Consultant MicrobiologistLeeds Teaching Hospitals NHS Trust - PDF document

Consultant MicrobiologistLeeds Teaching Hospitals NHS Trust BSAC Endocarditis workshopBSAC endocarditis working party has revised the 2004 guidelines in light of new evidence, particularly in relation to diagnosis and new treatment options.This lecture highlights some changes and explains some more controversial (Thornhill, 2011)©2011 by British Medical Journal Publishing GroupBSACEndocarditisworkshopIntroductionincreasingMonthlycasesSeparatefortrendstandarddeviations(brokenRedrepresentmovingaveragefigureforcaseseverythreemonths BSAC Endocarditis workshopType of IE (%) Type of IEN AmericaEuropeNative valve7274Prosthetic valve2020Pacemaker, ICD87(Murdoch, 2009)Implantableelectroniccardiac(pacemaker,infectionshavecomplexitiesareseparateproject. BSAC Endocarditis workshopClinical Assessment and diagnosisRecommendation2.1containsanumberofcommonscenariosinwhichIEshouldbeconsideredandactivelyinvestigated.•DiagnosingIEremainsdifficult•Diagnosesoftendelayed•SpeedingupdiagnosismayimproveoutcomesNotes:“activelyinvestigated”maymeaninitialbloodculturesorechocardiographyorboth Sign%C96%Splinter haemorrhages8%Oslers nodes3%Janeway lesions5%Roth spots2%Conjunctival haemorrhages5%Splenomegaly11%New murmur48%(Murdoch, 2009) BSACEndocarditisworkshopClinicalAssessment”classic”areuncommon BSAC Endocarditis workshopClinical Assessment and diagnosis•Echocardiography is a cornerstone of IE •TTE (70-80%) is less sensitive than TOE (90-•Multiple scans may be needed to identify BSAC Endocarditis workshopClinical Assessment and diagnosis *TOEmandatoryisolatedrightnativevalvegoodTTEunequivocalechocardiographic Recommendation2.1:DukecriteriacanbeusedtoassistinthediagnosisofIEbutarenotasubstituteforclinicaljudgment.[C]•Dukecriteriaweredevelopedasaresearchtool•TheyhavehighspecificitybutlowersensitivityBSAC Endocarditis workshopClinical Assessment and diagnosis2.3 Diagnostic criteria and their limitations BSAC Endocarditis workshop•In patients with suspected IE and severe sepsis or septic shock…two sets of optimally filled •If a stable patient has suspected IE but is already on antibiotic treatment, consideration performing three sets of blood cultures off •Antibiotic therapy may need to be stopped for 7-ntibiotic therapy may need to be stopped for 7-BSAC Endocarditis workshop VegetationsBSACEndocarditisworkshopMicrobiologicalInvestigationexcisedvalvesRecommendation3.21excisedvalvefromembolectomy)fromcasesculturenegativereferredforbroadrange BSACEndocarditisworkshopMicrobiologicalInvestigationexcisedvalvesRecommendation3.22ApositivebroadrangePCRresultcanbereliablyusedtoidentifythecauseofendocarditisbutcannotbeusedtoinferongoingpresenceofinfectionandshouldnotthereforebeusedalonetojudgethedurationofpostoperativeantimicrobialtherapy.[B] Recommendation5.11•IEpatientsneedtobegenerallysuitable…Recommendation5.12•IEpatientswhomightbeconsideredforOPATwouldincludethose:whoarestableandrespondingwelltotherapy;withoutsignsofheartfailure;withoutanyoftheindicationsforsurgerylistedinTable4;or,uncontrolledextra-cardiacfociofinfection.