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167 Cards in this Set
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which valve has highest % of IE
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Mitral Valve + Aortic
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Mitral valve
which species seen |
usually strep viridans
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which IE valve has highest morb/mortality
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Aortic
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species seen in tricuspid
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staph
IVDU usually get this (cuz veins go to right side) |
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subacute classification of IE
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low-grade fever
mitral valve mainly usually viridans or enterococci |
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acute classifications of IE
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high fever
fulminating AORTIC valve virulent bugs-staph areus, pyogenes,strep pneumoniae |
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what are 2 highest risk factors for IE
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prosthetic valve
previous endocarditis others-IVDU(right sided) |
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clinical presentation of IE
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heart murmurs
low fever leukocytosis night sweats/chills |
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what are the peripheral manifestations of IE
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stigmata
-janeway lesions -splinter hemorrhages -oslers nodes -roth spots -clubbing of fingers |
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define janeway lesions
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painless lessions on palms of hands or soles of feet
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splinter hemorrhages
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under nail bed
-vertical lines |
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Osler's nodes
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PAINFUL
on pads of fingers and feet |
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roth spots
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retinal infarcts
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how to diagnosis IE
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cultures- get before abx tx
-don't delay abx in toxic pt's! echocardiography-within 12H of presentation, TTE, TEE |
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whats hallmark of endocarditis
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persistent/continuous bactermia
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TTE vs. TEE
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TTE- noninvasive, not good for small vegatations
do if IE suspicion is low TEE-invasive, detect small veg <3mm, assess prosthetic heart valves do when IE susp. is HIGH |
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what is modified duke criteria, major 1 in IE
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need 2 separate persistently positive blood cultures
usually-strep virdans, bovis, HACEK, staph areus, enterococci |
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what is modified duke criteria, major 2 in IE
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evidence of endocardial involvement
-TEE positive for IE -new murmur -myocardial abscess |
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what is modified duke criteria, minor in IE
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heart condition or IVDU
temp >38 C stigmata (janeway) oslers nodes positive blood culture not good for major criteria |
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define definite IE diagnosis (major + minor variations)
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2 major
1major/3minor 5 minor |
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possible IE diagnosis (major + minor variations)
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1major/1minor
3minor |
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most common pathogen in IE
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STREP (50%)
-viridans, bovis |
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what are gram neg pathogens in IE
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psudeomonas
HACEK- -H. flu -Actinbacillus, -Cardobacterium hominis, -Eikenella corrodens -Kingella kingae + dentrificans |
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organisms seen in NVE-native valve IE
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viridans step>staph aureus>enterocc
IV drug users-staph aureus |
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organisms of PVE
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<2months postop- CoNs**, enterobacteriace, fungi
late >2months-viridans**, CoNs, enterocc, staph areus **-most common |
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step bovis is associated with?
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IE or cancer
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strep IE usually presents as
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subacute
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strep in IE
cure rate? use what drug to tx |
98% curable
usually use Penicillin vanco if pen allergy |
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3 classifications of Strep tx
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pen susp <.12
relativ pen resistant >.12 <.5 Pen resistant >.5 |
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tx for strep or bovis NVE
MIC<.12 |
Aq penicillin 18 mill units continuous
or ceftriax -both for 4 wks pen or ceftriax + gentamycin (all for 2 weeks)-if crcl<20 don't use gentamycin if allergy-vanco for 4 wks |
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tx for strep or bovis NVE
>.12 <.5 |
aq pen 24mill units (4wks)
or ceftriax (4wks) + gentamycin (2wks) vanco for 4 wks in allergy |
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tx for strep or bovis NVE
>.12 |
use enterococcie IE tx
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tx for strep or bovis PVE
pen susp strain MIC<.12 |
Pen G 24 mil units x 6wks
or ceftriax x 6wks +/- gentamycin (crcl<30 don't use)x2wks -------------------------------------- allergy-vanco x 6 wks |
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tx for strep or bovis PVE
