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A Change of Heart: A Case of Enterococcal Endocarditis

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Jeni Burckart

on 29 April 2013

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Transcript of A Change of Heart: A Case of Enterococcal Endocarditis

A Case of Enterococcal Endocarditis A Change of Heart The Literature AHA Scientific Statement IE 2005 Treatment Options
Ampicillin 2g IV Q4H
Penicillin G 18-30 million units IV per 24H
Gentamicin 3mg/kg/day Mechanism of Action Enterococcus Double B-lactam Therapy Ampicillin 2g IV Q4H
Ceftriaxone 2g IV Q12H Supporting Literature Gavalda et al. 1999 Pertinent Patient History Double B-lactam MOA 85 YO F admitted for complaints of fever, chills, and headache Vital Signs and Pertinent Labs Pertinent Patient History Diagnosis Common Microorganisms Duke Criteria Your Treatment Choice? Ampicillin 2g Q4H
Gentamicin 3mg/kg/day


Ampicillin 2g Q4H
Ceftriaxone 2g Q12H Infective Endocarditis Risk Factors Case Progression Clinical Pearls Image From: http://www.ganoksin.com/borisat/nenam/south-sea-pearls.htm References Major Criteria Minor Criteria 1 1. "AHA Scientific Statement on Infective Endocarditis" Circulation. 2005;111:e394–e434 2. "Contemporary clinical profile and outcome of prosthetic valve endocarditis" Wang et al. JAMA. 2007 Mar 28;297(12):1354-61. Past Medical History - Aortic valve replacement and CABG approx 45 days ago

