65 y/o M hx of prosthetic MV p/w fevers, chills and night sweats found to have endocarditis
Dr. Yoko Furuya | Morning Report | 12/29/2016
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Endocarditis Pearls
- Can sometimes see microscopic hematuria on exam
- Duke's Criteria doesn't always apply to prosthetic valves if pre-test probability is high
- Need to draw 3 sets of blood cultures with set 1 and 3 an hour apart
Posted 12/29/16 09:07:27 AM by Ying Liu
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Indications for Surgery in Endocarditis
- CHF from severe valvular dysfunction
- Peri-annular abscess
- Systemic embolism to lungs for CNS
- Persistent sepsis and inability to clear blood cultures
- Difficult Organisms (S Aureus, Staph Lugdenensis, VRE, Fungal…etc.)
- Prosthetic Valve
Posted 12/29/16 09:08:03 AM by Ying Liu
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- Major constituent of skin flora
- Historically considered contaminants but have increasingly been recognized as a cause of significant infections
- Most frequent cause of prosthetic valve endocarditis in the first year after surgery. Also becoming a common cause of native valve endocarditis
- Difficult to treat given tendency to form biofilms
- Staph Lugdenensis in particular is an aggressive strain of coag negative staph that has been associated with native valve endocarditis and has resulted in more aggressive disease and worse mortality as compared to other coag neg staph.
Posted 12/29/16 09:11:50 AM by Ying Liu
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IDSA Guidelines for Treatment of Coag Neg Staph Endocarditis
- Commonly Oxacillin resistant (60-70% of isolates)
- Optimal antibiotic therapy is Vancomycin + Rifampin + Gentamicin for 6 weeks with Gentamicin limited to first two weeks
- For Oxacillin susceptible organisms, treatment can be Nafcillin and Rifampin for 6 weeks with 2 weeks of Gentamicin
- Will often wait to add rifampin given likelihood of developing resistance and interactions with other drugs
- Duration of therapy is from date of Blood Cx clearance or surgery (if surgical culture is positive).
- Will sometimes extend therapy to 8-12 weeks depending on clinical circumstances
Posted 12/29/16 09:15:02 AM by Ying Liu
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Concept of Synergy
- Combination of Cell-Wall Agent with Aminoglycosides and/or Rifampin
- Data strongest for Enteroccocus
- For Staph and in particular coag neg staph, some data to support use of gentamicin and rifampin with a cell-wall agent to improve synergy and reduce rifampin resistance, but mechanism unclear
Posted 12/29/16 09:16:56 AM by Ying Liu
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For further reading...
Posted 12/29/16 09:17:16 AM by Ying Liu
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