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23 Cards in this Set

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What is endocarditis?
Endocarditis is infection of heart valves. Endocarditis usually begins with seeding of a pre-existing valve abnormality during a period of transient bacteremia.
Native valve disease is usually caused by what bug in IVDU?
Staphylococcus aureus
Native valve disease is usually caused by what bug in "other" patients?
Streptococcus species
Prosthetic valve disease within 2 months of valve replacement is likely due to what bugs?
Staphylococcus epidermis, S. aureus, or a gram-negative organism.
Prosthetic valve disease past 2 months of valve replacement is likely due to what bugs?
Streptococcal species or S. aureus.
Streptococcus bovis endocarditis is associated with what?
Colon cancer; you should order a colonoscopy.
How serious is endocarditis infection?
mortality from endocarditis ranges from 10%-50%. The highest mortality rates occur in patients infected in the 2 months after receiving their prosthetic valve.
How do I recognize the clinical presentation of endocarditis?
Presentation can be acute: high fever and systemic toxicity

Presentation can be subtle: cough, dyspnea, fatigue, arthralgias, abdominal or back pain.

Some patients present with complications such as CHF, stroke or arrhythmia and lung abscesses.
Do most patients with endocarditis have fever?
Yes, although older patients may have a normal temperature.
What are some risk factors for endocarditis?
1. injection drug use
2. prior valve abnormality
3. recent invasive procedures (dental, upper respiratory, lower GI, GU) likely to cause transient bacteremic episodes.
What do you look for in physical exam?
1. septic emboli in the fundi (Roth spots)
2. septic emboli in the palms and finger pads (tender Osler's nodes, red nontender Janeway lesions)
3. splinter hemorrhages in the nail beds (also septic emboli)
4. new murmur
5. abnormal lung sounds
How do I diagnose endocarditis?
1. Diagnose with at least 3 sets of blood cultures drawn at least one hour apart within the first 24 hours, BEFORE antibiotics.

*DO NOT withhold antibiotics in the acutely ill
What can a CXR show you in endocarditis?
It may show multiple patchy peripheral and lower lobe infiltrates with tricuspid valve endocarditis.
What can an echo show you in endocarditis?
Echo can confirm the diagnosis by showing a valvular vegetation, but can't rule out endocarditis as the sensitivity of TTE is only 55%-65%.
Is a TEE more sensitive than a TTE in diagnosing endocarditis?
Yes, transesophageal echo is more sensitive and is recommended for suspected prosthetic valve endocarditis, suspected myocardial abscess, or valve perforation. A TEE should be obtained despite a normal TTE if the suspicion of endocarditis remains high.
What antibiotics are appropriate for endocarditis?
Treat with empiric bactericidal antibiotics based on the presentation.
For IVDU, what antibiotics should you select for endocarditis?
Start gentamicin and nafcillin to cover presumptive S. aureus. Substitute vancomycin for nafcillin if the patient is penicillin allergic or if the patient resides in an area with a high rate of MRSA.

Uncomplicated tricuspid valve S. aureus endocarditis can be treated with 2 weeks of nafcillin and an aminoglycoside.
For patient with prosthetic valves, what antibiotics should you select?
Prosthetic valve infections should be covered empirically with vancomycin, gentamicin, and rifampin.
For patients with native valves, what antibiotics should you select?
Most native-valve streptococcal infections can be covered with penicillin or ceftriaxone.
What is the general strategy when the blood cultures come back?
Narrow therapy when culture results are available and treat 4-6 weeks with IV and oral antibiotics, depending on the clinical situation.
What are the 2 major criteria for diagnosing endocarditis according to the Duke Criteria?
(1) 2 separate positive blood cultures with a typical microorganism
(2) New regurgitant or characterisitic echo findings: vegetation, myocardial abscess, partial dehiscence of a prosthetic valve.
What are the 6 minor criteria for diagnosing endocarditis according to the Duke Criteria?
(1) Presence of a predisposing condition
(2) Fever greater than 38 degrees
(3) Embolic disease
(4) Immunologic phenomena: glomerulonephritis, Osler nodes, Roth spots, rheumatoid factor
(5) Positive blood cultures not meeting major criteria
(6) Positive echo not meeting major criteria
REVIEW:

Duke Criteria for the Diagnosis of Endocarditis

Major Criteria
Minor Criteria

Definite diagnosis with 80% accuracy when there are :
2 major criteria
OR
1 major criterion plus 3 minor criteria
OR
5 minor criteria

*** Endocarditis unlikely when there are: none of the criteria AND alternative explanation for illness found OR fever defervesces within 4 days.
Duke Criteria for the Diagnosis of Endocarditis

Major Criteria
(1) Two separate postive blood cultures with a typical microorganism.
(2) New regurgitant murmur or characteristic echo findings: vegetation, myocardial absess, partial dehiscence of a prosthetic valve

Minor Criteria
(1) Presence of a prediposing condition
(2) Fever greater than 38 degress.
(3) Embolic disease
(4) Immunologic phenomena: glomerulonephritis, Osler nodes, Roth spots, rheumatoid factor
(5) Positive blood cultures not meeting major criteria
(6) Positive echo not meeting major criteria

Definite diagnosis with 80% accuracy when there are :
2 major criteria
OR
1 major criterion plus 3 minor criteria
OR
5 minior criteria

*** Endocarditis unlikely when there are: none of the criteria AND alternative explanation for illness found OR fever defervesces within 4 days.