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Empiric Therapy of Cardiovascular Infections Subacute ...

Chapter 2. Empiric Therapy : Cardiovascular Infections51 Empiric Therapy of Cardiovascular InfectionsSubacute Bacterial Endocarditis (SBE)SubsetUsualPathogensPreferred IVTherapyAlternate IVTherapyPO Therapy or IV-to-PO SwitchNo obvioussourceS. viridansGroup B,C,G streptococciNutritionally-variant streptococciCeftriaxone 2 gm (IV) q24hx 2 weeksplusGentamicin 120 mg (IV) q24h x 2 weeksor monotherapywithCeftriaxone2 gm (IV) q24hx 2 weeksPenicillin G 3 mu (IV) q4hx 2 weeksplusGentamicin180 mg (IV) q24hx 2 weeksor monotherapywithVancomycin1 gm (IV) q12hx 2 weeksorLinezolid600 mg (IV) q12hx 2 weeksAmoxicillin1 gm (PO) q8hx 2 weeksorLinezolid600 mg (PO) q12hx 2 weeksGI/GUsource likely(Treat initiallyfor E. faecalis;if lateridentified as , treataccordingly)E.

56 Antibiotic Essentials Clinical Presentation: Prolonged fevers and chills following prosthetic valve replacement (PVR) Diagnosis: High-grade blood culture positivity (3/4 or 4/4) with endocarditis pathogen and no other source of infection Early PVE (< 60 days post-PVR) Diagnostic Considerations: Blood cultures persistently positive. Temperature usually ≤ 102°F

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Transcription of Empiric Therapy of Cardiovascular Infections Subacute ...

1 Chapter 2. Empiric Therapy : Cardiovascular Infections51 Empiric Therapy of Cardiovascular InfectionsSubacute Bacterial Endocarditis (SBE)SubsetUsualPathogensPreferred IVTherapyAlternate IVTherapyPO Therapy or IV-to-PO SwitchNo obvioussourceS. viridansGroup B,C,G streptococciNutritionally-variant streptococciCeftriaxone 2 gm (IV) q24hx 2 weeksplusGentamicin 120 mg (IV) q24h x 2 weeksor monotherapywithCeftriaxone2 gm (IV) q24hx 2 weeksPenicillin G 3 mu (IV) q4hx 2 weeksplusGentamicin180 mg (IV) q24hx 2 weeksor monotherapywithVancomycin1 gm (IV) q12hx 2 weeksorLinezolid600 mg (IV) q12hx 2 weeksAmoxicillin1 gm (PO) q8hx 2 weeksorLinezolid600 mg (PO) q12hx 2 weeksGI/GUsource likely(Treat initiallyfor E. faecalis;if lateridentified as , treataccordingly)E.

2 Faecalis Vancomycin1 gm (IV) q12hx 4-6 weeksplusGentamicin80 mg (IV) q8hx 4-6 weeksor monotherapywith Ampicillin 2 gm (IV) q4hx 4-6 weeksMeropenem1 gm (IV) q8hx 4-6 weeksorImipenem1 gm (IV) q6hx 4-6 weeksorLinezolid600 mg (IV) q12hx 4-6 weeksAmoxicillin1 gm (PO) q8hx 4-6 weeksorLinezolid600 mg (PO) q12hx 4-6 weeks E. faecium (VRE) Linezolid600 mg (IV) q12hx 4-6 weeks Quinupristin/dalfopristin mg/kg (IV) q8hx 4-6 weeksLinezolid600 mg (PO) q12hx 4-6 weeks S. bovisTreat the same as no obvious source subset, aboveAntibiotic Essentials52 Subacute Bacterial Endocarditis (SBE) (cont d)SubsetUsual PathogensPreferred IVTherapyAlternate IVTherapyPO Therapy or IV-to-PO SwitchApparent culturenegative SBE*Hemophilus actinomycetem- comitansCardiobacteriumhominisEikenella corrodensKingella kingaeCeftriaxone2 gm (IV) q24hx 4 weeksorAny 3rd generationcephalosporin (IV)x 4 weeks orCefepime2 gm (IV) q12hx 4 weeksAmpicillin2 gm (IV) q4hx 4 weeksplus eitherGentamicin120 mg (IV) q24hx 4 weeks orLevofloxacin500 mg (IV) q24hx 4-6 weeksLevofloxacin500 mg (PO) q24hx 4 weeksorCiprofloxacin500 mg (PO) q12hx 4 weeksTrue culture negative SBE*LegionellaCoxiella burnetii(Q fever)

