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Infective endocarditis
Lecture 9
19
Pharmacology
Professional
02/23/2013

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Term
What are different types of endocarditis?
Definition
- Acute - fulminating form, develops suddenly. Usually S. aureus
- Subacute - Indolent, slow growing. Preexisting valvular disease. Usually S. viridans.
- Prosthetic valve - following insertion
- Right sided - seen in IV drug users
- Left sided - more common than right and severe. Mitral valve
- Native valve - Mt
- Culture negative - improper draw or fastidious organism
Term
What pathogens cause infective endocarditis?
Definition
- Primarily S. aureus, sometimes Staph viridans. Very rarely enterococci
**More males:females, in older patients and IVDA, diabetes, dialysis, dental
Term
What valves are affected in endocarditis in drug users?
Definition
Tricuspid > aortic > mitral
- Mostly S. aureus. Mostly young men --> tx w/ Nafcillin or vanc
**Normal: Mitral and Aortic
Term
What are risk factors for endocarditis?
Definition
- Presence of prosthetic heart valve
- Previous endocarditis
- Diabetes
- IVDA
Term
What is the pathogenesis of endocarditis?
Definition
A heart defect leads to pressure gradients --> fibrin platelet deposition --> bacteria colonize these clots, esp. those w/ adherins (gram+) --> vegetation
Term
What are vegetations in endocarditis?
Definition
Bacteria colonization - destroys valvular tissue, leading to perforation
**Emboli affect organs with HIGH blood flow: Kidneys, spleen, brain
Term
What is the clinical presentation of the 2 types of endocarditis?
Definition
- Non-virulent = Strep viridans: Low fever, malaise, fatigue, weight loss
- Virulent = S. aureus: High fever, chills, sweats, septic
**Heart murmur, Enlarged spleen, Osler nodes (edemedous fingers), Janeway lesions on feet, splinter hemorrhage on nails, Petechiae, clubbing of fingers, roth spots (retinal infarction), emboli on toes
Term
What lab finding is indicative of endocarditis?
Definition
- Blood culture! x3 from different venous punctures
- Also incr ESR and CRP
- Echo: TTE or TEE (for high risk, more specific)
Term
What is the duke criteria definition of endocarditis?
Definition
- Major - 2 separate + BCs, persistent + BC, BC + for C. burnetti or IgG, positive echo, new valvular regurgitation
- Minor - predisposing heart condition, Fever > 38/100.4, vascular/immune phenomena, micro evidence
**2 major, 1 major + 3 minor, or 5 minor = DEFINITE
**1 major + 1 minor, or 3 minor = POSSIBLE
Term
What are complications from endocarditis?
Definition
- CHF - most common
- Embolism
- Aneurysm
- Glomerulonephritis
- Resistant organism = relapse
Term
How is endocarditis in a native valve treated?
Definition
- PCN - PCN or ceftriaxone w/ or w/o gent. NAFCILLIN or Vanc/Dapto
- PCN intermediate - higher dose X4 weeks, have to use gent
- PCN resistant - w/ regimen for enterococcal endocarditis
- PCN allergy: Vanc
**never use extended dosing AGs
Term
How is tx for prosthetic valve endocarditis different?
Definition
- MSSA: Nafcillin + rifampin + gent
- MRSA: Vanc + rifampin + gent
**Incr in nephrotoxicity, must monitor patient.
**Daptomycin also approved, not better than Vanc
Term
How is enterococcal endocarditis treated?
Definition
- PCN susceptible - PCN + gent/streptomycin if gent resistant
- PCN allergic - Vanc + gent
- PCN resistant - Also Vanc + gent
- Vanc resistant: E. faecium (Linezolid or synercid), E. faecalis (Imipenem + ampicillin OR ceftriaxone)
Term
What is HACEK endocarditis?
Definition
H - H. parainfluenzae
A - Actinobacillus actinomycetemcomitans
C - Cardiobacterium hominis
E - Eikenella corrodens
K - Kingella kingae
Rare gram(-), do not normally adhere. Tx w/ ceftriaxone 2g q24h or Cipro in a PCN allergy
Term
How is gram(-) endocarditis treated?
Definition
- P. aerug - Piperacillin/Ceftazidime/Cefepime + Tobra
- E. coli - Ampicillin or PCN or broad spec cef + AG
Term
How is fungal endocarditis treated?
Definition
Rare, seed in IVDA and the immune compromised. Candida or aspergillus
Tx ONLY with amphotericin B
Term
When is surgery needed for endocarditis?
Definition
- Persistent vegetation
- Valve dysfunction
- Evidence of failure
Term
When can FQNs be used for endocarditis?
Definition
Only when Staph is Oxacillin susceptible.
Term
When should dental procedures be prophylaxed for endocarditis?
Definition
- Prosthetic heart valve
- Previous endocarditis
- Congenital heart disease
- Cardiac transplant
**Amox 2g or equivalent
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