Infective bacterial endocarditis (IBE) is a serious bacterial infection of the heart that can be fatal if not treated promptly. It occurs when bacteria enter the bloodstream and attach to abnormal areas of the heart, forming vegetations. Common causes include Staphylococcus aureus, viridans streptococci, and enterococci. Diagnosis involves blood cultures, echocardiography, and application of the Modified Duke Criteria. Treatment involves antibiotics for 4-6 weeks based on the identified pathogen, with goals of eradicating the infection and preventing complications like heart failure, embolism, and metastatic infection. Prognosis depends on the causative organism and presence of complications.
This document summarizes information about febrile seizures in children. It defines febrile seizures as seizures occurring between ages 6 months and 5 years when a child has a fever of 38°C or higher, without signs of infection or other causes. Febrile seizures are classified as simple or complex based on duration and recurrence. Risk factors include age under 2 years, high fever, male sex, viral infections, immunizations, and genetic or nutritional factors. Febrile seizures recur in 30-50% of cases depending on number of prior episodes. Only 2-7% of children with febrile seizures later develop epilepsy, with risk factors including family history, neurodevelopmental issues, and seizure type.
A 32-year-old man with a history of rheumatic heart disease and mitral valve repair presented with fever, chills, myalgia and shortness of breath. Examination revealed signs of infective endocarditis including a heart murmur, splenomegaly, splinter hemorrhages and skin lesions. Blood cultures and echocardiography were performed to diagnose infective endocarditis and determine the causative organism and extent of valve involvement. The document discusses the pathogenesis, clinical features, diagnostic criteria and treatment guidelines for infective endocarditis based on the infecting organism and type of valve affected.
- Generalized tonic-clonic status epilepticus (GCSE) is a condition that will likely not terminate rapidly or spontaneously and requires prompt medical intervention. It is defined as continuous seizure activity lasting more than 5 minutes in children over 5 years old.
- Prolonged GCSE can cause respiratory, hemodynamic, metabolic, and other systemic complications that increase the risk of mortality and neurological injury if not treated promptly. Initial treatment involves rapid-acting benzodiazepines followed by longer-acting anticonvulsants like phenytoin or phenobarbital.
This document discusses refining the neurological history. It emphasizes that the neurological history should answer where in the nervous system the lesion is located, the pathological process, and if it is purely neurological or a manifestation of systemic disease. A detailed history remains important as it is the safest, most cost-effective diagnostic tool, helps establish trust in the doctor-patient relationship, and can provide a diagnosis when tests are negative. Key elements to address in the history, like dizziness, slurred speech, blurred vision and numbness are discussed.
Topic Discussion 1 Rate and Rhythm Control AFibAmy Yeh
This document defines atrial fibrillation (AF), describes its pathophysiology and risk factors, and outlines treatment strategies for rate and rhythm control of AF. AF is the most common cardiac arrhythmia, characterized by disorganized atrial electrical activity resulting in irregular heartbeat. Treatment involves anticoagulation to prevent stroke, rate control to slow heart rate, and rhythm control to restore normal sinus rhythm. Rate control is preferred for most and involves beta blockers or calcium channel blockers. Rhythm control uses antiarrhythmic drugs, cardioversion, or ablation and may be considered if rate control fails or symptoms persist. Patient education emphasizes lifestyle modification and medication adherence.
Evaluation and Initial Treatment of Supraventricular TachycardiaSun Yai-Cheng
This document provides information to help differentiate types of supraventricular tachycardia, including:
1. The initial differential diagnosis should focus on regularity, rate, and onset rather than atrial activity on ECG.
2. Regular types include sinus tachycardia, atrial flutter, AV nodal reentrant tachycardia, AV reciprocating tachycardia, and atrial tachycardia. Irregular types include atrial fibrillation, atrial flutter with irregular conduction, and multifocal atrial tachycardia.
3. Adenosine can help distinguish types by terminating rhythms dependent on AV node conduction like AV nodal reentrant
This document summarizes information about febrile seizures in children. It defines febrile seizures as seizures occurring between ages 6 months and 5 years when a child has a fever of 38°C or higher, without signs of infection or other causes. Febrile seizures are classified as simple or complex based on duration and recurrence. Risk factors include age under 2 years, high fever, male sex, viral infections, immunizations, and genetic or nutritional factors. Febrile seizures recur in 30-50% of cases depending on number of prior episodes. Only 2-7% of children with febrile seizures later develop epilepsy, with risk factors including family history, neurodevelopmental issues, and seizure type.
A 32-year-old man with a history of rheumatic heart disease and mitral valve repair presented with fever, chills, myalgia and shortness of breath. Examination revealed signs of infective endocarditis including a heart murmur, splenomegaly, splinter hemorrhages and skin lesions. Blood cultures and echocardiography were performed to diagnose infective endocarditis and determine the causative organism and extent of valve involvement. The document discusses the pathogenesis, clinical features, diagnostic criteria and treatment guidelines for infective endocarditis based on the infecting organism and type of valve affected.
- Generalized tonic-clonic status epilepticus (GCSE) is a condition that will likely not terminate rapidly or spontaneously and requires prompt medical intervention. It is defined as continuous seizure activity lasting more than 5 minutes in children over 5 years old.
- Prolonged GCSE can cause respiratory, hemodynamic, metabolic, and other systemic complications that increase the risk of mortality and neurological injury if not treated promptly. Initial treatment involves rapid-acting benzodiazepines followed by longer-acting anticonvulsants like phenytoin or phenobarbital.
This document discusses refining the neurological history. It emphasizes that the neurological history should answer where in the nervous system the lesion is located, the pathological process, and if it is purely neurological or a manifestation of systemic disease. A detailed history remains important as it is the safest, most cost-effective diagnostic tool, helps establish trust in the doctor-patient relationship, and can provide a diagnosis when tests are negative. Key elements to address in the history, like dizziness, slurred speech, blurred vision and numbness are discussed.
Topic Discussion 1 Rate and Rhythm Control AFibAmy Yeh
This document defines atrial fibrillation (AF), describes its pathophysiology and risk factors, and outlines treatment strategies for rate and rhythm control of AF. AF is the most common cardiac arrhythmia, characterized by disorganized atrial electrical activity resulting in irregular heartbeat. Treatment involves anticoagulation to prevent stroke, rate control to slow heart rate, and rhythm control to restore normal sinus rhythm. Rate control is preferred for most and involves beta blockers or calcium channel blockers. Rhythm control uses antiarrhythmic drugs, cardioversion, or ablation and may be considered if rate control fails or symptoms persist. Patient education emphasizes lifestyle modification and medication adherence.