3 Chlamydia psittaciBrucellaLevofloxacin500 mg (IV) q24hx 4-6 weeksDoxycycline 200 mg (IV) q12h x 3 days, then100 mg (IV) q12hx 4-6 weeksDoxycycline 200 mg (PO) q12h x 3 days, then 100 mg (PO) q12hx 4-6 weeks**orLevofloxacin500 mg (PO) q24h x 4-6 weeksVRE = vancomycin-resistant enterococci. Duration of Therapy represents total time IV, PO, or IV + PO. Most patientson IV Therapy able to take PO meds should be switched to PO Therapy soon after clinical improvement* Treat only IV or IV-to-PO switch** Loading dose is not needed PO if given IV with the same drugClinical Presentation: Subacute febrile illness localizing symptoms/signs in a patient with a heartmurmur. Peripheral manifestations are commonly absent with early diagnosis/treatmentDiagnosis: Positive blood cultures plus vegetation on transthoracic/transesophageal echoSBE (No Obvious Source)Diagnostic Considerations: M o s t c o m m o n p a t h o g en i s S.

4 V i r i d a n s . S o u r c e i s u s u a l l y f r o m t h e m o u t h ,although oral/dental infection is usually inapparent clinicallyPitfalls: Vegetations without positive blood cultures or peripheral manifestations of SBE are notdiagnostic of endocarditis. SBE vegetations may persist after antibiotic Therapy , but are sterileTherapeutic Considerations: In penicillin-allergic (anaphylactic) patients, vancomycin may be usedalone or in combination with gentamicin. Follow ESR weekly to monitor antibiotic response. No needto repeat blood cultures unless patient has persistent fever or is not responding clinically. Two-weektreatment is acceptable for uncomplicated S. viridans SBE. Treat nutritionally-variant streptococci(B6/pyridoxal deficient streptococci) the same as for S.

5 Viridans SBEP rognosis: Related to extent of embolization/severity of heart failureSBE (GI/GU Source Likely)Diagnostic Considerations: Commonest pathogens from GI/GU source are Enterococci (especiallyE. faecalis). If S. bovis, look for GI polyp, tumor. Enterococcal SBE commonly follows GI/GUinstrumentationTherapeutic Considerations: E. faecalis SBE may be treated with ampicillin alone; gentamicin maybe added if synergy testing is positive ( , isolate sensitive to < 500 mcg/mL of gentamicin). Do notChapter 2. Empiric Therapy : Cardiovascular Infections53add gentamicin if MIC > 500 mcg/mL. For penicillin-allergic patients, use vancomycin plus gentamicin;vancomycin alone is inadequate for enterococcal (E. faecalis) SBE.

6 Treat enterococcal PVE the same asfor native valve enterococcal SBE. Treat S. bovis SBE the same as S. viridans SBE. Non-enterococcalGroup D streptococci (S. bovis) is penicllin sensitive, unlike Group D enterococci (E. faecalis)Prognosis: Related to extent of embolization/severity of heart failureApparent culture Negative SBED iagnostic Considerations: culture of HACEK organisms requires enhanced CO2/special media(Castaneda vented bottles) and prolonged incubation (2-4 weeks). True culture negative SBE is rare,and is characterized by peripheral signs of SBE with a murmur, vegetation, and negative blood culturesPitfalls: Most cases of culture negative SBE are not really culture negative, but due to fastidiousorganisms (HACEK group) requiring prolonged incubation with enhanced CO2 atmosphere for vegetations may persist after antibiotic therapyTherapeutic Considerations: Follow clinical improvement with serial ESRs, which should return topretreatment levels with Therapy .

7 Verification of cure by blood culture is not needed if patient is afebrileand clinically wellPrognosis: Related to extent of embolization/severity of heart failureTrue culture Negative SBED iagnostic Considerations: Diagnosis by specific serology. Large vessel emboli suggests culturenegative SBE in patients with negative blood cultures but signs of SBEP itfalls: Do not diagnose culture negative SBE in patients with a heart murmur and negative bloodcultures if peripheral SBE manifestations are absent Therapeutic Considerations: Treatment is based on specific organism identified by diagnostic testsPrognosis: Related to extent of embolization/severity of heart failureAcute Bacterial Endocarditis (ABE)SubsetUsualPathogensPreferred IVTherapyAlternate IVTherapyPO Therapy or IV-to-PO SwitchNormalhosts*(Treat initiallyfor MSSA; iflater identifiedas MSRA, treataccordingly)S.