MIC>.12 |
penG 24mil units
or ceftriax +gentamycin ALL for 6 wks -like NVE >.12 to <.5 tx, but for 6 wks |
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whats most common cause of PVE
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coag neg staph
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Staph in NVE
MSSA tx |
naf /oxacil- 6wks
or cefazolin (if pen allergy)-6wks + gentamicin 3-5 days |
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Staph in NVE
MRSA tx |
vanco 15mg/kg or
dapto 6 wks vanco goal is 15-20 |
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Staph in PVE
MSSA tx |
naf/oxacill >6WKS**
+rifampin >6wks +gentamcin 2 wks |
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Staph in PVE
MRSA tx |
vanco >6wks
+rifampin >6wks +genamicin 2 wks |
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if txing IE and vanco allergy use what
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dapotmycin
FDA approved for IE |
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enterococci
reistant to what? think which drugs to tx |
relative resistant to PCN, vanco, ampicillin
think-ampicillin, vanco, linezo, dapto but usually these are static |
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enterococci NVE or PVE
PCN susp. tx if allergy use |
ampicillin or pen g
+gentamicin 4-6 wks (6wks if sx>3months of PVE) allergy-use vanco + gentamcin 6 wks |
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Enterococi NVE or PVE
PCN resistant tx if allergy use? |
amp/sulbactam
+gentamicin (6wks) allergy or amp resist- vanco + gentamicin (6wks) |
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Enterococci NVE or PVE
vanco resistant tx |
E. Faecium- linezo or quinu/dalfopristin >8wks
E. Faecalis- imipenem/cilastatin or ceftriax +ampcillin >8wks |
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linezo
static against? cidal against? causes |
static-staph
cidal-strep cause periph neuropathy>6wks** and optic neuritis |
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synercid
(quin/dalfo) active against |
MRSA +VRE(not faecalis)
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HACEK organisms
what kind of culture require what |
associated with subacute NVE + usually **culture negative** IE
slow growing-hold for 1 month |
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HACEK organisms tx
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ceftriax
or amp/sulbactam or ciproflox (can be PO) ALL 4wks 6wks of cipro if PVE |
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Oral FQ good for
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bactermia, IE
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oral azoles good for
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fungemia
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oral linezolid good for
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VRE in blood
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culture neg IE -NVE
tx |
amp/sulbactam(4-6 wks)
+gentamicin (4-6wks) ____________________________ vanco +gentamicin +ciproflox (4-6wks) |
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culture neg IE -PVE >1yr
tx |
vanco
+gent +cipro +rifampin ALL 4-6WKS |
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culture neg IE PVE <1yr
tx |
vanco 6wks
+gent 2 wks +cefepime 6wks +rifampin 6wks |
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fungal IE tx
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ampho + flucytosine -6wks + valve replacement
alt-fluconazole need long term azole to tx relapse |
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indications for surgery in IE
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fungal/abx resistance
left sided gram neg IE INCR. in veg even though on abx infxn after 1 wk of abx tx |
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IE prophylaxis used when
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when pt undergoes procedure that may cause TRANSIENT BACTERMIA
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IE prophylaxis
dental,oral,respiratory tract procedures prior to procedure give- |
amoxicillin 2g 1H before
allergy-clindamycin cephalexin, cephadroxil cefazolin azithro or clarithro |
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IE prophylaxis
High risk GU + GI procedure if allergy? |
amp + gentamicin before
amp or amox 6H after if allergy -vanco + gentamicin before |
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IE prophylaxis
moderate risk GU allergy? |
amox or ampicillin 30 mins before
allergy-vanco 30 mins before |
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moderate risk category
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acquired valvular dysfxn
hypertrophic cardiomyopathy mitral valve prolaps w/ regurgitation |
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4 classes of antifungals
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polyene-ampho (cidal)
azole-fluconazole (s) flucytosine (s) echino-candins (c) |
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ampho B
spectrum MOA |
broad spectrum
binds ergosterol |
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Ampho S.E
WHAT TO MONITOR? |
hypoK, hypoMG (monitor**)
nephro tox infsuion rxns-riggers(tx with demerol) premedicate with benadryl+tylenol lipid vs-dec tox + infsn rxns |
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azole
MOA mech of resistance |
moa-inhibit ergosterol synthesis
reist-efflux pumps |
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candins
MOA mech of resist |
moa-inhbit synthesis of B(1.3) glucan synthesis
resist-binding site |
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flucytostine
MOA resist. |
inhibits nucleic acid synthesis
resist-binding site |
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AmphoB deoxy dose
Abelcet dose ambisome dose |
amphoB conventional-1mg/kg ONCE DAY
abelcet 5-10mg/kg ONCE DAY ambisome 5-10mg/kg ONCE DAY |
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Fluconazole
take with food? levels needed? |
no difference w/ or w/o food
no levels needed IV->PO dose same |
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Itraconazole
food? levels? |
needs acidic environment
need through .5-1.5 |
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posaconazole
food levels |
fatty meals
need random .5-1.5 level |
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voriconazole
food? level? |
empty stomach
trough 1-6 (highlevels=visual problems) IV->PO same dose |
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S.E. in all azoles?
