Infective endocarditis resident survival guide: Difference between revisions

Jump to navigation Jump to search
No edit summary
No edit summary
 
(317 intermediate revisions by 6 users not shown)
Line 1: Line 1:
<div style="width: 80%;">
__NOTOC__
__NOTOC__
'''For infective endocarditis prevention resident survival guide click [[infective endocarditis prevention resident survival guide|here]].'''


{{WikiDoc CMG}}; {{AE}} {{FK}}
{{CMG}}; {{AE}} {{FK}}; {{MM}}; {{Rim}}


==Definition==
{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
[[Infection]] of the [[endothelium]] of the heart including but not limited to the valves. It can be either [[acute]] or [[subacute]].  Acute bacterial endocarditis is defined as [[Infection]] of normal [[heart valves]] with a virulent organism like [[S. aureus]], Group A or other [[beta-hemolytic streptococci]], [[Streptococcus pneumoniae]].  Subacute bacterial endocarditis is an indolent infection of abnormal valves with less virulent organism like [[Streptococcus viridans]].
|-
 
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Infective endocarditis Resident Survival Guide Microchapters}}
 
|-
{|class="wikitable"
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[{{PAGENAME}}#Overview|Overview]]
! Criteria!! Definite Infective Endocarditis According to Modified Duke Criteria
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[{{PAGENAME}}#Causes|Causes]]
|-
|-
| '''Pathological Criteria'''||
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[{{PAGENAME}}#FIRE:Focused Initial Rapid Evaluation|FIRE]]
: Microorganisms demonstrated by culture or histological examination of a vegetation
: Pathological lesions; vegetation or intracardiac abscess confirmed by histological examination showing active endocarditis
|-
|-
| '''Clinical Criteria''' ||
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[{{PAGENAME}}#Complete Diagnostic Approach|Diagnosis]]
: 2 major criteria; or
: 1 major criterion and 3 minor criteria; or
: 5 minor criteria
|-
|-
| '''Possible IE''' ||
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[{{PAGENAME}}#Treatment|Treatment]]
: 1 major criterion and 1 minor criterion; or
: 3 minor criteria
|-
|-
| '''Rejected''' ||
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[{{PAGENAME}}#Do's|Do's]]
: Firm alternative diagnosis explaining evidence of IE; or
: Resolution of IE syndrome with antibiotic therapy for 4 days; or
: No pathological evidence of IE at surgery or autopsy, with antibiotic therapy for 4 days; or
: Does not meet criteria for possible IE as above
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[{{PAGENAME}}#Don'ts|Don'ts]]
|}
|}