Evaluation and Initial Treatment of Supraventricular TachycardiaSun Yai-Cheng
This document provides information to help differentiate types of supraventricular tachycardia, including:
1. The initial differential diagnosis should focus on regularity, rate, and onset rather than atrial activity on ECG.
2. Regular types include sinus tachycardia, atrial flutter, AV nodal reentrant tachycardia, AV reciprocating tachycardia, and atrial tachycardia. Irregular types include atrial fibrillation, atrial flutter with irregular conduction, and multifocal atrial tachycardia.
3. Adenosine can help distinguish types by terminating rhythms dependent on AV node conduction like AV nodal reentrant
A 50-year-old male presented with difficulty breathing, coughing, wheezing and chest tightness for 5 hours. He has a history of asthma for 5 years. Examination found reduced chest expansion and wheezing. Tests showed eosinophilia and reduced lung function. He was diagnosed with status asthmaticus and treated with oxygen, nebulized salbutamol, hydrocortisone and other drugs. He was prescribed inhaled corticosteroids, bronchodilators and montelukast for long-term control of his asthma.
1. Febrile seizures are common in children between ages 1-3 years, occurring in 2-4% of pediatric population. They present as seizures associated with fever but have no long term brain effects.
2. Febrile seizures are categorized as simple or complex based on features such as duration, recurrence, and presence of neurological deficits. Treatment involves controlling fever and in some cases short term use of anticonvulsants to prevent recurrence of seizures.
3. Long term prognosis of febrile seizures is excellent with majority of children not developing epilepsy. They have normal intelligence and development with low risk of future neurological problems. Proper management can alleviate parental anxiety over this common childhood seizure disorder.
Acute rheumatic fever is an autoimmune disease primarily affecting children that can result from untreated strep throat infections. It is characterized by inflammation of the heart (carditis) and joints (arthritis). Long term, it can lead to rheumatic heart disease where the heart valves are damaged. Proper treatment of strep throat infections with antibiotics can prevent most cases from occurring.
Transverse myelitis is an acute or subacute inflammation of the spinal cord characterized by motor, sensory and autonomic dysfunction. It can be caused by infections, autoimmune disorders or be idiopathic. Symptoms develop rapidly and include weakness, sensory changes, bowel and bladder issues. Diagnosis involves ruling out other causes and may include CSF analysis showing inflammation or MRI revealing a gadolinium enhancing spinal cord lesion. Prognosis is variable, with many patients experiencing partial recovery starting within months, though some degree of disability is common. Risk of developing multiple sclerosis is higher in cases of partial cord involvement or brain lesions on MRI.
A 10-year-old girl presented with pain and swelling in multiple small and large joints of both upper and lower limbs for the past 7 months. On examination, her knees, elbows, and small joints of hands and feet were swollen, warm, tender with restricted movement. Based on the symmetrical involvement of multiple joints, she was provisionally diagnosed with polyarticular juvenile idiopathic arthritis.
This document discusses neurotuberculosis, specifically tuberculous meningitis. It begins by classifying neurotuberculosis and describing the pathogenesis of tuberculous meningitis. It then covers the clinical features and stages of tuberculous meningitis, diagnostic criteria, complications, management including treatment with antitubercular drugs and corticosteroids, and differential diagnosis. Imaging and diagnostic tests for tuberculous meningitis like CSF analysis are also summarized.
status epilepticus in child je workshop mksdrmksped
Status epilepticus is a medical emergency defined as continuous seizure activity lasting more than 30 minutes or recurrent seizures without regaining consciousness between seizures. It requires prompt treatment to prevent neurological injury and death. The document discusses the epidemiology, pathophysiology, treatment, and prognosis of status epilepticus. Initial treatment involves maintaining airway, breathing, and circulation while administering benzodiazepines like lorazepam or diazepam. For refractory cases, additional anticonvulsants like fosphenytoin, phenobarbital, midazolam, or propofol may be used. Outcomes depend on factors like duration and etiology of seizures, with mortality ranging from 3-30
Infective endocarditis is an infection of the inner lining of the heart chambers and heart valves. It has an incidence of about 1 in 1,000 hospital admissions and risks include structural heart disease, immunosuppression, pacemakers, prolonged cardiac surgery, intravenous drug use, and nosocomial infections. Clinical presentations can be acute with toxicity and metastatic infection developing over days to weeks, or subacute progressing over weeks to months with less toxicity. Complications include heart failure, abscesses, and embolism, with an overall mortality rate of 10-20%. Treatment involves antibiotics tailored to the infecting organism and surgery may be required in some cases.
Headaches can have many different causes. They are generally classified into primary headaches like tension headaches and migraines, which are benign and self-limiting, and secondary headaches caused by underlying conditions like meningitis, brain tumors, or head injuries. The brain itself is not sensitive to pain, but structures like the blood vessels, dura, and sinuses surrounding it can stimulate pain fibers when tugged, stretched, or inflamed. Different areas of stimulation lead to pain being referred to specific parts of the head. Common primary headaches include tension, migraine, and sinus headaches.
The patient, a 16-year-old girl, presented with fever, vomiting, bloody diarrhea, jaundice, decreased urine output, and swelling over 10 days. Laboratory tests showed hemolytic anemia, thrombocytopenia, and acute kidney injury consistent with hemolytic uremic syndrome (HUS). Stool culture grew E. coli, indicating the patient had Shiga toxin-producing E. coli (STEC) HUS, the most common type of HUS in children. The patient was diagnosed with HUS likely caused by STEC infection.
Recent Advances In The Management Of Juvenile Idiopathic ArthritisNaveen Kumar Cheri
The term “rheumatologicaldisorders” refers to diseases that affect the major connective tissues of the body (e.g. skin, bone, blood vessels, cartilage and basement membrane).
Juvenile Idiopathic Arthritis (JIA) is the most common pediatric rheumatologic disease. It is associated with significant long term morbidity.
It was previously called as, Juvenile Rheumatoid Arthritis (by ACR –American College of Rheumatology) or Juvenile Chronic Arthritis (by ELAR –European League Against Rheumatism).
This document describes a case of encephalitis in a 43-year-old male. He presented with fever, vomiting, seizures, and loss of consciousness. Examination found him to be stuporous. Tests found no focal brain lesions but CSF analysis showed elevated proteins. He was initially diagnosed with acute meningoencephalitis and treated unsuccessfully with antibiotics. A Paul Bunnell test then found positive for scrub typhus. Treatment with doxycycline led to dramatic recovery and discharge after 7 days. Scrub typhus is an emerging disease transmitted by mites, with varied clinical presentations including neurological involvement. Early diagnosis and doxycycline treatment are important to reduce mortality.
Infective Endocarditis is an infection of the heart valves or endocardium. It is characterized by vegetation formation on the valves due to bacterial colonization. It can affect native or prosthetic valves. There are different classifications based on the virulence of the organism and severity. Predisposing factors include underlying heart conditions and immunosuppression. Common causative organisms are staphylococci and streptococci. Diagnosis is based on modified Dukes criteria using blood cultures, echocardiography and clinical features. Treatment involves long-term antibiotic therapy based on the identified organism along with surgery in some severe cases. Endocarditis prophylaxis is recommended for high risk patients undergoing certain medical procedures.