BBW in itraconazole vorinconaozle S.E |
all-hepatotx watch LFTs
itracon-BBW in CHF vorincon-visual probls, mental -non linear kinetics |
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which candin doesn't need loading dose?
which don't need adjust in mod liver failure |
NO LOAD-micafungin
no adjustment-anidulafungin + micafungin |
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easiest candin to dose
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micafungin
no loading dose no hepatic adjustment |
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candins cidal against?
static against |
cidal against all candida species
static-aspergillis |
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fungi consists of which 2 groups
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yeasts and moulds
yeast= candida + cryptococcus moulds-everything else (zygomycetes, aspergillus, endemic fungi) |
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3 endemic fungi
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histo, blasto, coccidiodes
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histo
where found? begins to infect |
in ohio/miss river valley
aerolized in disturbed soil infects 10-15 days after inhal |
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histo acute vs chronic
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acute-pulmonary, flu like symptoms
chronic-pulmonary, calcified granulomas, fibrosis can resolve w/o tx |
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how to diagnosis Histo
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urinary antigen (most common)
biopsy PCR |
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histo tx
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if mild:itraconazole
severe-amphoB then itracon usually need lifelong suppression |
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blasto
affects what found where |
pulmonary- disseminates to skin + bone
in ohio/miss valley, canada |
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blasto presentation
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like TB-night sweats, weight loss, productive cough
goes to skin, prostate, CNS |
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blasto diagnosis
tx? |
biopsy-need tissue
tx- life threatening: amphoB mild/mod-itraconazole suppression w/ itraconazole |
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coccidio
wheres found who gets it most |
dry, hot, sandy areas
get from soil, construction** fillipinos have it most type A or AB, immunocomped |
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coccidio presentation
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pulmonary
diffuse rash looks like flu, fever, cough |
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diagnosis of coccidio
who to tx |
bioopsy CSF-cultures
tx-large inoculum, HIV, transpl, steroid, preg pts |
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coccidio tx
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sever dx or preg-amphoB
mod/chronic:traconazole/fluconazole supp continuted for LIFE |
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step down tx in histo + blasto is?
in coccidio is? |
histo + blasto - itraconazole
coccidio-fluconazole |
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most common pathogens in zygomycetes
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mucor, rhizopus, rhizomucor
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zygomycetes
found where? biggest RF? |
found in mouldy bread, tongue depressors
rf- diabetes |
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zyogmycetes
pathogenesis |
respiratory tract-very severe-necrosis
cutaneous |
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zygomycetes
occasional cases related to RF |
innoculation (immunocompentent)
RF-uncontrolled diabetes, stem cell, long term steroids |
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when you hear sinusistis bony erosion, think?