==Overview==
Infective endocarditis is an [[infection]] in the [[endothelium]] of the heart, including but not limited to the [[valves]].  While ''acute'' bacterial endocarditis is caused by an infection with a virulent organism such as [[staphylococcus aureus]], group A or other [[beta-hemolytic streptococci]], ''subacute'' bacterial endocarditis is an indolent infection with less virulent organisms like [[streptococcus viridans]].  Patients with unexplained [[fever]] for more than 48 hours and who are at high risk for [[infective endocarditis]] and patients among whom [[valvular disease|valve regurgitation]] is newly diagnosed should undergo a diagnostic workup to rule out [[endocarditis]].  The diagnosis of endocarditis depends on a thorough history and physical exam as well as the results of blood cultures and the findings on [[TTE|transthoracic echocardiogram]] or [[TEE|transesophageal echocardiogram]].  The [[modified Duke criteria]] is used to establish the diagnosis of [[endocarditis]].  [[Endocarditis]] is initially treated with [[Endocarditis antimicrobial treatment|empiric antibiotic therapy]] until the causative agent is identified.<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary | url = http://circ.ahajournals.org/content/early/2014/02/27/CIR.0000000000000029.citation | publisher =  | date =  | accessdate = 4 March 2014 }}</ref><ref name="Baddour-2005">{{Cite journal  | last1 = Baddour | first1 = LM. | last2 = Wilson | first2 = WR. | last3 = Bayer | first3 = AS. | last4 = Fowler | first4 = VG. | last5 = Bolger | first5 = AF. | last6 = Levison | first6 = ME. | last7 = Ferrieri | first7 = P. | last8 = Gerber | first8 = MA. | last9 = Tani | first9 = LY. | title = Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = e394-434 | month = Jun | year = 2005 | doi = 10.1161/CIRCULATIONAHA.105.165564 | PMID = 15956145 }}</ref>
==Causes==
===Life Threatening Causes===
Acute [[endocarditis]] is a life-threatening condition and must be treated as such irrespective of the underlying cause.
===Common Causes===
*[[Enterococcus|Enterococcus infection]]
*[[Staphylococcus aureus|Staphylococcus aureus infection]]
*[[Streptococcus viridans|Streptococcus viridans infection]]
==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary | url = http://circ.ahajournals.org/content/early/2014/02/27/CIR.0000000000000029.citation | publisher =  | date =  | accessdate = 4 March 2014 }}</ref><ref name="pmid3516105">{{cite journal| author=Weinstein L| title=Life-threatening complications of infective endocarditis and their management. | journal=Arch Intern Med | year= 1986 | volume= 146 | issue= 5 | pages= 953-7 | pmid=3516105 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3516105  }} </ref>
<span style="font-size:85%">Boxes in salmon color signify that an urgent management is needed.</span>
<span style="font-size:85%">'''Abbreviations:''' '''CT:''' [[CT|Computed tomography]] ; '''CTA:''' [[CTA|Computed tomography angiography]]; '''MRA:''' [[Magnetic resonance angiography]]; '''MRI:''' [[Magnetic resonance imaging]]; '''TEE:''' [[Transesophageal echocardiography]]; '''TTE:''' [[Transthoracic echocardiography]] </span>
{{Family tree/start}}
{{familytree  | | | | | A01 | | | A01=<div style="text-align: left; width: 15em"> '''Identify cardinal signs and symptoms that increase the pretest probability of endocarditis'''<br>
❑ Persistent [[fever]] <br>
❑ New valvular regurgitation [[murmur]] <br>
❑ [[Bacteremia]] <br>
❑ [[Janeway lesion]] <br>
❑ [[Osler's node]] <br>
❑ [[Roth's spots]] <br>
❑ [[Glomerulonephritis]] <br>
❑ New [[AV block]] <br>
❑ High risk factors
:❑ Pre-existing cardiac abnormality
:❑ [[Prosthetic valve]]
:❑ Recent surgical or medical procedures
:❑ Intravenous [[drug use]]
:❑ Recent bacterial infection
:❑ History of previous [[endocarditis]]
</div> }}
{{familytree  | | | | | |!| | }}
{{familytree  | | | | | A02 | | A02=<div style="text-align: left; width: 15em">❑ Order blood cultures (at least 2 sets) <br>❑ Order [[TTE]], or <br>
❑ Order a [[TEE]] if one or more of the following is present
:❑ Non diagnostic [[TTE]] in a suspected [[infective endocarditis]]
:❑ Clinical complications
:❑ [[ICD|Intracardiac device]] leads
:❑ [[Staphylococcus aureus]] bacteremia without a known cause
:❑ [[Prosthetic valve]] with persistent [[fever]] without [[bacteremia]]
:❑ [[Prosthetic valve]] with a new [[murmur]]
:❑ Nosocomial [[Staphylococcus aureus]] bacteremia with known extra-cardiac port of entry
<br>❑ Evaluate the [[infective endocarditis resident survival guide#Modified Duke Criteria|modified Duke criteria]] </div>}}
