1. Diagnosing
1.1. DUKE Criteria
1.1.1. Looks for definite IE based on "major" and "minor" critera as defined.
1.1.2. Criteria serve to diagnose based on the microbiologic evidence (hematologic or histologic) with concurrent cardiac abnormalities (cardiac radiology)
1.2. Definite
1.2.1. 2 Major Criteria or 1 Major and 3 Minor or 5 Minor criteria
1.3. Possible
1.3.1. 1 Major and 1 Minor or 3 Minor
1.4. Ruled out
1.4.1. -Does not meet definite/possible criteria. -Resolution of SxSx with <4days ABTx -R/O with other diagnosis
2. Treatment
2.1. Strep
2.1.1. Native Valve
2.1.1.1. Low MIC(<0.12mcg/mL)
2.1.1.1.1. PenG 4wks or Ceftriaxone 4wks
2.1.1.1.2. Add Gentamicin to either to reduce to 2wk duration of Tx
2.1.1.1.3. Vanco 4wks if Pen-allergic
2.1.1.2. Rst. MIC (0.12-0.50)
2.1.1.2.1. (Pen-G or Ceftriaxone) 4wks (+) Gentamicin 2wks
2.1.1.2.2. Vanco 4wk if Pen-allergic
2.1.2. Prosthetic Valve
2.1.2.1. Low MIC
2.1.2.1.1. (Pen-G or Ceftriaxone) 4-6wks (+/-) Gentamicin 2wks
2.1.2.1.2. Vanco 6wks if Pen-allergic
2.1.2.2. Rst MIC
2.1.2.2.1. (Pen-G or Ceftriaxone) 6wks (+) Gentamicin 6wks
2.1.2.2.2. Vanco 6wks if Pen-allergic
2.2. Staph
2.2.1. Native Valve
2.2.1.1. (Nafcillin or Oxacillin) 4-6wks (+/-) Gentamicin 3-5 Days
2.2.1.2. MRSA or Pen-allergic Cefazolin 4-6wks (+/-) Gentamicin 3-5d Vanco 4-6 wks
2.2.2. Prosthetic Valve
2.2.2.1. (Nafcillin or Oxacillin) >=6wks (+) Rifampin >=6wks (+) Gentamicin 2wks
2.2.2.2. MRSA or Pen-allergic Vanco >=6wks (+) Rifampin >=6wks (+) Gentamicin 2wks
2.2.2.3. Daptomycin studied for VRSA coverage
2.3. Entero
2.3.1. Vanc-Susceptible
2.3.1.1. (High Dose Pen-G or Ampicillin) 4-6wks (+) Gentamicin 4-6wks
2.3.1.1.1. Amp preferred
2.3.1.2. Vanco 4-6wks (+) Gentamicin 4-6wks If Pen-allergic
2.3.2. VRE
2.3.2.1. Linezolid/Daptomycin
2.3.2.2. Synercid may be seen; fallen out of favor after losing FDA indication
2.4. HACEK
2.5. Fungal
3. Prophylaxis
3.1. Principal. Generally not favored. Want to reserve to pts with specific preexisting CARDIAC conditions, AND undergoing specific DENTAL procedures.
3.2. Tx is geared towards most likely causative agents for the specific qualifying pt population defined.
3.3. "Cardiac Conditions"
3.4. "Dental Procedures"
3.5. ppxTX:
4. Pathology
4.1. Physiology
4.1.1. Normal
4.1.1.1. Vena Cava> R. Atrium> TRICUSPID valve> R. Ventricle> PULMONARY valve> Pulm Artery> Lungs> Pulm Vein> L. Atrium> MITRAL valve> L. Ventricle> AORTIC valve> Aorta
4.1.2. IE Manifests
4.1.2.1. Mostly on Tricuspid/Mitral/Aortic valve Rarely on Pulmonary valve
4.1.2.2. Right sided is Tricuspid valve Left sided is the others
4.2. Native Valve IE
4.2.1. Occurs from an infecting pathogen from a hematologic source
4.2.2. Bacteremia a priori is needed. Most likely Tricuspid/Mitral/Aortic
4.3. Prosthetic Valve IE
4.3.1. Does not occur from hemat source, but from the surgical procedure itself
4.3.2. Often within 6 months of Sx
4.4. Clot/Vegetation/Emboli
4.4.1. Right sided IE. Septic pulmonary infarcts
4.4.2. Left sided IE. Emboli to systemic vasculature. Renal Splenic Cranial
5. Infectious Agents
5.1. Species
5.1.1. Gram (+)
5.1.1.1. Strep. Most like causative agent. Typically Viridans and Bovis. Less likely to be S. pneumo
5.1.1.2. Staph. Most likely to be Aureus/ Epi
5.1.1.3. Enterococi. least likey G(+), bc generally genitourinary. However, not uncommon in elderly with recent prostate manipulation. Or, young female with recent obstetric procedure.
5.1.2. Gram (-)
5.1.2.1. HACEK Haemophillus Actinobacter Cardiobacter Eikenella Kingella
5.1.2.2. Others E. coli Pseudomonas Klebsiella
5.1.3. Fungal Rare; severe
5.2. RFs Btwn Species
6. ROS/PE
6.1. Presents with generally non-specific features: -Dec plts -Inc WBCs -Fever -New or worsening heart murmur almost always present -General fatigue/malaise/hypoxia -General signs of clots/hemmorhage; Janway lesions; petichea; splinter hemmorhage; finger clubbing
6.2. Generally looking for Bacteremia with cardiac abnormalities.
6.2.1. 2-3 Bcx that are all positive and with the same organism
6.2.2. Cardiac abnormalities on radiology, trans thoracic and esophageal echocardiogram. Looks for lesions/vegetation and cardiac flow abnormalities.