Term
| Native Valve (NV) endocarditis |
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Definition
pt has never had any type of cardiac surgery before;
congenital heart disease (caused by PDA - patent ductus arteriosus);
valvular lesions;
mitral valve prolapse;
rheumatic valvular disease;
degenerative heart disease (valve stenosis); |
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Term
| Injectable Drug Abuse endocarditis |
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Definition
pt that uses heroin/injectable drug abuse;
younger median age for pts;
involvement with tricuspid valve;
Staph. aureus is most common pathogen; |
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Term
| Prosthetic Valve (PV) endocarditis |
|
Definition
occurs in pts who already have had a valve replacement;
- early disease (<60 days after surgery - Staph. organisms)
- late diseases (>60 days after surgery - Strep. organisms)
more difficult to diagnose (blood cultures & ECHO often negative) |
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Term
| Local Complications of Endocarditis |
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Definition
abscess;
congestive heart failure;
arrhythmias;
pericarditis |
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Term
| Systemic Complications of Endocarditis |
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Definition
intracerebral hemorrhage;
embolic stroke;
meningitis;
lung abscess/pneumonia |
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Term
| Risk Factors for Endocarditis |
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Definition
elderly;
prosthetic valves;
history of dx;
IV drug abuse;
shunts, IV, &/or central catheters;
ESRD/hemodialysis;
cardiac transplantation;
congenital heart disease |
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Term
| Signs & Symptoms of Endocarditis |
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Definition
FEVER (most common);
chills, weakness, sweats, dyspnea, arthralgias --> Flu-like;
weight loss/anorexia;
cardiac murmur;
embolic complications;
splenomegaly;
skin lesions: Janeway lesions, Osler's nodes, Roth spots or hemorrhage on retina, clubbing of nails or fingers, nail bed hemorrhages, petechiae |
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Term
| Diagnosis for Endocarditis: Laboratory Findings |
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Definition
chronic anemia (decreased Hgb/Hct, thrombocytopenia);
elevated ESR;
increased WBC;
positive blood culture (send at least 2 blood cultures PRIOR to antibiotics);
daily blood cultures until negative |
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Term
| Diagnosis of Endocarditis: Imaging Studies |
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Definition
Echocardiography (ECHO):
- Transthoracic Echocardiography (TTE) --> noninvasive probe of area of chest;
- transesophageal echocardiography (TEE) --> more invasive, probes into esophagus to take a look at chest;
ECG: rhythm abnormalities may help determine where site of infection is found |
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Term
| Empiric Treatment of Native Valve Endocarditis in IV drug user |
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Definition
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Term
| Empiric Treatment of Native Valve Endocarditis in Non-IV drug user |
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Definition
ampicillin or penicillin G or vancomycin
AND
gentamicin |
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Term
| Empiric Therapy for Prosthetic Valve Endocarditis |
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Definition
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Term
| Treatment of Native Valve Endocarditis caused by Penicillin Sensitive Streptococci (Viridans Group or Strep Bovis) |
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Definition
MIC <0.12 mcg/mL
Penicillin 18 MU/day x 4 wks
If PCN Allergic:
- ceftriaxone x 4 wks
OR
- vancomycin x 4 wks |
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Term
| Treatment of Native Valve Endocarditis caused by relatively PCN-resistant Streptococci |
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Definition
MIC >0.12 mcg/mL but <0.5 mcg/mL;
Penicillin 24 MU/day x 4 wks
PLUS
Gentamicin x 2 wks;
For PCN-Allergy:
- ceftriaxone x 4 wks
PLUS
- gentamicin x 2 wks
OR
- vancomycin x 4 wks |
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Term
| Tx of Prosthetic Valve Endocarditis in Pencillin-sensitive Streptococci |
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Definition
MIC <= 0.12 mcg/mL
Penicillin G 24 MU/day x 6 wks
OR
Ceftriaxone x 6 wks
+/-
gentamicin x 2 wks;
PCN Allergy:
- vancomycin x 6 wks |
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Term
| Treatment of Prosthetic Valve Endocarditis caused by Relatively Resistant to Penicillin Streptococci |
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Definition
Penicillin 24 MU/day x 6 wks
OR
ceftriaxone x 6 wks
PLUS
gentamicin x 6 wks;
Penicillin Allergy:
- vancomycin x 6 wks |
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Term
| Treatment of Native Valve Endocarditis caused by MSSA |
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Definition
Nafcillin/oxacillin x 6 wks
PLUS (optional)
Gentamicin x 3-5 days;
Non-severe PCN Allergy:
- cefazolin x 6 wks
PLUS
gentamicin x 3-5 days;
Severe PCN Allergy:
- vancomycin x 6 wks (1st line)
OR
- daptomycin x 6 wks (NOT 1st line) |
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Term
| Treatment of Prosthetic Valve Endocarditis caused by MSSA |
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Definition
Nafcillin/oxacillin x >6 wks
PLUS
rifampin 300 mg PO q8 hrs >= 6 wks
PLUS
Gentamicin 1 mg/kg q8 hrs x 2 wks;
Non-severe PCN Allergy:
- cefazolin x >6 wks
PLUS
gentamicin x 2 wks
PLUS
rifampin x >=6 wks;
Severe PCN Allergy:
- vancomycin x 6 wks (1st line)
OR
- daptomycin x 6 wks (NOT 1st line) |
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Term
| Treatment of Native Valve Endocarditis caused by MRSA |
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Definition
vancomycin x 6 wks (1st line)
OR
daptomycin x 6 wks (NOT 1st line) |