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fungal sinusitis
tx with amphoB |
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zygomycetes tx
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amphoB DOC
posaconazole-not against rhizopus |
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how long does posaconazole tk to work
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takes 1 wk-too long to wait usually
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whos at risk for yeasts (candida)
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hematopoietic stem cell transplant
HIV, surgery |
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candida diagnosis
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cultures-take while
beta-glucan test- good but not specific (can be false + cuz albumin) PNA FISH-determins species |
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which candida species are resistant to fluconazole
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glabrata + krusei
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candida albicans + trpicalis suscept to
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ALL
flu, itra, posa vori, ampB, candins |
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candida Parapsilosis
suspectible to resistance to |
susp to everything except candinds
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candida glabrate susp to ?
|
candins
S-dose dep to Resist to everything else |
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candida krusei
susp to? |
posacon, voriconazole, candins
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empirical antifungal tx algorithm
|
hemodyn instab or neutropenia or azole exposure
Yes- Voricon, AmphoB, candin NO- do you suspect glab or kreuesi if yes use above, if NO use fluconazole |
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once cultures come back:
albacans/tropicl give glabrata give krusei |
alb/trop-fluconazole
glab-candins preferred parapisollis-fluconazole krusei-candin/ampho/voricon |
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candidemia
1st line tx when to tx |
flucon or candins
TX 14 DAYS AFTER*** last NEGATIVE blood culture |
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candidemia(neutropenia) 1st line tx
|
amphoB
or candins alt-vori or flucon |
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UTI Symptomatic
1st line tx |
use fluconazole
ONLY IF SYMPTOMATIC!! ALT-ampho or flucytosine TX for 14 days |
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esophageal candida tx
|
1st line fluconazole, ampho, candins 14-21 days
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principles of antifungal tx
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REMOVE CATHETER
tx for 2 weeks AFTER documented clearence if Candida in resp secretions-DO NOT TX!!!! |
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what exam is recommended to all Candida pt's
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a dilated retinal exam
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who gets aspergillus
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hematological diseases
BMT allogenic (other source) |
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which aspergillus is most pathogenic
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of course its the NIGER
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aspergillus terreus is resistant to
|
amphoB
use triazole |
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Diagnosis tools for aspergillus
|
BAL-invasive
CT scan- halo(early) and crescent sign*** Beta glucan-not specific galactomannan- false + from zosyn, augmentin |
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whos at risk for invasive aspergillis
high intermed. low |
high-allogenic BMT, neutropenia,
intermed-autologous BMT, transplant, HIV, cancer, steroids low-HIV?, cystic fibrosis |
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Invasive aspergillus fungal ball tx?
|
aspergilloma-amphoB+surgery
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ABPA- allergic broncho aspergillus
tx? |
corticosteroids
itra+steroids |
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prevent(prophylaxis) IA in pts @ high risk (skin grafts, AML)
use what |
posaconazole
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1st line tx for IA
|
voriconazole (superior)
alt-amphoB or L-ampho |
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salvage tx for IA
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Candins (micafungin, )
itraconazole |
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IA treatment principles
|
decrease steroids
emphric tx should be diff class if pt on antifungal prophylaxis tx for minimum of 6-12 WKs |
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cryptococcus
diagnosis |
CSF, sputum, skin lesion
direct exam: india ink |
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cryptococcus three phases or tx
|
initial tx
consolidation mt tx |
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induction tx of crypto
|
ampho only use 4-6wks
ampho + flucystosine x2wks |
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consolidation tx for crypto
|
fluconazole x 8 wks
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mt tx for crypto
|
fluconazole > or = 1 yr
alt-itracon or ampho >1yr |
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every pt with febrile neutropenia should get abx within
|
<2H!!
