How do we make decisions? (Inmedicine)
How do we make decisions? Inmedicine• Dogma:” Doctrine/Teaching”• Tradition: “We’ve always done it that way”• Convention: ...
Evidence Based Medicine(EBM)• Conscientious, ^yDoh idÌshg wkql+,&• Explicit, ^iqmeyeos,s&• Judicious ^m%{djkA;&• use of• “...
• First BSAC guidelines- in 2004- Mostly theexpert opinions• Latest in 2012 –– Majority of recommendations are evidencebas...
What is included in 2012 BSAC• Mx of Native valve endocarditis(NVE) &• Mx of Prosthetic valve endocarditis (PVE).• PVE inc...
What is excluded from 2012• Infective Endocarditis related to– pacemakers,– defibrillators or– ventricular-assist devices•...
The aim of these guidelines• Standardize the initial investigation andtreatment of IE;• Identify the patients who can deve...
Summary2004 Vs 2012• 2004 guidelines based on expert opinion• 2012 – Mostly are evidence based: Whenevidence is not availa...
Level of evidence gradation accordingto strength of evidenceC<B<A
IE- The clinical presentation is highlyvariable,• Vary according to the causative microorganism,• Vary according to presen...
IE may present as• An acute, rapidly progressive infection,• as a subacute or chronic disease,• low-grade fever and non-sp...
Presentation• The majority (90%) of patients present with fever,– with systemic symptoms of chills,– poor appetite– weight...
• Classic textbook signs( Rare)• Peripheral stigmata of IE are increasinglyuncommon (patients generally present at anearly...
Six right sided endocarditis patientswere followed up….Present/Yes Absent/No TotalEmbolicphenomena3Pneumonia3 6Isolate MRS...
• Atypical presentations– e.g. absence of fever is more common in the elderly,after antibiotic pre-treatment,– in the immu...
BSAC Guidelines
Summary of ECHO Recommendation of IE
The Duke criteria hasclinical,echocardiographicand microbiological findings,Were developed as a research tool- provide hig...
IE is a condition where you getcontinuous bacteremia• Generally all three blood cultures will bepositive• Single blood cul...
WE have stopped giving sensitivities on the isolates directly to the wards. AST shouldbe interpreted with the help of CLIN...
Why monitor only aminoglycosides(and Vancomycin?)• Low therapeutic index.• Bactericidal efficacy ᾀ peak concentrations• To...
Amino glycoside toxicity• More with divided doses than single oncedaily dose• Body weight is measured according to idealbo...
Monitoring For Aminoglycosides andVancomycinlevels- THK Protocol• RECEIVE THIS FROM MICRO DEPARTMENT
Use of Ɓ-Lactams• Can amphicillin/amoxycillin use fro treatment of IE• Why only penicillin is used?• What are the drugs gi...
5.3 b-Lactams• Amoxicillin and ampicillin → microbiologically equivalent andeither can be used.• Amoxicillin can be used i...
A history of a rash with ampicillin or amoxicillin may not indicate true allergy.Unless signs of immediate-type hypersensi...
5.5 Other antibiotics• linezolid and daptomycin• Only after consultating Micro Team
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
Infective endocarditis
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Infective endocarditis

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Infective endocarditis

  1. 1. How do we make decisions? (Inmedicine)
  2. 2. How do we make decisions? Inmedicine• Dogma:” Doctrine/Teaching”• Tradition: “We’ve always done it that way”• Convention: “Everyone does it this way”• Evidence-Based: “Evidence supports this way”
  3. 3. Evidence Based Medicine(EBM)• Conscientious, ^yDoh idÌshg wkql+,&• Explicit, ^iqmeyeos,s&• Judicious ^m%{djkA;&• use of• “current best evidence in making decisionsabout the care of individual patients”
  4. 4. • First BSAC guidelines- in 2004- Mostly theexpert opinions• Latest in 2012 –– Majority of recommendations are evidencebased,– Rest are consensus among the working partymembers (Expert Opinion)
  5. 5. What is included in 2012 BSAC• Mx of Native valve endocarditis(NVE) &• Mx of Prosthetic valve endocarditis (PVE).• PVE includes infections in– Prosthetic valves of all types,– Annuloplasty rings,– Intracardiac patches and– Shunts.
  6. 6. What is excluded from 2012• Infective Endocarditis related to– pacemakers,– defibrillators or– ventricular-assist devices• These dealt in a separate BSAC review
  7. 7. The aim of these guidelines• Standardize the initial investigation andtreatment of IE;• Identify the patients who can develop adversedrug reactions (Side Effects and Toxicity)• identify pts fail to respond to initial antimicrobialtherapy and may require a change in therapy orsurgery.
  8. 8. Summary2004 Vs 2012• 2004 guidelines based on expert opinion• 2012 – Mostly are evidence based: Whenevidence is not available→ Consensus– A-high-quality randomized controlled trials andmeta-analysis of randomized controlled trials;– B -observational data and non-randomized trials;and– C - expert opinion or Working Party consensus.