This document provides guidance on evaluating and diagnosing a patient presenting with polyarthritis. It outlines an approach involving assessing the site and distribution of pain, type of pain, associated features, duration and onset, risk factors, physical signs, differential diagnosis, and investigations. Key tests include radiographs, bloodwork including ESR/CRP, synovial fluid analysis, and serologic tests. Common arthritic conditions discussed include osteoarthritis, rheumatoid arthritis, gout, psoriatic arthritis, ankylosing spondylitis, and systemic lupus erythematosus.
1. Rate control has equivalent efficacy to rhythm control for managing atrial fibrillation and has less drug-related side effects.
2. Drugs like digoxin, beta blockers, and calcium channel blockers can be used for rate control, while antiarrhythmics like amiodarone, dofetilide and sotalol are used for rhythm control.
3. Electrical cardioversion can be used to restore sinus rhythm but has a risk of recurrence, so anticoagulation is recommended afterwards to prevent stroke from clots that may form during the arrhythmia.
Chronic stable angina is a chronic condition where episodes of chest pain occur periodically due to temporary deficiencies in the heart's blood supply. The document outlines the objectives, definition, epidemiology, pathophysiology, differences between chronic stable angina and acute coronary syndrome, pharmacological treatments including beta blockers, calcium channel blockers, nitrates, antiplatelet agents, ACE inhibitors, and ranolazine. It discusses patient education on drug effects, potential adverse effects and interactions, and monitoring requirements. Lifestyle recommendations including diet, exercise, smoking cessation, and weight loss are also provided.
This document discusses status epilepticus, which is defined as prolonged or repeated seizures without recovery between seizures. It classifies status epilepticus, explores its pathophysiology and etiology, and outlines its presentation, differential diagnosis, workup, and management. Status epilepticus results from either failed seizure termination mechanisms or initiation of mechanisms leading to prolonged seizures. It can cause neuronal death or injury if not promptly treated. Management involves initial treatment with benzodiazepines followed by anti-seizure medications like fosphenytoin or anesthetic doses if seizures persist over 40 minutes.
This document provides guidance on the assessment and treatment of arrhythmias presenting in the emergency department. It outlines an approach of first determining hemodynamic stability, then distinguishing between narrow and wide complex tachycardias, and finally determining the specific arrhythmia and appropriate treatment. For unstable patients with any arrhythmia, synchronized direct current cardioversion is recommended. Further treatment is tailored based on whether the arrhythmia has narrow or wide QRS complexes and is regular or irregular.
Gastrite é a inflamação do revestimento do estômago, podendo ser aguda ou crônica. Ela é causada principalmente pela bactéria H. pylori ou pelo uso de analgésicos, e seus sintomas incluem azia, náusea e dor abdominal. O diagnóstico envolve exames endoscópicos e de sangue, e o tratamento é feito com antibióticos ou medicamentos para reduzir a acidez estomacal, prevenindo úlceras e até câncer caso não tratada.
A 50-year-old male presented with difficulty breathing, coughing, wheezing and chest tightness for 5 hours. He has a history of asthma for 5 years. Examination found reduced chest expansion and wheezing. Tests showed eosinophilia and reduced lung function. He was diagnosed with status asthmaticus and treated with oxygen, nebulized salbutamol, hydrocortisone and other drugs. He was prescribed inhaled corticosteroids, bronchodilators and montelukast for long-term control of his asthma.
1. Febrile seizures are common in children between ages 1-3 years, occurring in 2-4% of pediatric population. They present as seizures associated with fever but have no long term brain effects.
2. Febrile seizures are categorized as simple or complex based on features such as duration, recurrence, and presence of neurological deficits. Treatment involves controlling fever and in some cases short term use of anticonvulsants to prevent recurrence of seizures.
3. Long term prognosis of febrile seizures is excellent with majority of children not developing epilepsy. They have normal intelligence and development with low risk of future neurological problems. Proper management can alleviate parental anxiety over this common childhood seizure disorder.
Acute rheumatic fever is an autoimmune disease primarily affecting children that can result from untreated strep throat infections. It is characterized by inflammation of the heart (carditis) and joints (arthritis). Long term, it can lead to rheumatic heart disease where the heart valves are damaged. Proper treatment of strep throat infections with antibiotics can prevent most cases from occurring.
Transverse myelitis is an acute or subacute inflammation of the spinal cord characterized by motor, sensory and autonomic dysfunction. It can be caused by infections, autoimmune disorders or be idiopathic. Symptoms develop rapidly and include weakness, sensory changes, bowel and bladder issues. Diagnosis involves ruling out other causes and may include CSF analysis showing inflammation or MRI revealing a gadolinium enhancing spinal cord lesion. Prognosis is variable, with many patients experiencing partial recovery starting within months, though some degree of disability is common. Risk of developing multiple sclerosis is higher in cases of partial cord involvement or brain lesions on MRI.
A 10-year-old girl presented with pain and swelling in multiple small and large joints of both upper and lower limbs for the past 7 months. On examination, her knees, elbows, and small joints of hands and feet were swollen, warm, tender with restricted movement. Based on the symmetrical involvement of multiple joints, she was provisionally diagnosed with polyarticular juvenile idiopathic arthritis.
This document discusses neurotuberculosis, specifically tuberculous meningitis. It begins by classifying neurotuberculosis and describing the pathogenesis of tuberculous meningitis. It then covers the clinical features and stages of tuberculous meningitis, diagnostic criteria, complications, management including treatment with antitubercular drugs and corticosteroids, and differential diagnosis. Imaging and diagnostic tests for tuberculous meningitis like CSF analysis are also summarized.
status epilepticus in child je workshop mksdrmksped
Status epilepticus is a medical emergency defined as continuous seizure activity lasting more than 30 minutes or recurrent seizures without regaining consciousness between seizures. It requires prompt treatment to prevent neurological injury and death. The document discusses the epidemiology, pathophysiology, treatment, and prognosis of status epilepticus. Initial treatment involves maintaining airway, breathing, and circulation while administering benzodiazepines like lorazepam or diazepam. For refractory cases, additional anticonvulsants like fosphenytoin, phenobarbital, midazolam, or propofol may be used. Outcomes depend on factors like duration and etiology of seizures, with mortality ranging from 3-30
Infective endocarditis is an infection of the inner lining of the heart chambers and heart valves. It has an incidence of about 1 in 1,000 hospital admissions and risks include structural heart disease, immunosuppression, pacemakers, prolonged cardiac surgery, intravenous drug use, and nosocomial infections. Clinical presentations can be acute with toxicity and metastatic infection developing over days to weeks, or subacute progressing over weeks to months with less toxicity. Complications include heart failure, abscesses, and embolism, with an overall mortality rate of 10-20%. Treatment involves antibiotics tailored to the infecting organism and surgery may be required in some cases.
