

What is the preferred regimen in enterococcus IE?

blocks all non-enterococcus PBPs to improve the efficacy of the Ampicillin

Why do we add Ceftriaxone to Ampicillin, since we know cephalosporins have no activity for enterococcus?

ampicillin + gentamicin, penicillin + gentamicin

What other regimens can be considered second line for enterococcus IE?

long-term aminoglycosides are awful

Why are these second line regimens for enterococcus IE not preferred?

vancomycin + gentamicin

What regimen can we use in enterococcus IE if the patient has a severe penicillin allergy and cannot tolerate Ampicillin + Ceftriaxone?

severe renal toxicity

What is one issue with the vanc + gent regimen used in patients with penicillin allergies with enterococcus IE?

daptomycin 10-12 mg/kg

What medications can we use in VRE (vanc-resistant enterococcus) with the dose as well?

Cefazolin

What regimen is preferred in MSSA IE?

Nafcillin, Oxacillin

What other options are available for MSSA?

risk for AKIs

Why are Nafcillin/Oxacillin not as preferred as Cefazolin?

Rifampin, Gentamicin

If the patient has a prosthetic valve with staph aureu (MRSA or MSSA), sometimes we can add _________ or _______ to the regimen (although this is less commonly done now).

vancomycin

If a patient has a severe b-lactam allergy, what can we use for IE MSSA?

2

Be careful - if vancomycin has an MIC of __, there is a higher risk for clinical failure and dapto should be considered.

vancomycin 15-20 mg/kg

What is the DOC in MRSA IE (include dose)?

Daptomycin > 8 mg/kg

If vanc cannot be used due to a high MIC, what medication should we use (plus dose)?

Ceftaroline, Ceftobiprole (MRSA-covering cephalosporins)

What medications can we add to an MRSA regimen if the patient is not improving?

Ceftobiprole

Which cephalosporin is FDA-approved for endocarditis treatment?

> 6 weeks

How long is MRSA endocarditis usually treated for?

Ceftriaxone

What is the DOC in endocarditis caused by HACEK (hamophilus, aggregatibacter, cardiobacterium, eikenall corroders, k.kingae) organisms?

Ampicillin, Ciprofloxacin

What are some other medications that can be used for HACEK organisms?

4 weeks

How long is HACEK IE usually treated for?

prosthetic valves, previous IE, congenital heart disease, cardiac transplantation

Who is a candidate for IE prophylaxis?

dental/oral procedures

For which procedures might a patient receive IE prophylaxis?

amoxicillin 2g PO 30-60min before procedure

What is the preferred agent for IE prophylaxis?

Ampicillin, Cefazolin/Ceftriaxone

What IV options are available for IE prophylaxis if needed?

clindamycin, keflex, macrolides

What IE prophylactic options are available if allergies to amoxicillin exist?