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risk factors for infexn in chemotherapy
|
chemo induced mucositits-candida enters bloodstream
Central venous cathers=infxn leukemia +HSCT pts have porlonged neutropenia cuz intense chemo |
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chemo induced mucositis
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painful, Gi damage from mouth to anus
manifest: erythema, ulcers |
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oral Tox scale
Grade 1 |
soreness +/- erythema
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oral Tox scale
Grade 2 |
erythema;ulcer
pt can swallow food |
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oral Tox scale
Grade 3 |
ulcer with extensive erythema
CAN NOT SWALLOW FOOD |
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oral Tox scale
Grade 4 |
pt needs TPN for nutrition
alimentation is not possible |
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which grades are considered severe mucositis
|
grade 3 + 4
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define fever in Febrile Neutropenia
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single temp >38.3 (101)
temp >38 (100.4) >1H |
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define neutropenia in FN
|
low neutrophils
ANC=(WBCX1000) + (%Bands + %Segs) <500=breakpoint for tx <100 profound neutropenia |
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factors in chemo induced neutropenia
|
severity/nadir- how low
rate of decline- how fast duration-how long |
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low risk for FN
|
BRIEF <7days neutropenic period + no/few comorbidities
MASCC score >21 |
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high risk for FN
|
prolonged >7days + profound neutropenia <100
and/ or co-morbidites and/or hepatic 5x normal /renal insuff (<30ml) and/or MASCC<21 and/or AML, HSCT induced neutropenia |
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monitor what in FN
cultures |
SCr, BUN, elctrolytes,
2 sets bllod cultures from diff catheters(central + peripheral) |
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GDH testing
what are steps? |
1) immunoassay GDH + toxin-
if both positive-rport positive if both neg-its neg if GDH (+), Tox (-) do step 2 step2-PCR- if neg-report neg(don't tx) if posit-its positive tx |
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GDH tests?
Toxin tests? PCR tests? |
GDH-detects C. diffe
Toxin + PCR- test for infection |
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when should we give prophylaxis tx in FN
give what drug? |
high risk pt + expected <100 ANC for >7 days
consider Resp FQ-levoflox adding gram + NOT recc. |
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what drug do we use to prophylaxis low risk pt in FN
|
NOT reccommended
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what abx would you use in high risk FN tx
-monotheraphy |
psuedomonas coverage
***cefepime,piper/tazo*** impenem/cilsatin or mero if resistance add FQ,amino and/or vanco |
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consider adding drugs to empiric tx
MRSA- VRE- ESBL KPC |
MRSA-Vanco, linezo, dapto
VRE-linezo or dapto ESBL-carbapenem KPC-colistic or tigecyclin |
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if allergy use what tx
|
cipro + clindamycin(use less cuz C.diff)
or AZTREONAM+vanco |
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which drugs would you chose for oral abx +readmission
|
cipro + augmentin
cipro/levo mono used also cipro + clinda also used |
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T or F
FQ prophylaxis = oral empiric FQ |
False not equal
use a b-lactam |
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modifying tx
D/C what after 48hours |
after 48hours and not evidence of gram (+) D/C vanco
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when do you switch from IV to PO tx
|
when clinically stable + good GI absorption
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when transitioning low rsk pt to outpt...when would you readmit and manage as high risk
|
when fever persists or reoccurs in 48H
|
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when to start empiric Antifungal tx
|
after 4-7days of broad spectrum abx and no soure IDed
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when to end empircal tx
in neutropenia in unexplained fever |
for duration of neutropenia or >500ANC
unexplained fever-continute till signs of marrow recovery or ANC >500 is sx resolved-resume po FQ prophylaxis till marrow recovery |
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what drugs to consider in prophylaxis in high risk pts for antifungals(candida)
|
fluconazole, itraconazole, voricon,
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when to consider empiric tx in high risk pts (antifungals)
|
recurrent fever for 4-7days of abx + overall neutropenia >7days
use a conazole |
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antifungals in low risk patient for neutropenia
|
antifungals NOT indicated
|
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prophylaxis influenza virus with what?
|
ostelamvir
zanamivir peramivir |
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tx HSV pt undergoing HSCT or leukemia with what
|
acyclovir
|
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consider prophylatic myleoid colony stimulating factor for..
prophylaxis who |
ANTICIPATED FEVER + NEUTROPENIA >20%
prophylaxis ALL pts, HSCT, lymphoma pts with HIV |
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T or F
CSFs (colony stim factors) are NOT recommended for established fever + neutropenia |
T its recommended for anticipated
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CLABSI tx for how long
|
14 days
remove catheter |
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tx how long for complicated CLABSI
|
4-6 wks
|
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how to prevent catheter infxn
|
hand hygiene
chlorhexadine |
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environmental precaustions in HSCT receipients
|
private rooms with hepa filter
|
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