Headaches can have many different causes. They are generally classified into primary headaches like tension headaches and migraines, which are benign and self-limiting, and secondary headaches caused by underlying conditions like meningitis, brain tumors, or head injuries. The brain itself is not sensitive to pain, but structures like the blood vessels, dura, and sinuses surrounding it can stimulate pain fibers when tugged, stretched, or inflamed. Different areas of stimulation lead to pain being referred to specific parts of the head. Common primary headaches include tension, migraine, and sinus headaches.
The patient, a 16-year-old girl, presented with fever, vomiting, bloody diarrhea, jaundice, decreased urine output, and swelling over 10 days. Laboratory tests showed hemolytic anemia, thrombocytopenia, and acute kidney injury consistent with hemolytic uremic syndrome (HUS). Stool culture grew E. coli, indicating the patient had Shiga toxin-producing E. coli (STEC) HUS, the most common type of HUS in children. The patient was diagnosed with HUS likely caused by STEC infection.
Recent Advances In The Management Of Juvenile Idiopathic ArthritisNaveen Kumar Cheri
The term “rheumatologicaldisorders” refers to diseases that affect the major connective tissues of the body (e.g. skin, bone, blood vessels, cartilage and basement membrane).
Juvenile Idiopathic Arthritis (JIA) is the most common pediatric rheumatologic disease. It is associated with significant long term morbidity.
It was previously called as, Juvenile Rheumatoid Arthritis (by ACR –American College of Rheumatology) or Juvenile Chronic Arthritis (by ELAR –European League Against Rheumatism).
This document describes a case of encephalitis in a 43-year-old male. He presented with fever, vomiting, seizures, and loss of consciousness. Examination found him to be stuporous. Tests found no focal brain lesions but CSF analysis showed elevated proteins. He was initially diagnosed with acute meningoencephalitis and treated unsuccessfully with antibiotics. A Paul Bunnell test then found positive for scrub typhus. Treatment with doxycycline led to dramatic recovery and discharge after 7 days. Scrub typhus is an emerging disease transmitted by mites, with varied clinical presentations including neurological involvement. Early diagnosis and doxycycline treatment are important to reduce mortality.
Infective Endocarditis is an infection of the heart valves or endocardium. It is characterized by vegetation formation on the valves due to bacterial colonization. It can affect native or prosthetic valves. There are different classifications based on the virulence of the organism and severity. Predisposing factors include underlying heart conditions and immunosuppression. Common causative organisms are staphylococci and streptococci. Diagnosis is based on modified Dukes criteria using blood cultures, echocardiography and clinical features. Treatment involves long-term antibiotic therapy based on the identified organism along with surgery in some severe cases. Endocarditis prophylaxis is recommended for high risk patients undergoing certain medical procedures.
This document provides guidance on evaluating and diagnosing a patient presenting with polyarthritis. It outlines an approach involving assessing the site and distribution of pain, type of pain, associated features, duration and onset, risk factors, physical signs, differential diagnosis, and investigations. Key tests include radiographs, bloodwork including ESR/CRP, synovial fluid analysis, and serologic tests. Common arthritic conditions discussed include osteoarthritis, rheumatoid arthritis, gout, psoriatic arthritis, ankylosing spondylitis, and systemic lupus erythematosus.
1. Rate control has equivalent efficacy to rhythm control for managing atrial fibrillation and has less drug-related side effects.
2. Drugs like digoxin, beta blockers, and calcium channel blockers can be used for rate control, while antiarrhythmics like amiodarone, dofetilide and sotalol are used for rhythm control.
3. Electrical cardioversion can be used to restore sinus rhythm but has a risk of recurrence, so anticoagulation is recommended afterwards to prevent stroke from clots that may form during the arrhythmia.
Chronic stable angina is a chronic condition where episodes of chest pain occur periodically due to temporary deficiencies in the heart's blood supply. The document outlines the objectives, definition, epidemiology, pathophysiology, differences between chronic stable angina and acute coronary syndrome, pharmacological treatments including beta blockers, calcium channel blockers, nitrates, antiplatelet agents, ACE inhibitors, and ranolazine. It discusses patient education on drug effects, potential adverse effects and interactions, and monitoring requirements. Lifestyle recommendations including diet, exercise, smoking cessation, and weight loss are also provided.
This document discusses status epilepticus, which is defined as prolonged or repeated seizures without recovery between seizures. It classifies status epilepticus, explores its pathophysiology and etiology, and outlines its presentation, differential diagnosis, workup, and management. Status epilepticus results from either failed seizure termination mechanisms or initiation of mechanisms leading to prolonged seizures. It can cause neuronal death or injury if not promptly treated. Management involves initial treatment with benzodiazepines followed by anti-seizure medications like fosphenytoin or anesthetic doses if seizures persist over 40 minutes.
This document provides guidance on the assessment and treatment of arrhythmias presenting in the emergency department. It outlines an approach of first determining hemodynamic stability, then distinguishing between narrow and wide complex tachycardias, and finally determining the specific arrhythmia and appropriate treatment. For unstable patients with any arrhythmia, synchronized direct current cardioversion is recommended. Further treatment is tailored based on whether the arrhythmia has narrow or wide QRS complexes and is regular or irregular.
Gastrite é a inflamação do revestimento do estômago, podendo ser aguda ou crônica. Ela é causada principalmente pela bactéria H. pylori ou pelo uso de analgésicos, e seus sintomas incluem azia, náusea e dor abdominal. O diagnóstico envolve exames endoscópicos e de sangue, e o tratamento é feito com antibióticos ou medicamentos para reduzir a acidez estomacal, prevenindo úlceras e até câncer caso não tratada.
Infective endocarditis is a serious infection of the heart valves, usually caused by bacteria entering the bloodstream and adhering to previously damaged valves. It can occur in patients with normal or abnormal heart anatomy. Viridans streptococci and Staphylococcus aureus are common causes. It may present with nonspecific symptoms like fever or with signs of complications. Diagnosis involves blood cultures, echocardiogram, and applying the Duke criteria. Treatment is antibiotics with possible surgery. Prevention focuses on antibiotic prophylaxis before procedures for high-risk patients.
2015 ESC Guidelines on Infective Endocarditis ppt. by Dr Abhishek Rathore MDdrabhishekbabbu
The document summarizes guidelines for the management of infective endocarditis (IE). It recommends an endocarditis team approach in a reference center for complicated IE cases. It emphasizes the importance of early diagnosis, antibiotic therapy, and consideration of early surgery. It also discusses new recommendations for specific IE situations, antibiotic prophylaxis, surgical management, and the roles of imaging and multidisciplinary care in IE management.
