Endocarditis 1

Question 1

_________ refers to infection of the heart valves by various microorganisms

Answer 1

Endocarditis

Question 2

The following are signs/symptoms of what?

• Sxs
  
  • Fever, chills, weakness, dyspnea, night sweats, weight loss, and/or malaise
• Signs
  
  • fever
  • heart murmur
  • embolic phenomenon
  • splenomegaly
  • Osler’s nodes (painful), Janeway’s lesions

Answer 2

Infective Endocarditis

Question 3

What is the name of the criteria used to dx endocarditis?

Answer 3

Duke Criteria

(major= blood culture + for infective endocarditis, evidence of endocardial involvement

minor= risk factors, fever, conjunctival hemorrhages, janeways lesions, etc)

Question 4

What 3 groups of organisms cause a majority of infective endocarditis cases?

Answer 4

Streptococci (9-38%)

Staphylococci (30-70%)

Enterococci

Question 5

Which specific staphylococci is the MC

Answer 5

Staph aureus

(coagulase positive)

Question 6

What is the tx approach for infective endocarditis (IE)?

Answer 6

1. isolate pathogen (blood culture from 2 dif sites)
2. Determine antimicrobial susceptibilities
3. High dose IV bactericidal abx for extended period

4. Surgery (valvectomy/valve replacement)- important adjunct in tx of NVE and PVE

(NVE= native valve, PVE= prosthetic valve)

Question 7

Why has Staphylococcal endocarditis become more prevalent?

Answer 7

b/c of increased IVDA

(also from more frequent use of peripheral/central venous catheters)

Question 8

What is the most common organism causing infective endocarditis among those with IVDA and persons with venous catheters

Answer 8

S. aureus

Question 9

What coagulase-negative staphylococci are prominent causes of PVE?

Answer 9

usually Staphylococcus epidermidis

Question 10

What valve is most frequently infected in a IVDA patient?

Answer 10

Tricuspid valve (right sided IE)

–> caused by S. aureus

Question 11

How do you tx an IVDA pt w/ staphylococcus endocarditis?

Answer 11

2 week course of:

Nafcillin or oxacillin + Aminoglycoside

Question 12

What is an especially common cause of endocarditis involving native valves? Is this generally acute or subacute?

Answer 12

Strep viridans (common inhabitants of mouth/gingiva)

subacute

Question 13

________ are normal inhabitants of the human GI tract and, occasionally, of the anterior urethra

Answer 13

Enterococci

(the cause of enterococcal endocarditis)

Question 14

How do you tx infective endocarditis caused by the HACEK group of organisms?

(HACEK= H. flu, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae)

Answer 14

High-dose ampicillin + gentamicin x4 weeks

Question 15

• What native valve does the HACEK group most commonly infect?
• Is this considered community or hospital acquired IE?
• Subacute or acute?

Answer 15

• Native Valve
• Community-acquired
• Subacute (w/ lg vegetations and emboli)

Question 16

What is the group of drugs that remain the drug of choice for endocarditis?

Answer 16

β-Lactam antibiotics

Question 17

Which β-Lactam antibiotic is the drug of choice for IE caused by strep?

Answer 17

Penicillin G (or ceftriaxone)

(this is not the only med used to tx this, just the specific B-lactam)

Question 18

Which β-Lactam antibiotic is the drug of choice for IE caused by staph?

Answer 18

Nafcillin

(this is not the only med used to tx this, just the specific B-lactam)

Question 19

Which β-Lactam antibiotic is the drug of choice for IE caused by enterococci?

Answer 19

Ampicillin

(this is not the only med used to tx this, just the specific B-lactam)

Question 20

Which group of microbes causes large vegetations and emboli?

Answer 20

HACEK group

• Haemophilus parainfluenzae, Haemophilus aphrophilus,
• Actinobacillus actinomycetemcomitans,
• Cardiobacterium hominis,
• Eikenella corrodens,
• Kingella kingae

Question 21

Empiric therapy for IE should cover what 3 groups of bacteria?

Answer 21

• Staphylococci (methicillin-susceptible and resistant)
• streptococci
• enterococci

Question 22

What is empiric drug therapy for Native Valve infective endocarditis?

Answer 22

Vancomycin + Ceftriaxone

Question 23

What is empiric drug therapy for Prosthetic Valve infective endocarditis?