  9. 9. Level of evidence gradation accordingto strength of evidenceC<B<A
  10. 10. IE- The clinical presentation is highlyvariable,• Vary according to the causative microorganism,• Vary according to presence or absence of pre-existing cardiac disease,• Presence of co-morbidities• Risk factors for the development of IE.(IVDU,HD,etc)
  11. 11. IE may present as• An acute, rapidly progressive infection,• as a subacute or chronic disease,• low-grade fever and non-specific symptoms that maycause confusion in initial assessment.• Patients present to a variety of specialists/GPs whomay consider a range of alternative diagnoses,– Any chronic infection,– Rheumatological disorder– and autoimmune disease or– malignancy.
  12. 12. Presentation• The majority (90%) of patients present with fever,– with systemic symptoms of chills,– poor appetite– weight loss.• Heart murmurs up to 85% (Pre existing heart murmurshould prompt heighten degree of suspicion for look for IE)• New murmurs reported in 48%.• New valvular regurgitation is more specific for a diagnosis ofIE
  13. 13. • Classic textbook signs( Rare)• Peripheral stigmata of IE are increasinglyuncommon (patients generally present at anearly stage of the disease)• Immunological phenomena, such as– Splinter hemorrhages,– Roth spots and– glomerulonephritis, are now less common,• Emboli to brain, lung or spleen occur in 30% ofpatients(Often could be presenting symptom)
  14. 14. Six right sided endocarditis patientswere followed up….Present/Yes Absent/No TotalEmbolicphenomena3Pneumonia3 6Isolate MRSA (3 out of 3 sets) 3patients3 6Risk factor Present in 3 cases1. CVP cannulation @ICU 3/12 before forMX of DHF2. Recurrent Bloodtransfusion for Thal3. Criminal Abortion4. Long Term HD5. Long Term HDRisk factors not present inone case6Classical risk factorssuch as IVDUNo Not present in all 6 case 6Outcome withsurgery3 responded forvegetectomyone died and 1 respondedfor treatment, oneundergoing treatment6
  15. 15. • Atypical presentations– e.g. absence of fever is more common in the elderly,after antibiotic pre-treatment,– in the immunocompromised patients and– in IE involving less virulent or atypical organisms.• The diagnosis of IE should also be considered inpatients who present with– a stroke or transient ischaemic attack and a fever.
  16. 16. BSAC Guidelines
  17. 17. Summary of ECHO Recommendation of IE
  18. 18. The Duke criteria hasclinical,echocardiographicand microbiological findings,Were developed as a research tool- provide high specificity and moderatesensitivity for the diagnosis of IE.These criteria an objective tool for evaluating the strength of evidence to support adiagnosis of IE, particularly in difficult cases.
  19. 19. IE is a condition where you getcontinuous bacteremia• Generally all three blood cultures will bepositive• Single blood culture = No culturing
  20. 20. WE have stopped giving sensitivities on the isolates directly to the wards. AST shouldbe interpreted with the help of CLIN_MICRO TEAM
  21. 21. Why monitor only aminoglycosides(and Vancomycin?)• Low therapeutic index.• Bactericidal efficacy ᾀ peak concentrations• Toxicity is related to total drug exposure• Nephrotoxicity (usually reversible) and ototoxicity(often irreversible)• The desired plasma concentration-time profile foraminoglycosides differs to most other drugs.
  22. 22. Amino glycoside toxicity• More with divided doses than single oncedaily dose• Body weight is measured according to idealbody weight (not the actual body weight)• Ideal body weight ± 20% is allowed
  23. 23. Monitoring For Aminoglycosides andVancomycinlevels- THK Protocol• RECEIVE THIS FROM MICRO DEPARTMENT
  24. 24. Use of Ɓ-Lactams• Can amphicillin/amoxycillin use fro treatment of IE• Why only penicillin is used?• What are the drugs given in pen allergy?• How do you ascertain a history of pen allergy as a trueimmediate type of HS?• With a history of rash with Amp, can you give pen?• In the backdrop of anaphylaxis, can you give CRO?
  25. 25. 5.3 b-Lactams• Amoxicillin and ampicillin → microbiologically equivalent andeither can be used.• Amoxicillin can be used instead of benzylpenicillin forsusceptible isolates (greater risk of Clostridium difficileinfection)• Need to be given more frequently (due to short t1/2)• No comparison of continuous with intermittent penicillinadministration for streptococcal endocarditis.• Dose modifications necessary for renal failure
  26. 26. A history of a rash with ampicillin or amoxicillin may not indicate true allergy.Unless signs of immediate-type hypersensitivity (anaphylaxis, angio-oedema, bronchospasmand urticaria) were reported, a trial with penicillin may be warranted,(A emergency trolleyneed to be kept bear)A rash occurs after 72 h- unlikely to be an immediate IgE-mediatedreaction (type I hypersensitivity).In a recent study, 72% of patients with a delayed-type hypersensitivity reaction toaminopenicillins had no cross-reactivity with penicillin.The American Heart Association (AHA) advises ceftriaxone for the penicillin-allergic pts,(for allergy other than immediate-type hypersensitivity, because of the risk of cross-sensitivity with penicillin)
  27. 27. 5.5 Other antibiotics• linezolid and daptomycin• Only after consultating Micro Team
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