The document provides guidelines for the management of infective endocarditis from the European Society of Cardiology. It discusses definitions of infective endocarditis, recommendations for antibiotic prophylaxis, the role of echocardiography in diagnosis, etiologic agents, predictors of poor outcome, surgical indications, and treatment of various microorganisms including streptococci, staphylococci, enterococci, and culture-negative cases. It also addresses management considerations for infective endocarditis in specific patient populations such as those with prosthetic valves, congenital heart disease, or pregnancy.
Revision de la guia ESC cardio de endocarditis con definicion de la enfermedad, epidemiologia, criterios diagnosticos y tratamiento
Revisar www.germen.org para perfil de resistencia bacteriana en Medellin Colombia
Endocarditis is an inflammation of the inner lining of the heart chambers and valves. It is usually caused by bacteria entering the bloodstream from another part of the body. There are three main stages of the disease: bacteremia, adhesion of bacteria to damaged heart valves, and colonization leading to infection. Symptoms can include fever, weakness, weight loss or new heart murmurs. Treatment involves intravenous antibiotics targeting the specific bacteria, with surgery sometimes needed for complications or resistant infections. The prognosis depends on several risk factors but prompt treatment is important for recovery.
This document provides an overview of infective endocarditis (IE), including its introduction, classification, pathogenesis, clinical manifestations, diagnosis, and treatment. Some key points:
- IE is defined as an infection of the inner lining of the heart (endocardium) that can involve heart valves, the inner lining of the heart chambers, or defects in the heart wall.
- It is classified based on temporal evolution (acute vs. subacute) and location (native valve, prosthetic valve, device-related, right-sided). Common causes include streptococci, staphylococci, and enterococci.
- Diagnosis is based on the Modified Duke Criteria, which considers
The document discusses infective endocarditis, including:
1. Vegetations form on heart valves from bacterial deposition, usually due to a susceptible cardiovascular substrate and source of bacteremia. Common causes are streptococcus, staphylococcus, and enterococcus.
2. Predisposing factors include age, pre-existing heart conditions, dental procedures, injection drug use, and medical implants.
3. Treatment involves antibiotics to eradicate the infection and sometimes surgery for complications. Outcomes depend on the causative organism and severity of cardiac involvement.
Infective endocarditis is an infection of the endocardial surface of the heart that is characterized by colonization or invasion of heart valves or endocardium by microbes, leading to formation of vegetations composed of thrombotic debris and organisms, often associated with destruction of underlying cardiac tissue. It can involve heart valves, ventricular septal defects, or mural endocardium. It is classified as either acute or subacute, with acute being more destructive and rapidly fatal if untreated. Diagnosis is based on modified Dukes criteria involving major and minor criteria. Treatment involves identification of the pathogen and administration of bactericidal antibiotics, with surgery indicated for complications or resistant organisms. Prophylactic antibiotics are recommended for high risk
Cardiovascular system infections include infections of the heart and blood vessels, such as infective endocarditis, myocarditis, pericarditis, mycotic aneurysms, and device-related infections. Infective endocarditis refers to microbial invasion of heart valves or inner lining of the heart, which can result in the formation of vegetations. It is commonly caused by Staphylococcus aureus, viridans streptococci, enterococci, and other bacteria and fungi. Diagnosis involves blood cultures, echocardiography, and application of the Modified Duke Criteria. Treatment involves prolonged courses of antibiotics depending on the causative organism.
Children with congenital heart disease or rheumatic heart disease are at highest risk for developing bacterial endocarditis. It commonly presents with fever, heart murmur, and embolic phenomena. Diagnosis is made using modified Duke criteria, which considers major and minor clinical criteria as well as positive blood cultures. Treatment involves prolonged intravenous antibiotics targeting the causative organism. Surgery may be needed for complications like heart failure or abscesses. Prevention focuses on antibiotic prophylaxis for high-risk patients during certain medical procedures.
This document defines infective endocarditis, discusses its etiologies and pathogenesis. It states that infective endocarditis is a microbial infection of the heart's endothelial surface, most commonly involving heart valves. The most common causes are gram positive cocci like streptococci. It occurs when bacteria adhere to sites of endothelial damage and proliferate. Clinical features result from the infection's hemodynamic effects, embolization, or immune reactions. Echocardiography and blood cultures are important for diagnosis. Treatment involves antibiotics for 4-6 weeks and sometimes surgery. Dental procedures require prophylactic antibiotics for at-risk patients.
This document provides an overview of infective endocarditis, including its definition, pathogenesis, epidemiology, clinical presentation, diagnosis, and treatment. It defines infective endocarditis as a microbial infection of the heart valves or endocardium. It discusses the typical pathogens involved and describes the formation of vegetations on heart valves. It also outlines the diagnostic criteria, including blood cultures and echocardiography. Treatment involves prolonged antibiotic therapy tailored to the causative organism, and may require surgery in cases of heart failure or uncontrolled infection.
This document summarizes key aspects of infective endocarditis including epidemiology, pathogenesis, microbiology, clinical manifestations, diagnosis, and treatment. Some key points are:
- It affects 10-20,000 people annually in the US and risk factors include structural heart disease, prosthetic valves, and intravenous drug use.
- Bacteria seed non-bacterial thrombotic vegetations on heart valves, adhere and grow within them, potentially causing valve damage.
- Common causative organisms are staphylococci, streptococci, and enterococci. Blood cultures help identify the organism.
- Symptoms include fever and heart murmurs. Echocardiography aids diagnosis.
- Treatment
This document discusses infective endocarditis (IE), a serious infection of the heart valves or inner lining of the heart. It provides details on the epidemiology, symptoms, physical exam findings, causative organisms, risk factors, diagnostic criteria (Modified Duke Criteria), investigations including echocardiography and blood cultures, and treatment approach for IE. Staphylococcus aureus is a leading cause worldwide and viridans group streptococci are common causes after dental procedures. Diagnosis relies on modified Duke criteria incorporating positive blood cultures, echocardiogram findings, and clinical features.
1. A 62-year-old woman with end stage renal disease on hemodialysis presents with weakness, fever, and chills. She has risk factors for infective endocarditis including diabetes and receiving dialysis.
2. Infective endocarditis is a serious infection of the heart valves. It requires alterations in the heart valves along with bacteremia for infection to develop. Common causes are viridans streptococci, staphylococci, and enterococci.
3. Initial empirical treatment should cover common gram-positive organisms given her risk factors, such as penicillin plus gentamicin for streptococci or vancomycin plus gentamicin for staphy
Infective endocarditis occurs when bacteria or fungi colonize the heart valves. It is classified into four groups depending on the valve affected and cause. The most common predisposing factors are intravenous drug use, prosthetic valves, previous endocarditis and dental procedures. Clinical presentations include fever, heart murmur, petechiae and neurological changes. Diagnosis involves blood cultures, echocardiography and application of the Duke Criteria. Treatment involves antibiotics for 2-6 weeks depending on the causative organism and affected valve.
