Therapy Exam II Infective Endocarditis

Infective endocarditiis classisffication

Acute days to 6 weeks, fulminant, s aureus

subsacute 6 weeks to 3 months

chronics 3 months, streptococci

Clinical characteristics of IE

Infectios process on valve

Septic vs bland emboli ie consistent with septic

Constant bactereremia metastatic foci infection

Circulating immune repsonses

Murmur

changing murmur

new regurgitant murmur

Clinical criteria definite

2 major, 1 major plus 3 minor

Clinical criteria Possible

1 major plus 1 minor, 3 minor

Clinical criteria rejection

Alternate diagnosis resolutio with 4 days of antibiotcs, no pathological evidence with 4 days

Major criteria

1. Psoivtive blood culture for IE

   1. Typcial micros conistent with IE S aureus, entercocci, strepcocci except pnemonai and pyogenes

   2. dont forgest S. Lugenesis

2. Single positve blood culture for coxiella burnetti or anti phase I IgG antibody titier greater 800

3. Evidence of endocardial involvement TTE or if needed TEE or Cardiac CT

Minor Criteria

1. Predisposition: heart condition or IV drug use

2. Fever greater thean 38 or 100.4

3. Vascualar phenomena: major arterial emboli, spetic pulmoonary infarcts, mycotic aneurysm, intracranial hemmorrhage, conjunctival hemmorhages, janeway lesions, splenic or cerebral abscess

4. Immunologic phenomena: glomerulonephritis, losler nodes, roth spots, and rehemtatoid fever

5. Microbiological evidence: psoitve blood culture but does not meet a major critieriaon or serologic evidence of active infection with oggransim consistant with IE. Excludes single positive culture for coagulase negative stpahlocci and organisms that do not cauuse endocarditits.

Impact of TEE

Most sensitive and specific diagnosistic tool

enchance detection of vegetation over TEE

Enhanced detection of abscess

critical to use in suspected PVE

most value in intermediate provability IE

Cause of Native valve endocarditis top 3

Strep

S aureus

entercocci

Causes of Prostethetic valve endocarditits

Strep

Entercocci

Staff

Coagulase netavie staphlococci

cauese of IE from IV drug use

Staff aureus

streptoccoi

enterocci

S bovis IE facts

elderly patiens

bivavlvuar involvement, most common

Colonic adenoma or cancer 47%

Treatment of Native valve endoarditis due to Peniccilin susceptible streptocci and stptoccoccus BOVIS MIC < .12

Aqueous Pencillin G 12-18 million units 24IV contin or q4-6h for 4 weeks

or

Ceftiaxone 2 gram once daily IV or IM 4 weeks

or

Aqueous pencillin G or Cefrtiaxone plus Gentamycin 3mgkg IM or IV 24 hrs 2 weeks

or

Vancomycin (allergy) 30mg kg 24 hours 2 divided doses 4 weeks

Treatment of Native valve endoarditis due to Peniccilin susceptible streptocci and stptoccoccus BOVIS MIC .12 to <035mcg

aqueous pencillin G or Cefrtiaxone plus Gentamycin 3mgkg IM or IV 24 hrs 4 weeks

or

Vancomycin (allergy) 30mg kg 24 hours 2 divided doses 4 weeks

Therapy Endocardidtis to Pencillin susceptible Enteroccoi Native or Prosthetic

Aqeuous penicccil G 18-30 million U24 IV or divided odeses plus gentamycin 1mg 4-6 weeks

or

Ampicciln plus gentamicin 2g IV 4 hours and 1mg q8-12 for 4-6 weeks

or

Ampicillin plus ceftriaxone 2g IV q4h and 2g iv q12 h for 6 weeks

All lenterocci causing endocaditits must be tested for susceptibility

streptomycin may be used in gentamicin resistant strains

cephalosporins are not alternatives

Standard therapy of endocarditis due to penicilin resitant enteroccoi or PCN intolerant Native or prostetic

Vancomycin plus gentamycin 30mg per 24 horus and 1mg im q8h for 6 weeks

Standard therapy of endocarditis due to Vancomycin resistant penicillin resistant and aminoglycoside resistant enteroccoci native or prothetic

Linezolid or daptomycin 600mg IV or po12 h or 10-12mgkg iv daily for less than 6 weeks

Treatment of Native valve endocarditisu to MSSA

Oxacillin/Nafcillin 12g 24 h in 4-6 divided does for 6 weeks

or

Cefazolin (PCN allergy) 6g 24 hours in 3 divided doses for 6 weeks

or

Vancomycin severe pcn allergy (anaplhylaxis) 15-29mg kg q 8-12 hours for 6 weeks

Treatment of Native Valce endocardidtis due to MRSA

Vancomycin 15-20mg kg q8-12H or 30 mg per 24 h in 2 divided doses for 6 weeks

or

Daptomycin 8mgkng iv once daily 6 weeks

Treatment of Prosthtic Valve endocarditis due to Staff Aureus MSAA

nafcillin/oxacillin

Add rifampin and getamycin mandatory . gent 2 weeks, rifampin 6 or more weeks

Treatment of Prosthtic Valve endocarditis due to Staff Aureus MRSA

Vancomycin

Add rifampin and getamycin mandatory gent 2 weeks, rifampin 6 or more weeks

Monitoring parameters for Penicillins and Cephalosporins

Rash, CBC, CHEM 7

Monitoring parameters for Vancomycin

Infusion syndrome, Nephrotoxity Serum monitoring,

Neutropenia, Thrombocytopenia

Monitoring parameters for Aminglycosides

Serum monitoring, nephorotoxicity, ototoxicity

Monitoring parameters for daptomycin

CPK monitoring weekly

Treatment of IE due HACEK organism

Ceftriaxone 2g IV/IM QD for 4 weeks

or

Ampicillin 2g IV/IM q 4 hours for 4 weeks

or

Cirpofloacin 1000mg 24 H orally or 800mg 24 h iv/im for 4 weeks

HACEK organism list

Haemophilis

Aggregativacter actinomytemocitus

cardiovbactterium hominus

eikennla corrodens

Kingella Kingaie

all gram negative

Role of Newer Agents

Talavancin salvage theraphy

Ceftaroline cephalosprin with MRSA activity, not approved for infective endocarditis

Ceftobiprole FDA approved for infective endocarditiis

Ortiancin

Dalbavancin

risk factors for endocarditis from dental proceduers

Prosthetic cardiac valve

previous IE

congential heart disease

cadiac transplant

Prophylaxis regiemns for dental procedures

Oral Amoxicillin

unable to take oral Ampicillin or Cefazolin or Ceftriaxone

Penicllin allergic

Clindamycin

cephalexin

Azithromycin

Clarithromycin

Clindamycin

30 to 60 mins before procedure