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Term
| Treatment of Prosthetic Valve Endocarditis caused by MRSA |
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Definition
vancomycin x >6 wks (1st line)
OR
daptomycin x >6 wks (NOT 1st line)
PLUS
rifampin 300 mg PO q8hrs >=6 wks
PLUS
gentamicin 1 mg/kg q8hrs x 2 wks |
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Term
| Treatment of Native OR Prosthetic Valve Endocarditis caused by Enterococci |
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Definition
Penicillin 18-30 MU/day x 6 wks
OR
ampicillin x 6 wks
PLUS
gentamicin x 6 wks;
PCN Allergy (Anaphylaxis):
vancomycin x 6 wks
PLUS
gentamicin x 6 wks |
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Term
| Treatment of Native or Prosthetic Valve Endocarditis caused by Enterococcus faecium |
|
Definition
resistant to PCN, aminoglycosides, & vancomyicin;
Tx:
Linezolid x >=8 wks
OR
dalfopristin/quinupristine x >=8 wks
OR
daptomycin x >= 8 wks |
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Term
| Treatment of Native or Prosthetic Valve Endocarditis caused by Enterococcus faecalis |
|
Definition
resistant to PCN, aminoglycosides, & vancomycin;
Imipenem/cilastatin x >=8 wks
PLUS
ampicillin x >= 8 wks
OR
ceftriaxone x >= 8 wks
PLUS
ampicillin x >=8 wks |
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Term
| HACEK - Haemophilus parainfluenzae, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corodens, Kingella kingae |
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Definition
cause of culture negative endocarditis;
can cause large vegetations & emboli;
rare cause of endocarditis |
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Term
| Treatment of Native or Prosthetic Valve Endocarditis caused with HACEK organisms |
|
Definition
ceftriaxone x 4 wks;
ampicillin/sulbactam x 4 wks;
ciprofloxacin x 4 wks |
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Term
| Pathogens causing Culture Negative Endocarditis |
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Definition
| Bartonella spp., Coxiella burnetii, Brucella spp., Legionella spp. |
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Term
| Treatment of Culture Negative Native Valve Endocarditis |
|
Definition
ampicillin/sulbactam
PLUS
gentamicin x 4-6 wks
OR
vancomycin
PLUS
gentamicin x 4-6 wks
PLUS
ciprofloxacin x 4-6 wks |
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Term
| Treatment of Culture Negative EARLY (<60 days) Prosthetic Valve Endocarditis |
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Definition
Think Staph infection;
Vancomycin x 6 wks
PLUS
gentamicin x 2 wks
PLUS
cefepime x 6 wks
PLUS
rifampin x 6 wks |
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Term
| Treatment of Culture Negative LATE (>60 days) Prosthetic Valve Endocarditis |
|
Definition
Think Strep. infection;
ceftriaxone x 6 wks
PLUS
gentamicin x 2 wks
PLUS/MINUS
doxycycline x 6 wks |
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Term
|
Definition
can be safe, cost-effective, & efficacious for certain pts;
Pt MUST be stable (after >2 wks of inpatient therapy);
PO is UNRELIABLE & NOT recommended;
Must have some form of health care or a visiting nurse;
May use outpatient infusion centers; |
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Term
|
Definition
May be required in:
- prosthetic valve endocarditis > native valve endocarditis;
- congestive heart failure/hemodynamic instability;
- infectious endocarditis w/ aggressive &/or resistant pathogens (Pseudomonas, Coxiella, Brucella, Candida);
ECHO shows valve dehiscence, perforation, rupture, fistula, or significant abscess;
-septic emboli --> depending on event, may be a relative C/I |
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Term
| Pharmacist's Role in Monitoring Endocarditis Treatment |
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Definition
Length of stay: count from 1st day in which blood cultures are NEGATIVE;
Blood cultures: follow cultures drawn & adjust antimicrobial therapy once results are finalized; ate least 2 sets of cultures daily until cultures are clear;
- adjust doses based on renal function (SCr & BUN);
- obtain drug levels & adjust dose/frequency to meet goal peaks/troughs |
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Term
| Pts at High Risk for Endocarditis |
|
Definition
- may require prophylaxis;
Prosthetic cardiac valve or prosthetic material used for valve repair;
Previous IE;
Congenital Heart disease;
Cardiac transplantation |
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Term
| Prophylaxis of Endocarditis for Respiratory Procedures |
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Definition
| NOT RECOMMENDED prior to bronchoscopy |
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Term
| GI/GU Tract Procedure Prophylaxis |
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Definition
NOT RECOMMENDED for pts including routine colonoscopies;
May consider if pts are undergoing a procedure w/ ongoing GI or GU infections |
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Term
| Dental Procedure Prophylaxis |
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Definition
| RECOMMEND ONLY HIGH RISK PTs should receive prior to procedures that involve manipulation of gingival tissue or perforation of oral mucosa |
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Term
| Recommended regimens for Dental Procedure Prophylaxis |
|
Definition
ORAL:
amoxicillin 2 gm x 1 dose;
Parenteral:
ampicillin 2 gm IV/IM
cefazolin 1 gm IV/IM
ceftriaxone 1 gm IV/IM |
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Term
| Recommended Regimens for Dental Procedure Prophylaxis in pts w/ PCN Allergy |
|
Definition
OraL:
cephalexin 2 gm
clindamycin 600 mg
azithromycin 500 mg
clarithromycin 500 mg
Parenteral:
cefazolin
ceftriaxone
clindamycin |
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Term
| Cardiac Surgery Prophylaxis to prevent Endocarditis |
|
Definition
inpatients undergoing surgery to place a prosthetic heart valve or prosthetic intravascular or intracardiac material MUST use
Tx:
cefazolin 1 gm IV q8 hrs x 24-48 hrs
PCN Allergy: vancomycin 1 gm IV q12 hrs x 24-48 hrs |
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