Infective Endocarditis

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giddyupp
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63999
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Infective Endocarditis
Updated:
2011-02-04 11:47:53
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Infective Endocarditis PHPR523 Test2
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Infective Endocarditis
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  1. What are the key features of infective endocarditis (IE)?
    • Vegetations: collections of platelets, fibrin, microorganisms, and inflammatory cells; most often on valves
    • Typical patient population:
    • males
    • > 50 yo
    • hx of injection drug use
    • Risk factors:
    • hx of IE
    • heart valve abnormalities
    • heart valve replacement
    • IV drug use
    • hemodialysis
    • prolonged hospital stay
  2. How is IE classified?
    • By affected valve:
    • aortic
    • mitral
    • pulmonary (rare)
    • tricuspid (IV drug users)
  3. What are the symptoms of acute IE?
    • Fever/chill
    • leukocytosis/ceucopenia
    • tachycardia
    • tachypnea
    • hemodynamic instability
    • "sepsis-like"
  4. What are the symptoms of subacute IE?
    • fever/chills/weakness
    • night sweats
    • weight loss
    • Increased WBC
    • Increased ESR (erythrocyte sedimentation rate)
    • Splenomegaly
  5. What are the more specific symptoms of IE?
    • Osler nodes
    • Janeway lesions (S. aureus infection)
    • Conjunctival petechiae (Roth's spots)
    • Retinal infarct
    • Splinter hemorrhages
  6. How would you describe the pathophysiology of IE?
    • Endocardium damaged: platelet aggregation and fibrin deposits at site
    • Bacteria colonize the damaged site:
    • hematogenous route (bacteremia)
    • direct inoculation (surgery)
    • Immune response stimulated, but doesn’t clear infecting organism:
    • more platelets and fibrin production
    • vegetation grows
    • Vegetations:
    • protects bacteria
    • penetrates valve, causing more damage
    • can break off (septic emboli)
    • can form antibodies against vegetation itself (tissue damage b/c antibodies are not very specific for the vegetation)
  7. What are the complications associated with IE?
  8. Damage to heart valves
    • HF
    • Arrhythmias
    • Cardiac fistulas b/w ventricles
    • Microembolic events
    • Stroke
    • Can be fatal
  9. What pathogens cause IE in the general population?
    • Viridans streptococci
    • S. bovis
    • S. pneumoniae
    • MSSA
    • MRSA
    • S. epidermidis
    • E. faecalis
    • E. faecium
    • Haemophilus spp
    • Actinobacillus
    • Cardiobacterium hominis
    • Eikenella corrodens
    • Kingella kingae
  10. What is the HACEK group in IE?
    • gram (-) organisms:
    • Haemophilus
    • Actinobacillus
    • Cardiobacterium hominis
    • Eikenella corrodens
    • Kingella kingae
  11. What pathogens cause IE in IV drug users?
    • MRSA
    • P. aeruginosa
    • polymicrobial
    • Viridans streptococci
    • S. bovis
    • S. pneumoniae
    • MSSA
    • S. epidermidis
    • E. faecalis
    • E. faecium
    • Haemophilus spp
    • Actinobacillus
    • Cardiobacterium hominis
    • Eikenella corrodens
    • Kingella kingae
  12. What is the theory behind antimicrobial therapy for IE?
    • supportive care
    • IV ONLY!! (never switch to PO)
    • cidal agents only
    • consider short-term use of Gentamicin and/or Rifampin for synergy
  13. What is the empiric therapy for IE?
    • Vancomycin + Gentamicin +/- Rifampin
    • (hold Gent if REALLY bad kidneys)
  14. What is the treatment for IE caused by streptococci highly susceptible to PCN?
    • Pen G x 4wks
    • Ceftriaxone x 4wks
    • Pen G + SDD Gentamicin x 2wks
    • Ceftriaxone + SDD Gentamicin x 2wks
    • Vancomycin x 4wks
  15. What is the treatment for IE caused by streptococci relatively PCN resistant?
    • High dose Pen G x 4wks + SDD Gentamicin x 2wks
    • Ceftriaxone x 4wks + SDD Gentamicin x 2wks
    • Vancomycin x 4wks
  16. What is the treatment for IE caused by Methicillin-susceptible staphyloccoci?
    • Nafcillin x 6wks +/- Gentamicin x 3-5d
    • Oxacillin x 6wks +/- Gentamicin x 3-5d
    • Cefazolin x 6wks +/- Gentamicin x 3-5d
    • Vancomycin x 6wks
    • FOR UNCOMPLICATED RIGHT-SIDED IE, 2wk therapy is acceptable
  17. What is the treatment for IE caused by Methicillin-resistant staphylococci?
    Vancomycin x 6wks
  18. What is the treatment for IE caused by HACEK?
    • Ceftriaxone x 4wks
    • Ampicillin sulbactam x 4wks
    • Ciprofloxacin x 4wks
  19. What should be used to treat IE if Vancomycin is not working?
    Daptomycin
  20. When is surgery required for IE?
    • when patients require or have valve repair/replacement
    • HF
    • Pathogens that do not respond to treatment (P. aeruginosa, Brucella, Coxiella burnetii, fungal endocarditis, Enterococci
  21. When is prophylaxis recommended for IE?
    • Prior to dental work in pts who have had:
    • Prosthetic valve
    • Previous IE
    • CHD
    • Cardiac transplant who develop cardiac valvulopathy
  22. What is the IE prophylaxis for dental procedures?
    • Oral:
    • Amoxicillin 2g PO (DOC)
    • Unable to take oral meds:
    • Ampicillin IM or IV
    • Cefazolin IM or IV
    • Ceftriaxone IM or IV
    • Allergic to pen or ampicillin oral:
    • Cephalexin
    • Clindamycin
    • Azithromycin
    • Clarithromycin
    • Allergic to pen or ampicillin and unable to take oral meds:
    • Cefazolin IM or IV
    • Ceftriaxone IM or IV
    • Clindamycin IM or IV

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