[C]BSAC Endocarditis workshop5. ANTIBIOTIC DOSING, DELIVERY AND MONITORING5.6 Home/community/outpatient therapy (OPAT) Recommendation5.13•IEcausedbyanyorganismmaybeappropriateforOPATprovidedtheconditionsinrecommendation5.12aresatisfied,however,Staphylococcusaureusisthemicroorganismassociatedwithhighestmortalityandcomplicationsandcautionisthereforeadvisedwherethisisthecause.[C]Recommendation5.15•WhenpatientsaremanagedusingOPAT,systemsshouldbeinplacetomonitorthepatient’sclinicalconditiononadailybasis.[C]BSAC Endocarditis workshop5. ANTIBIOTIC DOSING, DELIVERY AND MONITORING5.6 Home/community/outpatient therapy (OPAT) Antimicrobial Dose/route 1. NVE – indolent presentation Amoxicillin* (optional) gentamicin* 2g 4-hourly IV 1 mg/kg 12 hourly IV If patient is stable, ideally await blood cultures. Better activity against enterococci and many HACEK microorganisms compared with benzyl penicillin. Use regimen 2. If genuine penicillin allergy. BSAC Endocarditis workshop6. Empirical Therapy -NVEMostcommoncausesarecurrently:Staphylococcuscoagulasenegativestaphylococcistreptococcienterococciareculturenegative(Murdoch, Antimicrobial Dose/route Comment 2. NVE, severe sepsis (no risk factors for EnterobacteriaceaePseudomonas Vancomycin* gentamicin* dosed according to local guidelines, IV 1 mg/kg 12 hourly IV In severe sepsis, staphylococci (including meticillin resistant staphylococci) need to be covered. If allergic/intolerant to vancomycin replace with daptomycin 6mg/kg 24 hourly IV If acute kidney injury present, use ciprofloxacin in place of gentamicin 3. NVE, severe sepsis AND risk factors for muti-resistant Enterobacteriaceae Vancomycin* Meropenem* dosed according to local guidelines, IV 2g 8 hourly, IV Will provide cover against staphylococci (including meticillin resistant staphylococci), streptococci, enterococci, HACEK and Enterobacteriaceae and Pseudomonas aeruginosa. BSAC Endocarditis workshop6. Empirical Therapy -NVE 4. Prosthetic valve endocarditis pending blood cultures, or with negative blood cultures. Vancomycin* AND gentamicin* AND rifampicin* 1g 12 hourly IV 1mg/kg 12 hourly 300-600mg 12-hourly po/iv Use lower dose of rifampicin in severe renal impairment. BSACEndocarditisworkshopEmpiricalTherapyRecommendationunchangedfromprevious. Recommendation7.2•GentamicinshouldnotbeaddedtoflucloxacillinfortheinitialtreatmentofnativevalvestaphylococcalIE.[A]•Unchanged from previous guidelines•Nephrotoxicity data analysed from daptomycin vs comparator RCT(Cosgrove, 2009; Fowler,2006)BSAC Endocarditis workshop Figure 2. Time to a clinically significant decrease in (ASP, antistaphylococcal penicillin) fallreduction •RCT of daptomycin vs flucloxacillin or vancomycin plus low-dose gentamicin for BSACEndocarditisworkshopStaphylococcalendocarditis(Fowler,2006) BSAC Endocarditis workshopOutcomes (success at 42 days) of RCT Type of IEDaptomycinStandard therapy㻟/㻢㻝/ã»  㻡/㻝㻟㻢/㻝㻞㻝/9㻞/9(Fowler, 2006) BSAC Endocarditis workshop Treatment of streptococci (penicillin MIC �0.125 - 0.5) Benzyl Penicillin AND Gentamicin2.4g 4-hourly IV 1mg/kg 12 hourly IV 4-6 Preferred regimen, particularly for patients at risk of C. difficile BSAC Endocarditis workshopTreatment -enterococci•Thereshouldbealowthresholdforstoppinggentamicininpatientswithdeterioratingrenalfunctionorothersignsoftoxicity.[B] BSAC Endocarditis workshopNew evidence justifies new approaches to Changing resistance patterns and microbial