This document discusses acute bacterial meningitis (BM), including its definition, incidence, risk factors, etiology, clinical presentation, diagnosis, treatment goals and principles, specific treatment recommendations for common causative organisms, prevention through vaccination, and outpatient management considerations. The prognosis of untreated BM is poor, with high treatment failure rates and risk of neurological complications; however, prompt administration of appropriate antibiotic therapy can significantly improve outcomes.
Infective endocarditis is a microbial infection of the heart valves or endocardium. It is caused by bacteria, usually streptococci or staphylococci, entering the bloodstream and colonizing injured heart valves or endothelium. Predisposing conditions include rheumatic heart disease, congenital heart disease, prosthetic heart valves, and intravenous drug use. Symptoms include fever, chills, sweats, and heart murmur. Diagnosis involves blood cultures, echocardiography, and clinical criteria. Treatment consists of intravenous antibiotics for 4-6 weeks along with surgery if needed to repair or replace damaged valves. Prophylactic antibiotics are recommended for high risk patients before certain medical procedures to prevent
Infective Endocarditis is a microbial infection of the heart valves or inner lining of the heart. It is most commonly caused by bacteria and can lead to the formation of vegetations on the heart valves. The diagnosis is based on the modified Duke criteria which incorporates blood culture results, echocardiography findings and clinical features such as fever, heart murmur and embolic phenomena. Early diagnosis is important to guide treatment, which typically involves prolonged intravenous antibiotics.
This document discusses a case of infective endocarditis in a 6-year-old female child presenting with fatigue, joint pain, fast breathing, and other symptoms. After examination and testing, vegetative mass was discovered on the septal tricuspid valve. The child was diagnosed with tricuspid valve infective endocarditis. The document then provides definitions, classifications, clinical features, diagnostic criteria, management guidelines, and complications of infective endocarditis in children. It emphasizes the importance of blood cultures, echocardiography, and long-term antibiotic treatment along with monitoring for complications like embolism.
1) Infective endocarditis is an infection of the heart valves or endocardial surface. It can be caused by various organisms and has multiple risk factors.
2) It presents with non-specific symptoms like fever and heart murmur, and can lead to complications affecting the heart, brain, spleen and other organs. Investigations include blood cultures, echocardiography and modified Duke's criteria.
3) Management involves long-term intravenous antibiotics based on culture results, treating complications, and possibly surgery to repair or replace infected valves. Patients are monitored in the hospital for resolution of symptoms and complications of infective endocarditis.
This document provides an overview of infective endocarditis, including its definition, epidemiology, anatomy, pathogenesis, classification, etiology, risk factors, clinical manifestations, diagnosis, management, and complications. Infective endocarditis is a bacterial or fungal infection of the heart valves or endocardium. It most commonly affects the mitral valve and is usually caused by streptococci, staphylococci, or enterococci. It can be acute or subacute and is diagnosed using the modified Duke criteria.
This document provides information about infective endocarditis:
- Infective endocarditis is a microbial infection of the heart valves, heart lining, or blood vessels that is usually caused by bacteria.
- It can affect both native and prosthetic heart valves. Staphylococcus aureus is now the most common cause.
- Diagnosis is based on modified Duke criteria using clinical findings, blood cultures, and echocardiography findings. Treatment involves prolonged antibiotic therapy and may require surgery to remove infected tissues.
- Complications can include heart valve damage, embolic events, heart failure, and extension of the infection. Proper antibiotic prophylaxis is important for those at high risk
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1. 1
Infective Bacterial Endocarditis
Amy Yeh, PharmD Candidate 2015
APPE Internal Medicine I
March 19, 2015
Objectives
Define infective bacterial endocarditis (IBE)
Describe the significance, etiology, pathophysiology, and clinical presentation of IBE
Explain the diagnostic parameters and prognosis of IBE
Recommend an appropriate pharmacologic regimen for patients presenting with IBE
Describe how IBE medications are monitored for safety and efficacy
Abbreviations
IBE infective bacterial endocarditis
Abx antibiotic
Tx treatment/treating
DDIs drug-drug interactions
ADRs adverse drug reactions
HR heart rate
IV intravenous
IM intramuscular
HACEK Haemophilus aphrophilus
Actinobacillus actinomycetemcomitans
Cardiobacterium hominis
Eikenella corrodens
Kingella kingae
TTE transthoracic echocardiography
TEE transesophageal echocardiography
MIC minimum inhibitory concentration
Strep Streptococcus
Staph Staphylococcus
Vanco vancomycin
PCN penicillin
Rxns reactions
PVE prosthetic valve endocarditis
NVE native valve endocarditis
IBW ideal body weight
ABW actual body weight
What is infective bacterial endocarditis (IBE)? How common is it? What is the prognosis?
IBE is a bacterial infection of the inner lining of the heart (endocardium)
Incidence
o 10,000-20,000 infections per year
o More common in men than women
3-9 times as many cases
Prognosis
o Fatal if not treated promptly and correctly
o In-hospital mortality rate 18-23%
2. 2
o 6 month mortality rate of 22-27%
o S. aureus IBE + neurologic complications 74% mortality rate
Risk factors
o Age > 60
o Male sex
o IV drug use
o Poor dental hygiene/dental infection
o Comorbidities
Structural heart disease
Prosthetic heart valves
Implanted medical devices
Long-standing IV catheter
History of IBE
Chronic hemodialysis
HIV infection
Etiology/Pathophysiology
Typical causes of IBE
o Staphylococcus aureus (31%)
Risk of IBE especially high
Evaluate all patients with bacteremia for IBE
o Viridans streptococci (17%)
o Enterococci (11%)
o Streptococcus bovis (7%)
o HACEK group (2%)
Haemophilus aphrophilus
Actinobacillus actinomycetemcomitans
Cardiobacterium hominis
Eikenella corrodens
Kingella kingae
Bacteria enters bloodstream from cuts/abrasions attaches to damaged areas of heart proliferates inside
vegetations
o Preexisting clot on heart facilitates the binding
o Structural heart defect must be present in order for infection to occur
o Sources of bacteria
Skin
GI tract
Lining of mouth
What is a vegetation?