8 Aureus(MSSA)Nafcillin2 gm (IV) q4hx 4-6 weeksorMeropenem1 gm (IV) q8hx 4-6 weeks orImipenem 1 gm (IV) q6h x 4-6 weeksLinezolid600 mg (IV) q12hx 4-6 weeksorVancomycin1 gm (IV) q12hx 4-6 weeksMinocycline100 mg (PO) q12hx 4-6 weeksorCephalexin1 gm (PO) q6hx 4-6 weeksorLinezolid600 mg (PO) q12hx 4-6 weeksS. aureus(MRSA)Vancomycin1 gm (IV) q12hx 4-6 weeksorLinezolid 600 mg (IV) q12hx 4-6 weeksMinocycline100 mg (IV) q12hx 4-6 weeksLinezolid 600 mg (PO) q12hx 4-6 weeksorMinocycline100 mg (PO) q12hx 4-6 weeksAntibiotic Essentials54 Acute Bacterial Endocarditis (ABE) (cont d)SubsetUsualPathogensPreferred IVTherapyAlternate IVTherapyPO Therapy orIV-to-PO SwitchIV drugabusers(Treat as MSSA before cultureresults; treataccording topathogen afterculture results)S.

9 Aureus(MSSA)Before culture resultsVancomycin1 gm (IV) q12hplus eitherGentamicin120 mg (IV) q24horAmikacin 500 mg (IV) q24hAfter culture resultsNafcillin 2 gm (IV)q4h x 4 weeksorMeropenem 1 gm(IV) q8h x 4 weeks orImipenem 1 gm (IV)q6h x 4 weeksorVancomycin 1 gm(IV) q12h x 4 weeksorLinezolid 600 mg (IV)q12h x 4 weeksAfter culture resultsLinezolid 600 mg (PO) q12hx 4 weeks orMinocycline 100 mg (PO) q12hx 4 weeksorCephalexin1 gm (PO) q6hx 4 weeksS. aureus(MRSA)Before culture resultsTreat the same as MSSAA fter culture resultsVancomycin 1 gm(IV) q12h x 4 weeksorLinezolid 600 mg (IV)q12h x 4 weeksorMinocycline 100 mg(IV) q12h x 4 weeksAfter culture resultsLinezolid 600 mg (PO) q12hx 4 weeksorMinocycline100 mg (PO) q12hx 4 weeksP. aeruginosa* Before culture resultsTreat the same as MSSAA fter culture resultsOne A drug + one B drug A DrugsPiperacillin 4 gm (IV)q8h x 4-6 weeks orCefepime 2 gm (IV)q8h x 4-6 weeksorMeropenem 1 gm(IV) q8h x 4-6 weeks B DrugsAmikacin 500 mg (IV)q24h x 4-6 weeksorAztreonam 2 gm (IV)q8h x 4-6 weeksAfter culture resultsCiprofloxacin750 mg (PO) q12hx 4-6 weeksMSSA/MRSA = methicillin-sensitive/resistant S.

10 Aureus. Duration of Therapy represents total time IV, PO, or IV + patients on IV Therapy able to take PO meds should be switched to PO Therapy after clinical improvement * Treat only IV or IV-to-PO switchChapter 2. Empiric Therapy : Cardiovascular Infections55 Acute Bacterial EndocarditisDiagnostic Considerations: Patients are critically ill and febrile (temperature 102oF). Vegetationsare almost always presentPitfalls: Obtain a baseline echocardiogram; watch for valve destruction, heart failure, ring/perivalvularabscess. Obtain cardiology consultation Therapeutic Considerations: Treat for 4-6 weeks. Follow teichoic acid antibody levels weekly in ABE, which fall (along with the ESR) with effective therapyPrognosis: Related to extent of embolization/severity of heart failureAcute Bacterial Endocarditis (IV Drug Abusers)Diagnostic Considerations: IVDAs with S.


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