Answer 23

Vancomycin + Gentamicin + Rifampin

Question 24

Example test question:

Someone has prosthtic valve Endocarditis caused by strep viridans and is allergic to PCN- what are you going to order and for how long? (it is sensitive to penicillin)

(she said to not memorize the chart but then said this was a sample test question so IDK)

Answer 24

Vancomycin x6 weeks

Question 25

What are the 2 major **adverse drug rxns** of **Daptomycin** and what are the monitoring parameters?

Answer 25

ADEs: 1. **Myopathy-** monitor creatinine phosphokinase weekly 2. **Rhabdomyolysis**- monitor for signs/sxs of mm. pain

Question 26

What are the 3 major **ADEs** of **Gentamicin**?

Answer 26

ADEs: 1. Nephrotoxicity 2. Ototoxicity 3. neuromuscular blockade

Question 27

What are the 3 major **ADEs** of **linezoli**d and how do you **monitor?**

Answer 27

ADEs: 1. **Thrombocytopenia** 2. **optic neuropathy** 3. **peripheral neuropathy** Monitoring: 1. platelet counts at baseline and weekly 2. visual changes

Question 28

WHat is the 1 major ADE of Rifampin and how do you monitor?

Answer 28

**Hepatotoxicity** monitor baseline liver function tests, and then at least every 2-4 wks during therapy

Question 29

What are the 2 major ADEs of Vancomycin?

Answer 29

1. Nephrotoxicity 2. Red Man Syndrome

Question 30

Daptomycin- when is more frequent monitoring warrented?

Answer 30

In patients w/ renal dysfunction or receiving concomitant therapy w/ HMG-CoA reductase inhibitors (statins)

Question 31

When should Daptomycin be discontinued?

Answer 31

If symptomatic and CPK \>5x upper limit of normal (ULN) or if CPK \> 10x ULN

Question 32

If taking Gentamicin, you should avoid concomitant use of what?

Answer 32

- of other nephrotoxic agents such as diuretics, nonsteroidal anti-inflammatory drugs, and radiocontrast media

Question 33

T/F: you should avoid rapid IV administration of Gentamicin?

Answer 33

True

Question 34

ADEs of Linezolid: Thrombocytopenia is MC in \>\_\_\_ weeks of prolonged therapy

Answer 34

\>2 weeks

Question 35

ADEs of Linezolid: Visual symptoms are MC after \>\_\_\_ days of prolonged therapy

Answer 35

28

Question 36

Which medication might cause red or orange discoloration of bodily secretions (urine, sweat, tears)?

Answer 36

Rifampin

Question 37

ADE of Vancomycin: How is red man syndrome managed?

Answer 37

Red man syndrome may be managed by prolonging the infusion time from 1-2 hours Administration of antihistimine prior to loading or maintenacne doses also be considered

Question 38

Although there is controversy over antimicrobial prophylaxis of infective endocarditis (what to give and when), everyone agrees on what makes a patient "high risk". **What makes a person high risk**?

Answer 38

1. Presence of prosthetic heart valve 2. prior dx of infective endocarditis 3. cardiac transplantation w/ subsequent valulopathy 4. congenital heart disease

Question 39

For patients w/ high risk underlying cardiac conditions, What types of procedures should be given antimicrobial prophylaxis for infective endocarditis?

Answer 39

any that require perforation of the oral mucosa or manipulation of the periapical region of the teeth of gingival tissue

Question 40

What is the MC drug prescribed for prophylaxis of infective endocarditis? Which drug do dentists really like to give for prophylaxis?

Answer 40

MC- Oral amoxicillin Dentists- oral Clindamycin

Question 41

Infective endocarditis prophylaxis for dental procedures should be recommended only for patients with what?

Answer 41

underlying cardiac conditions associated with the highest risk

Question 42

Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergoe which 2 types of procedures?

Answer 42

**genitourinary** or **GI tract procedure**

Question 43

According to UpToDate, when is prophylaxis not recommended?

Answer 43

1. Common valvular lesions for which antimicrobial prophylaxis is NOT recommended include: 1. bicuspid aortic valve 2. acquired aortic or mitral valve disease (including mitral valve prolapse with regurgitation) 3. hypertrophic cardiomyopathy with latent or resting obstruction

Question 44

T/F: the following are examples of dental procedures where IE prophylaxis is recommended: Tooth extractions, drainage of dental abscess, routine dental cleaning

Answer 44

True

Question 45

Clinical Pearl: Initiation of ________ for tx of native valve infective S. aureus is optional.Why? Routine use of _________ for tx of native valve endocarditis should be avoided

Answer 45

**_gentamicin_** recent literature reports increased risk of nephrotoxicity when combining gentamicin w/ vanco or antistaphylococcal agents in comparison to daptomycin monotherapy