o An avascular aggregate of fibrin, platelets, leukocytes, RBC fragments, and bacteria
o Often develops in low-pressure areas (away from turbulent flow)
Vegetation formation
o Endocardial injury attachment of platelets and fibrin secondary infection from pathogens microbial
proliferation activates clotting pathway more fibronectin is deposited
Vegetations shield bacteria from immune system difficult to eradicate infection
Treatment may or may not eradicate vegetations
o May take years to clear the debris
o Detection of non-viable organisms is not indicative of tx failure
3. 3
Complications
o Cardiac (up to 50% of patients)
Heart failure
Vascular damage valvular insufficiency
The most common cause of IBE-related death
Warrants cardiac surgery
Perivalvular abscess (30-40% of patients)
Involvement of conduction system heart block
Mycocardial infarction
Caused by embolized fragments of vegetations
o Metastatic infection
Septic embolization (13-44% of patients)
Occlusion/damage of vessels complications
o Stroke
o Paralysis
o Blindness
o Pulmonary embolism
o Metastatic abscess
Mycotic aneurysm
High risk of rupture and hemorrhage High mortality rate
o Neurologic
Outcomes are variable for those with neurologic complications
May be the presenting symptom in IBE
Consider IBE for stroke, meningitis, brain abscess patients
Acute encephalopathy
Meningitis
Cerebral hemorrhage
Seizures
o Renal failure
o Musculoskeletal
Osteomyelitis
Septic arthritis
Acute involvement of joints suspect IBE
o Complications from tx
Drug-induced
Ototoxicity or nephrotoxicity
C. difficile infection
Allergic rxns
IV-associated thrombosis or infection
Clinical Presentation
Flu-like symptoms
o Fever
o Chills
o Fatigue
o Myalgia
o Night sweats
o Headache
Dyspnea or persistent cough
New heart murmur or changes in existing heart murmur
Skin, fingernail, or eye changes
4. 4
o Nonspecific
Petechiae: spots of broken blood vessels under the skin
Splinter hemorrhages under the nail
o Specific
Janeway lesions: nonpainful, erythematous lesions on palms and soles
Osler’s nodes: painful pustular nodules on fingers and toes
Roth spots: hemorrhagic lesions on retina
Unexplained weight loss
Diagnosis
Obtain 3 sets of blood cultures before initiating abx therapy
From different venipuncture sites
Minimum of 10 mL higher detection rate of bacteremia
Echocardiography
Allows detection and visualization of vegetations/abnormalities
TTE for patients with suspected IBE
Positive if vegetation present
Indications for TEE
Further evaluation after positive TTE
Determine if surgery is required
o Significant valvular regurgitation
Risk factors for perivalvular abscess
Prosthetic valves
Valvular abnormality or history of IBE infection
Obscured visibility
obesity
mechanical ventilation
Modified Duke Criteria for diagnosis
Positive blood cultures for suspicious organisms + evidence of endocardial infection
Definite IBE
2 major criteria
1 major and 2 minor criteria
5 minor criteria
Major criteria
Positive blood culture for typical IBE pathogens
Positive echocardiogram
New valvular regurgitation
Minor criteria
Predisposing heart condition or IV drug use
Fever
Vascular phenomena
Immunologic phenomena
Evidence of active infection with IBE pathogen
Differential diagnosis
Bacteremia without endocardial involvement
Skin and soft tissue infection
Cardiac device infection
Prosthetic joint infection
Intravascular catheter infection
Osteomyelitis
Meningitis
5. 5
Pneumonia
Cardiac vegetation without positive blood culture
Culture-negative endocarditis
Marantic endocarditis
Lupus
Antiphospholipid syndrome
Goals of therapy
Eradicate infection
Minimize morbidity and mortality
Prevent future recurrence of IBE
General principles of treatment for native valve IBE (NVE)
Empiric therapy
For acutely ill patients with signs/symptoms of IBE
Non-acute wait for results
Obtain at least 2 sets of blood cultures before abx therapy
Cover Staph, Strep, and Enterococci
Vanco 15-20 mg/kg IV every 8-12 hours (max 2 g/dose)
Target pathogen found in blood culture
Repeat blood culture 48-72 hours later to assess response
Patient should become afebrile 3-5 days after initiation of appropriate abx
Tx for 4-6 weeks, depending on location and complexity of infection
Once hemodynamically stable, continue IV therapy in outpatient setting
*Dosing information provided in this handout*
*IV administration, unless otherwise stated
IV/IM are acceptable for ceftriaxone and gentamicin
*Adult dosing with normal renal function
Native Valve IBE: Viridans streptococci and Streptococcus bovis
Most are PCN-susceptible (MIC ≤ 0.12)
o High cure rate
PCN-susceptible (MIC ≤ 0.12)
o 4 weeks (elderly, renal/otic impairment)
Aqueous PCN G (continuously or 4-6 times daily)
Ceftriaxone IV/IM daily
Vanco bid
Only if allergic to PCN and ceftriaxone
Target trough 15-20
Max 2 g/24 hrs
o 2 weeks (no complications + CrCl ≥ 20 + no otic disease)
Aqueous PCN G (continuously or 4-6 times daily) + Gentamicin (daily, bid, or tid)
Ceftriaxone daily + Gentamicin (daily, bid, or tid)
Gentamicin monitoring (once weekly)
Renal function
Gentamicin serum concentrations
o 2-3 daily doses (hospitalized patients)
Peak 3-4 mcg/mL (1 hr post-dose)
6. 6
Trough < 1 mcg/mL
o 1 daily dose (outpatients)
Peak 10-12 mcg/mL
Trough < 1 mcg/mL
PCN-Intermediate susceptibility (MIC > 0.12 and ≤ 0.5)
o Higher dose of PCN G
24 million units daily
o Same monitoring parameters for gentamicin and vanco
o Options
Aqueous PCN G (4 weeks) + gentamicin (first 2 weeks)
Ceftriaxone daily (4 weeks)+ gentamicin (first 2 weeks)
Vanco bid (4 weeks)
Max 2 g/24 hrs
Only if allergic to PCN and ceftriaxone
Target trough 15-20
PCN-Resistant (MIC > 0.5)
o Follow enterococcal regimen
Native Valve IBE: Enterococci
Resistant to low concentrations of PCN
o Give PCN, ampicillin, or vanco with gentamicin
Most cases caused by E. faecalis
Susceptible to PCN, gentamicin, and vanco
o Gentamicin tid for 4-6 weeks
Monitoring (once weekly)
Peak 3-4 mcg/mL
Trough < 1 mcg/mL
Renal function
o PLUS one of the following
Aqueous PCN G (continuously or 6 times daily) for 4-6 weeks
Ampicillin 6 times daily for 4-6 weeks
Higher risk of allergic rxns than PCN
Vanco bid for 6 weeks
Max 2 g/dose
For PCN and cephalosporin allergy
Trough 15-20 mcg/mL
o Duration
4 wks if symptoms present ≤ 3 months
6 wks
Symptoms present > 3 months
Vanco tx option
o less activity against Enterococci than PCN
Relapsed infection
Prosthetic valve infection
