Download file (Treatment of Infective Endocarditis)

Treatment of Infective Endocarditis
Samantha Allen
PharmD Candidate 2012
March 14, 2012
Objectives:
 Identify risk factors for acquiring infective endocarditis (IE)
 Define characteristics of endocarditis infections
 Identify common microbiology of intravenous drug use (IVDU) associated IE
 Determine appropriate pharmacological interventions to treat IVDU associated IE
 Define follow-up monitoring parameters and patient education for IE
 Apply evidence to a patient case for the treatment of IVDU associated IE
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Risk Factors for Infective Endocarditis:
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Injection Drug Use
Prosthetic Heart Valve
Structural Cardiac Abnormality
History of Infective Endocarditis
Hemodialysis
Characteristics of Infective Endocarditis:
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Initial Symptoms: Fever, loss of appetite, unexplained weight loss, new rashes, headache,
backache, joint pain, confusion, SOB, sudden weakness face/limbs
Diagnostic Criteria:
o Pathological-Microorganism identified, embolization of vegetation, intracardiac abscess
o Clinical-2 major criteria OR 1 major & 3 minor criteria OR 5 minor criteria
o Possible- 1 major and 1 minor criteria OR 3 minor criteria
o Rejected-Alternative diagnosis, resolution with antibiotics ≤4 days, no pathologic
evidence, does not meet criteria
Echocardiographic Features Suggest Potential for Surgical Intervention:
o Vegetation
o Valvular dysfunction
o Perivalvular extension
Common Microorganisms IVDU Associated IE:
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S. aureus (OSSA & ORSA)
Coagulase-negative staphylococci
β-hemolytic streptococci
Fungi
Aerobic Gram-negative bacilli (including Pseudomonas aeruginosa)
Polymicrobial
Antimicrobial Therapy for IVDU Associate IE:
Organism
AHA Treatment Recommendations for Adults
Medication
Dosage
Treatment
Duration
Comments
Absence Prosthetic Material
Nafcillin or oxacillin
OSSA
(oxacillin-sensitive
S. aureus)
With optional
gentamicin
PCN allergy (nonanaphylactoid):
Cefazolin
(with optional
gentamicin)
ORSA
(oxacillin-resistant
S. aureus)
Vancomycin
CoagulaseNegative
Staphylococci
β-hemolytic
streptococci
Highly PCN
sensitive
12 g/24 hr IV in 4-6
equally divided doses or
continuous infusion
3 mg/kg per 24 h in 2 or 3
equally divided doses
6 weeks
For complicated right-sided
IE and for left-sided IE
3-5 days
Clinical benefit of
aminoglycosides has not
been established
6 g/24 hr is 3 equally
divided doses
6 weeks
30 mg/kg per 24 hours in
2 equally divided doses
6 weeks
Trough concentration 1015 µg/mL
Treat based on susceptibility to oxacillin
Aqueous PCN G
Sodium
OR
Ceftriaxone
____________
12-18 million U/24hr IV
continuously or in 4-6
equally divided doses
2 gm IV daily
Aqueous PCN G
Sodium
OR
Ceftriaxone
PLUS
Gentamicin
___________
12-18 million U/24hr IV
continuously or in 6
equally divided doses
2 gm IV daily
Vancomycin
30 mg/kg/24 hr IV in 2
equally divided doses
4 weeks
PCN Preferred in patients > 65
y/o or if impairment of 8th
cranial nerve or renal function
Highly sensitive=
MIC ≤0.12 µg/mL
2 weeks
2 week regimen not indicated
if cardiac or extracardiac
abscess or Clcr< 20 mL/min or
impaired 8th cranial nerve
function
3 mg/kg IV daily
4 weeks
Vancomycin only for patients
unable to tolerate PCN or
ceftriaxone
Trough concentration 10-15
µg/mL
β-hemolytic
streptococci
Relatively PCN
resistant
Aqueous PCN G
Sodium
OR
Ceftriaxone
PLUS
Gentamicin
___________
24 million U/24hr IV
continuously or in 4- 6
equally divided doses
2 gm IV daily
3 mg/kg IV daily
2 weeks
Vancomycin
30 mg/kg/24 hr IV in 2
equally divided doses
4 weeks
β-hemolytic
streptococci
Highly PCN
resistant
Vancomycin
