AM report PEARLS 2/8: approach to prosthetic valve endocarditis and fungemia! (many thanks to HH!)

Approach to prosthetic valve endocarditis:

  • Early (<30d): often are virulent organisms including S aureus, GNR. Fungemia is BAD!
  • Late: similar organisms to native valve endocarditis, plus Staph epi and fungal organisms.
    1. A few pearls on fungal infections:
      1. most commonly Candida and Aspergillus!
      2. Often are large and friable
  • May present with large vessel occlusion!

 

Approach to fungemia!

  • Think about source! (eg classic association with IVDU and needle licking)
  • Think about susceptibility!
    1. Candida parapsilosus may be azole resistant, so may want to start with an echinocandin from the get-go
  • If you have fungal endocarditis, need surgical management! Can’t be cured with antifungals alone.

 

Other misc pearls from the case!

  • For all prosthetic valve endocarditis: generally speaking, need a TEE (not TTE)!
  • In general, bacterial endocarditis causes regurgitant valvular dysfunction!
  • New anemia in a patient with a prosthetic valve: think about a MAHA (from perivalvular leak; shear stress causing hemolysis! This is the one MAHA that is not DIC/TTP/HUS)
  • A few words on ambisome + flucytosine (5-FC):
    • Remember that ambisome can cause renal failure! As such, often given with IVF. This can be challenging for patients with heart failure!
    • Ambisome + flucytosine = synergy!
      • We often see this used in cryptococcal meningitis induction treatment but in general can be considered in any severe fungal infection
      • Flucytosine is the prodrug to 5-FU. Clearance is decreased in the setting of impaired GFR (renal failure). Thus, using it with ambisome (which can cause renal failure) must be done with great caution!

 

Evernote link: https://www.evernote.com/shard/s34/sh/d4e3e0c4-dcdb-4599-8423-aa4d1a24f760/f65c8b4e9fe1e88d14d48cfa543422e8

 

ADDENDUM: one more pearl! On anticoagulation:

  • for native valve endocarditis: generally, anticoag is contraindicated (c/f hemorrhagic conversion of septic emboli)
  • for prosthetic valve: generally, benefits>risks for anticoag
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