Second Chance - Infective Endocarditis
What subjective findings support the diagnosis of endocarditis? (MULTI)
Malaise
Chills
Weight loss
Hunger
Dyspnea
What physical exam findings are consistent with the diagnosis of endocarditis? (MULTI)
Heart murmur
Osler nodes
Janeway lesions
Splinter hemorrhages
Petechiae
Bilateral crackles
Options for strep viridans/bovis, native valve IE with PCN MIC < 0.12
Ceftriaxone x 4 wks
PCN G + Gentamicin 3mg/kg q24hr x 2wks
PCN G 12-18 million units/day x 4 wks
Penicillin G x 2 weeks
Vancomycin x 4 weeks
When should adjust body weight be used? (= Ideal body weight + 0.4 (Actual – Ideal))
Actual > 120% of Ideal
Ideal ≤ Actual ≤ 120% of Ideal
Actual < Ideal*
What is the role of adding gentamicin?
Synergy
Better coverage
Less drug needed overall
When does the clock start for duration of the antibiotics?
From the first day the patient received effective antibiotics
From the first day the patient is afebrile
From the first day the patient has normal white count
From the first day the blood cultures cleared (became negative)
What treatment should be used for PCN IgE-mediated allergies?
Ceftriaxone x 4 wks
PCN G + Gentamicin 3mg/kg q24hr x 2wks
PCN G 12-18 million units/day x 4 wks
Penicillin G x 2 weeks
Vancomycin x 4 weeks
Options for strep viridans/bovis, native valve IE with PCN MIC 0.25-0.5
Ceftriaxone x 4 wks
PCN G + Gentamicin 3mg/kg q24hr x 2wks
PCN G 12-18 million units/day x 4 wks
Penicillin G x 2 weeks
Vancomycin x 4 weeks
PCN G 24 million units/day x 4 wks
Options for strep viridans/bovis, native valve IE with PCN MIC 0.25-0.5 + PCN IgE rxn
Ceftriaxone x 4 wks
PCN G + Gentamicin 3mg/kg q24hr x 2wks
PCN G 12-18 million units/day x 4 wks
Penicillin G x 2 weeks
Vancomycin 15-20mg/kg IV x 4 weeks
PCN G 24 million units/day x 4 wks
Options for strep viridans/bovis, PROSTHETIC valve IE with PCN MIC < 0.12
Ceftriaxone x 4 wks
PCN G + Gentamicin 3mg/kg q24hr x 2wks
Vancomycin 15-20mg/kg IV x 4 weeks
PCN G 24 million units/day x 4 wks
PCN G 24 million units/day x 6 wks
Options for strep viridans/bovis, PROSTHETIC valve IE with PCN MIC < 0.12 IgE rxn
Ceftriaxone x 4 wks
PCN G + Gentamicin 3mg/kg q24hr x 2wks
Vancomycin 15-20mg/kg IV x 4 weeks
PCN G 24 million units/day x 4 wks
PCN G 24 million units/day x 6 wks
Vancomycin 15-20mg/kg IV x 6 weeks
Options for strep viridans/bovis, PROSTHETIC valve IE with PCN MIC > 0.12 IgE
Ceftriaxone x 4 wks
PCN G + Gentamicin 3mg/kg q24hr x 2wks
PCN G 12-18 million units/day x 4 wks
Penicillin G x 2 weeks
Vancomycin x 4 weeks
PCN G 24 million units/day + Gentamycin x 6 wks wks
Prophylaxis regimen for high-risk + invasive procedure? (MULTI) non-PCN allergy
Amoxicillin 2 g PO x 1
Cephalexin 2 g PO x 1
Clindamycin 600 mg PO x 1
Azithromycin 500 mg PO x 1
Clarithromycin 500 mg PO x 1
Ampicillin 2 g IV/IM x 1
Ceftriaxone 1 g IV/IM x 1
Prophylaxis regimen for high-risk + invasive procedure? (MULTI) PCN allergy
Amoxicillin 2 g PO x 1
Cephalexin 2 g PO x 1
Clindamycin 600 mg PO x 1
Azithromycin 500 mg PO x 1
Clarithromycin 500 mg PO x 1
Ampicillin 2 g IV/IM x 1
Ceftriaxone 1 g IV/IM x 1
MRSA + Prosthetic Valve Regardless of allergy:
Ceftriaxone x 4 wks
PCN G + Gentamicin 3mg/kg q24hr x 2wks
Vancomycin 15-20mg/kg IV x 4 weeks
PCN G 24 million units/day x 4 wks
PCN G 24 million units/day x 6 wks
Vanco + Rifampin x 6 wks + Gentamicin x 2 wks
Why is rifampin required for MRSA infections? (MULTI)
Synergy with vanco + genta
Biofilm penetration on prosthetic valve
Less drug needed
Double-coverage isn't enough
Drug level goals for vanco and genta?
Vanco = 15-20 trough, Genta = 15-20
Vanco 15-20 trough, Genta peak 3-4mcg/mL trough <1
Vanco 15-20 trough, Genta peak 3-4mcg/mL trough <5
ADE for Vanco? (MULTI)
Nephrotoxicity (trough, SCr)
Thrombocytopenia (Platelets)
Hepatotoxicity – LFTs
Red, orange bodily fluids
ADE for Genta?
Nephrotoxicity (trough, SCr)
Thrombocytopenia (Platelets)
Hepatotoxicity – LFTs
Red, orange bodily fluids
ADE for Rifampin
Nephrotoxicity (trough, SCr)
Thrombocytopenia (Platelets)
Hepatotoxicity – LFTs
Red, orange bodily fluids
MSSA + Prosthetic Valve NKDA
PCN G + Gentamicin 3mg/kg q24hr x 2wks
PCN G 12-18 million units/day x 4 wks
PCN G 24 million units/day + Gentamicin x 6 wks wks
Vanco + Rifampin x 6 wks + Gentamicin x 2 wks
Nafcillin/Cefazolin + Rifampin x 6 wks + gentamicin 2 wks
MSSA + Prosthetic Valve PCN IgE rxn
PCN G + Gentamicin 3mg/kg q24hr x 2wks
PCN G 12-18 million units/day x 4 wks
PCN G 24 million units/day + Gentamicin x 6 wks wks
Vanco + Rifampin x 6 wks + Gentamicin x 2 wks
Nafcillin/Cefazolin + Rifampin x 6 wks + gentamicin 2 wks
MRSA + Native Valve no PCN IgE rxn
Vanco/Dapto + 6 wks
Nafcillin/Cefazolin x 6 wks
Nafcillin/Cefazolin + Rifampin x 6 wks + gentamicin 2 wks
PCN G 24mill units/day x 6 wks
MSSA + Native Valve no PCN IgE rxn
Vanco/Dapto + 6 wks
Nafcillin/Cefazolin x 6 wks
Nafcillin/Cefazolin + Rifampin x 6 wks + gentamicin 2 wks
PCN G 24mill units/day x 6 wks
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