Pseudomonas
Gentamicin
PLUS
Extended spectrum
PCN
OR
Ceftazadime
OR
Cefepime
Fungi
(Candida &
Aspergillus)
Amphotericin B
30 mg/kg/24 hr IV in 2
equally divided doses
4 weeks
4 weeks
6 weeks
Vancomycin only for
patients unable to tolerate
PCN or ceftriaxone
Trough concentration
10-15 µg/mL
Highly resistsant=
MIC >0.5 µg/mL
Peak 15-20 µg/mL
Trough ≤ 2 µg/mL
8mg/kg/day IV once daily
See specific medication
dosing
Relatively resistant=
MIC > 0.12 to ≤0.5 µg/mL
≥6 weeks
Extended spectrum =
piperacillin or ticarcillin
Guidelines recommend
“full doses” of medication
chosen in combination with
gentamicin
2 gm IV every 8 hours
2 gm IV every 8 hours
Dose based on
formulation available
≥6 weeks
May consider lifelong oral
azole therapy due to high
rate of relapse
12 g/24 hr IV in 4-6
equally divided doses or
continuous infusion
≥6 weeks
PCN G 24 million U/24 hr IV in 4-6
equally divided doses instead of
nafcillin or oxacillin if susceptible
Prosthetic Valve
Nafcillin or oxacillin
OSSA
(oxacillin-sensitive
S. aureus)
PLUS
Rifampin
PLUS
Gentamicin
Vancomycin
ORSA
(oxacillin-resistant
S. aureus)
PLUS
Rifampin
PLUS
Gentamicin
May substitute cefazolin if PCN
allergy (non-immediate type
hypersensitivity)
900 mg per 24 hr IV/PO in
3 equally divided doses
≥ 6 weeks
3 mg/kg per 24 h in 2 or 3
equally divided doses
30 mg/kg per 24 hours in
2 equally divided doses
2 weeks
Use vancomycin if immeditatetype hypersensitivity to PCN
≥6 weeks
Vancomycin trough
concentration 10-15 µg/mL
900 mg per 24 hr IV/PO in
3 equally divided doses
≥ 6 weeks
3 mg/kg per 24 h in 2 or 3
equally divided doses
2 weeks
CoagulaseNegative
Staphylococci
β-hemolytic
streptococci
Highly PCN
sensitive
Assume oxacillin-resistance and treat same as ORSA
Aqueous PCN G
Sodium
OR
Ceftriaxone
WITH OR WITHOUT
Gentamicin
___________
Vancomycin
β-hemolytic
streptococci
Relatively PCN
resistant
β-hemolytic
streptococci
Highly PCN
resistant
Pseudomonas
Fungi
24 million U/24hr IV
continuously or in 4- 6
equally divided doses
2 gm IV daily
6 weeks
3 mg/kg IV daily
2 weeks
30 mg/kg/24 hr IV in 2
equally divided doses
6 weeks
6 weeks
Highly sensitive=
MIC ≤0.12 µg/mL
Gentamicin has not
demonstrated superior cure
rates. Avoid if Clcr<30mL/min
Vancomycin only for patients
unable to tolerate PCN or
ceftriaxone
Same as in absence of prosthetic valve
Follow-up Monitoring and Patient Education:
 At Completion of Therapy
o Obtain TTE to establish new baseline
o Drug rehabilitation referral for IVDU
o Educate regarding signs of endocarditis
o Discuss need for antibiotic prophylaxis for certain dental/surgical/invasive procedures
o Thorough dental evaluation
o Removal IV catheter at completion of antimicrobial therapy
 Short-Term Follow-Up
o Obtain 3 sets of blood cultures from separate sites for any febrile illness or before
starting any antimicrobial therapy
o Physical exam for evidence of CHF
o Evaluate for signs toxicity from long-term antimicrobial use
 Long-Term Follow-Up
o Obtain 3 sets of blood cultures from separate sites for any febrile illness or before
starting any antimicrobial therapy
o Evaluation of valvular and ventricular function via echocardiography
o Scrupulous oral hygiene and frequent dental office visits
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References:
1. Baddour LM, Wilson WR, Bayer AS et al. Infective endocarditis: diagnosis,
antimicrobial therapy, and management of complications. Circulation.
2005;111:e394-e434.
2. Cabell CH, Abrutyn E, Karchmer AW. Bacterial endocarditis: the disease, treatment,
and prevention. Circulation. 2003;107:e185-e187.
3. Wilson W, Taubert KA, Gewitz M et al. Prevention of infective endocarditis.
Circulation. 2007;115:1736-54.
4. Micromedex. Ceftazadime. (accessed 2012 March 9).
5. Micromedex. Cefepime. (accessed 2012 March 9).