- CKD Stage III Vital Signs BP 152/85
HR 78
Temp 36.8 Pertinent Labs WBC 10.7
SrCr 1.6
Blood cultures + for Enterococcus faecalis 3/3 bottles after 9, 13, 15 hours TEE shows 4mm mobile echodensity on prosthetic aortic valve http://drsvenkatesan.files.wordpress.com/2008/09/ie.png Heart Valve Endothelium Injury = Fibrin Clot = Enterococcus faecalis Circulating Enterococcus IE Pathophysiology 2 http://www.pbase.com/mediman30/image/84760204 http://www.elsevier.pt/en/revistas/revista-portuguesa-cardiologia-334/artigo/a-case-of-native-valve-infective-endocarditis-in-90091344 http://usmlemd.wordpress.com/2008/06/27/osler-nodes-vs-janeway-lesions-2/ -Predisposing heart condition/IVDA
-Fever >38C
-Intermittent bacteremia http://en.wikipedia.org/wiki/File:Osler_Nodules_Hand.jpg http://www.aao.org/theeyeshaveit/acquired/images/endocarditis.jpg 23% 17% 13% 12% 11% 24% - Structural defects
- Regurgitation or stenosis
- Previous IE Mortality 2 In-hospital mortality 23% in patients with prosthetic valve endocarditis
risk factors for mortality were:
older age
healthcare-associated infection (30.5%)
Staphylococcus aureus infection (34.4%)
heart failure (32.8%)
stroke (33.7%)
intracardiac abscess (32.6%)
persistent bacteremia (55.1%) 3. "Infective Endocarditis" Dynamed Accessed 4-18-13
http://web.ebscohost.com.proxy.lib.uiowa.edu/dynamed/detail?vid=3&sid=a49c3cd6-c78e-4242-a428-97f14610bd36%40sessionmgr110&hid=121&bdata=JkF1dGhUeXBlPWlwLGNvb2tpZSx1aWQsdXJsJnNpdGU9ZHluYW1lZC1saXZlJnNjb3BlPXNpdGU%3d#db=dme&AN=113919&anchor=top 4 Treat for 6 weeks for non-native valve 4. "AHA guideline on diagnosis and management of infective endocarditis" Circulation 2005 Jun 14;111 (23):e394 AMP Gent Duration of 6 weeks Enterococcus PBP 4 PBP 5 PBP 3 PBP 2 Amp Amp Ceftriaxone Ceftriaxone Nuria et al 2013 5. "Ampicillin Pluse Ceftriaxone Is as Effective as Ampicillin Plus Gentamicin for Treating Enterococcus faecalis Infective Endocarditis" Nuria et al. Clinical Infectious Diseases Feb 25 2013 Outcomes 22% 21% 8% 7% 1% 2% 3% 4% 1% 25% 23% 0 AC AG Tx Mortality 3 mo. Mortality Abx Failure Relapse Rate D/C dt ADE ^ SrCr >/= 25% 5 6, 7 6. "Brief Communication: Treatment of E faecalis Endocarditis with Ampicillin plus Ceftriaxone" Gavalda et al Annals of Internal Medicine 2007;146:574-579. 7. "Efficacy of Ampicillin plus Ceftriaxone in Treatment of Experimental Endocarditis Due to E. faecalis Strains Highly Resistant to Aminoglycosides" Gavalda et al. Antimicrobial Agents and Chemotherapy Mar 1999;43:639-646. Rabbits w/ catheter-induced HLAR E. faecalis endocarditis tx with 2g ampicillin Q4H alone or combined with 2g ceftriaxone Q12H After 24h ≥ 2 log10 decrease in CFU/ml between combo and amp alone found for all 10 strains
In 36% of strains produced a cidal effect (≥ 3 log10 killing with respect to initial inoculum) 7 Gavalda et al. 2007 6 Observational, multicenter, open-label clinical trial of 43 patients evaluated efficacy of tx with 2g ampicillin Q4H + ceftriaxone 2g Q12H in patients with E. faecalis IE Authors concluded AC may be treatment of choice for patients with HLAR E. faecalis and a good alternative to those with non HLAR and risk of nephrotoxicity Mortality rate of 28.6% similar to that found in other studies ID service recommendations: ampicillin 2g IV Q4H + ceftriaxone 2g IV Q12H X 6 weeks Blood cultures negative after 2 days of treatment Monitoring: weekly CBC, SrCr, LFT's F/U with ID in 2 weeks, blood cultures 2 weeks after treatment course finished AC is a reasonable alternative to AG for patients with E. faecalis endocarditis and a predisposition to aminoglycoside related toxicities Monitoring for AC therapy is weekly SrCr, LFT's, CBC Learning Objectives Explain the MOA of double B-lactam therapy in E. faecalis endocarditis

Explore the current literature regarding AC vs AG therapy of E. faecalis endocarditis

Apply the different side-effect profiles and bacterial activity of AC vs AG therapy to make patient-specific treatment recommendations AC therapy produces a synergistic bacteriostatic effect AG therapy produces a synergistic bacteriocidal effect Osler's Nodes Roth Spots Janeway Lesions Bacteriocidal Synergy Bacteriostatic Synergy Observational, retrospective, nonrandomized, comparative multicenter cohort conducted at 18 hospitals

246 adult patients diagnosed with E. faecalis IE

ampicillin 2g IV Q4H + ceftriaxone 2g IV Q12H (n=159)
ampicillin 2g IV Q4H + gentamicin 3mg/kg/day (n=87) Penicillin Allergic Patients IDSA recommends treatment with vancomycin 30mg/kg/day in 2 divided doses + gentamicin Penicillin, Aminoglycoside, and Vancomycin Resistant strains IDSA recommnedations imipenem/cilastatin 2g/24h (2 divided doses) + amp
ceftriaxone 4g/24h (2 divided doses) + amp Home Medications Noncontributory: all disease states managed appropriately 2 major or
1 major 3 minor Risk Factors 23% 17% 13% 12% 11% 24% Class IA recommendation Nuria et al. Strengths and Weaknesses Strengths:
large patient population (246)
generalizable population Weaknesses:
restrospective study design
gentamicin levels not always at goal Class IIb recommendation PBP 1 Amp P=0.81 P=0.72 P=0.54 P=0.67 P<0.001 P<0.001
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