PCN-resistant (MIC > 16), susceptible to aminoglycosides and vanco
o Beta-lactamase producing
Gentamicin tid for 6 wks
Same monitoring as above
PLUS one of the following
Ampicillin-sulbactam 4 times daily for 6 wks
o If gentamicin resistance, more than 6 wks of tx will be required
7. 7
Vanco bid for 6 wks
o If PCN resistance or allergy
o Trough 15-20 mcg/mL
o Intrinsic PCN resistance
Consult with infectious disease specialist
Vanco bid + gentamicin tid for 6 wks
Resistant to PCN, aminoglycosides, and vanco
o Surgical resection may be required for refractory cases
Cure rate < 50%
o E. faecium
Widespread vanco resistance, but rare cause of IBE
Tx recommendations based on case reports
Linezolid IV/PO bid for at least 8 wks
Monitor hematology
o After 2 wks of tx, severe thrombocytopenia may occur
Quinupristin-dalfopristin tid for at least 8 wks
Effective against E. faecium only
Severe myalgia may warrant d/c of tx
o E. faecalis
Imipenem-cilastatin qid + Ampicillin 6 times daily for at least 8 wks
Ceftriaxone bid + Ampicillin 6 times daily for at least 8 wks
Bid dosing of ceftriaxone is more effective than once daily dosing
Native valve IBE: Staphylococcus aureus
Variable success rate
o Most strains are PCN-resistant
o Test to verify MIC and absence of beta-lactamase activity
PCN-sensitive (MIC ≤ 0.1) + no beta-lactamase activity
Aqueous PCN G (4-6 times daily) x 6 wks
May add gentamicin IV/IM (2-3 times daily) for 3-5 days
Clinical benefit is undetermined
May result in more renal toxicity
Oxacillin-sensitive [methicillin-susceptible]
o Nafcillin or oxacillin 4-6 times daily x 6 wks
Flucloxacillin q4-6h is an alternative
May add gentamicin IV/IM (2-3 times daily) for 3-5 days
Clinical benefit is undetermined
May result in more renal toxicity
o Cefazolin tid x 6 wks
For moderately PCN allergic patients
If severe allergy, use vanco bid x 6 wks
May add gentamicin IV/IM (2-3 times daily) for 3-5 days
Clinical benefit is undetermined
May result in more renal toxicity
Oxacillin-resistant or severe PCN allergy
o Vanco bid x 6 wks
Max 2 g/24 hrs
Target trough 15-20 mcg/mL
8. 8
Native Valve IBE: HACEK organisms
A group of gram-negative bacilli
o Fastidious delayed growth 7 days to incubate in traditional blood culture (5 days in automated culture
systems)
o Ampicillin-resistant due to beta-lactamase production
Highly sensitive to third and fourth generation cephalosporins
Ceftriaxone 2 g IV/IM daily x 4 wks
o Cefotaxime, ceftazidime, ceftizoxome, cefepime may be substituted
Ampicillin-sulbactam 3 g qid x 4 wks
o Beta-lactamase inhibitor required for efficacy
For PCN allergy/intolerance
o Ciprofloxacin 1000 mg PO daily x 4 wks
o Ciprofloxacin 400 mg IV bid x 4 wks
General principles of tx for prosthetic valve endocarditis (PVE)
Tx of PVE is more difficult than that of native valve endocarditis
o Many cases refractory to abx monotherapy
o Invasive infections/complications are common
o Surgery may be required
Obtain 3 sets of blood cultures before initiating abx tx
o Hemodynamic instability or critically ill empiric tx
Vanco + gentamicin + (cefepime or carbapenem)
Adjust tx depending on culture results
o Not acute wait for results to return
Minimum tx duration of 6 wks
o Begin tx in hospital that offers cardiac surgery
o Hospitalize patients until afebrile and need for surgery is ruled out
o Complete tx as outpatient
Use native valve IBE abx regimens for PVE
o Exception for Staphylococcus-induced PVE
Tx of Staphylococcus-induced PVE
Immediate surgery often required
Triple drug regimen
o 6 times more effective than monotherapy
o In NVE, one drug is sufficient
Clinical benefit of gentamicin is undetermined
o Still recommended for optimal efficacy
o If resistance to gentamicin
Use an alternative aminoglycoside for 2 wks
o If resistance to aminoglycosides
Use a fluoroquinolone for 6 wks
o If resistance to aminoglycosides and fluoroquinolones
Linezolid x 2 wks
Ceftaroline x 2 wks
Trimethoprim-sulfamethoxazole x 2 wks
Gentamicin monitoring
o Dose using IBW
o Monitor renal function weekly
o Monitor serum level weekly
Trough < 1 mcg/mL
9. 9
Peak 3-4 mcg/mL
Rifampin is effective against Staph growing on foreign material
o Essential for PVE tx
o Must use with other drugs to minimize resistance
High mutation rate
Assess susceptibility to rifampin if tx failure occurs
o CYP3A4 inducer
DDIs: increases clearance of warfarin and other drugs
If refractory to vanco
o Test isolate for vanco and daptomycin resistance
o Alternatives to vanco
High dose daptomycin
Telavancin
Ceftaroline
Linezolid
Oxacillin-sensitive
o (Nafcillin or oxacillin 6 times daily + rifampin tid for 6 wks) + gentamicin IV/IM 2-3 times daily (2 wks)
If PCN-sensitive (MIC ≤ 0.1) and no beta-lactamase
PCN G (2-6 times daily) may be used instead of nafcillin or oxacillin
o (Cefazolin tid + rifampin IV/PO tid for 6 wks) + gentamicin IV/IM 2-3 times daily (2 wks)
Cefazolin for moderate PCN allergy
o (Vanco bid + rifampin IV/PO tid for 6 wks) + gentamicin IV/IM 2-3 times daily (2 wks)
Vanco for severe PCN allergy
Dosing based on ABW
May need to be given tid
Target trough 15-20 mcg/mL
Oxacillin-resistant
o (Vanco bid + rifampin IV/PO tid for 6 wks) + gentamicin IV/IM 2-3 times daily (2 wks)
Follow-Up/Patient Education
o At completion of tx
Perform TTE to establish new baseline
Refer drug users to rehab facility
Patient Education
Signs/symptoms of IBE relapse
Proper dental hygiene
Avoidance of IV drug use, body piercing, and tattoos
o Short-term/long-term follow-up
If relapse, get 3 sets of blood cultures before initiation of tx
Perform Echo to evaluate cardiac function
Evaluate for toxicity from abx therapy
Ototoxicity
Renotoxicity
Colitis due to C. difficile
Maintain oral hygiene and professional dental cleanings
10. 10
References
UpToDate website. Accessed March 16, 2015 at http://www.uptodate.com.proxy.pba.edu/contents/search.
Lexi-Comp website. Accessed March 16, 2015 at http://online.lexi.com.proxy.pba.edu/.
Cabell CH, Abrutyn E, Karchmer AW. Bacterial endocarditis: The disease, treatment, and prevention.
Circulation. 2003;107:e185-187.
Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis: diagnosis, antimicrobial therapy, and
management of complications: a statement for healthcare professionals from the Committee on Rheumatic
Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils
on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association.
Circulation. 2005;111:e394-433.