{{familytree  | | | | | |!| | }}
{{familytree  | | | | | B01 | | | B01= <div style="text-align: left; width: 15em">'''Does the patient have any findings suggestive of complications of endocarditis that require urgent intervention?'''<br> </div> }}
{{familytree  | | | |,|-|^|-|-|-|-|-|-|-|-|v|-|-|-|-|-|-|.| |}}
{{familytree  |boxstyle= text-align: left; background: #FA8072; padding: 0;| | | B02 | | | | | | | | | B03 | | | | | B04 | B02=<div style="padding: 5px;">{{fontcolor|#F8F8FF|Yes, the patient has cardiac complications}}</div>| B03= <div style="text-align: left; width: 15em; background: #FA8072; color: #F8F8FF; padding: 5px;">Yes, the patient has extra cardiac complications </div>| B04= <div style=" background: #FFFFFF; text-align: left; padding: 5px; height: 80px; line-height: 20px;"> No, the patient does not have any complications </div>}}
{{familytree  | |,|-|^|-|.| | | | | |,|-|-|^|-|-|.| | | |!| }}
{{familytree  |boxstyle=background: #FA8072; color: #F8F8FF;| C04 | | C05 | | | | C06 | | | | C07 | | |!| | C04=<div style="text-align: left; width: 15em">❑ [[Dyspnea|<span style="color:white;">Dyspnea </span>]] <br> ❑ [[Edema|<span style="color:white;">Edema</span>]] <br> ❑ Decreased [[ejection fraction|<span style="color:white;">ejection fraction</span>]] </div> | C05= <div style="text-align: left; width: 15em">❑ [[Valvular disease|<span style="color:white;">Severe valvular insufficiency</span>]] <br> ❑ Valvular [[abscess|<span style="color:white;">abscess</span>]] <br> ❑ Valvular dehiscence <br> ❑ Valvular rupture <br> ❑ Valvular fistula <br> ❑ Periannular extension of the infection </div>| C06= <div style="text-align: left; width: 15em">'''Focal neurological deficits''' <br> ❑ [[Facial droop|<span style="color:white;">Facial droop </span>]] <br> ❑ [[Hemiparesis|<span style="color:white;">Unilateral hemiparesis</span>]] <br> ❑ [[Aphasia|<span style="color:white;">Aphasia</span>]] <br> ❑ [[Hemispatial neglect|<span style="color:white;">Neglect</span>]] <br> ❑ [[Hemianopsia|<span style="color:white;">Hemianopsia</span>]] <br> ❑ [[Headache|<span style="color:white;">Headache</span>]] <br> ❑ [[Altered mental status|<span style="color:white;">Altered mental status</span>]] </div>| C07= <div style="text-align: left; width: 15em">❑ Tender pulsatile mass <br> ❑ [[Hematemesis|<span style="color:white;">Hematemesis</span>]], [[Hemobilia|<span style="color:white;">hemobilia</span>]], [[jaundice|<span style="color:white;">jaundice</span>]] (suggestive of involvement of the hepatic artery) <br> ❑ [[Arterial hypertension|<span style="color:white;">Hypertension</span>]] <br> [[Hematuria|<span style="color:white;">Hematuria</span>]] (suggestive of involvement of the renal artery) <br> ❑ Massive [[bloody diarrhea|<span style="color:white;">bloody diarrhea</span>]] (suggestive of involvement of a bowel artery) </div>}}
{{familytree  | |!| | | |!| | | | | |!| | | | | |!| | | |!| |}}
{{familytree  |boxstyle=background: #FA8072; color: #F8F8FF;| |!| | | |!| | | | | C09 | | | | C10 | | |!| |C09= <div style="text-align: left; width: 15em">❑ Order non contrast head [[CT|<span style="color:white;">CT scan</span>]]<br> ❑ Order [[MRA|<span style="color:white;">MRA</span>]] or [[CTA|<span style="color:white;">CTA</span>]] </div>| C10= ❑ Order abdominal [[CT scan|<span style="color:white;">CT scan</span>]] or [[MRI|<span style="color:white;">MRI</span>]]}}
{{familytree  | |!| | | |!| | | |,|-|^|-|.| | | |!| | | |!| |}}
{{familytree  |boxstyle= text-align: left; background: #FA8072; padding: 0;| D01 | | D02 | | D03 | | D04 | | D05 | | D06 |D01= <div style="text-align: left; width: 15em; line-height: 70px; height:70px; background: #FA8072; color: #F8F8FF;"> {{fontcolor|#F8F8FF| [[Heart failure|<span style="color:white;">Decompensated heart failure</span>]]}} </div>| D02= <div style="text-align: left; width: 15em; line-height: 70px; height:70px; background: #FA8072; color: #F8F8FF;"> {{fontcolor|#F8F8FF| [[Valvular disease|<span style="color:white;">Severe valvular involvement </span>]]}} </div> | D03= <div style="text-align: left; width: 15em; line-height: 70px; height:70px; background: #FA8072; color: #F8F8FF;"> {{fontcolor|#F8F8FF| [[Embolism|<span style="color:white;">Embolism</span>]] to the brain}} </div> | D04= <div style="text-align: left; width: 15em; line-height: 70px; height:70px; background: #FA8072; color: #F8F8FF;"> {{fontcolor|#F8F8FF| [[Mycotic aneurysm|<span style="color:white;">Intracranial mycotic aneurysm </span>]]}} </div> | D05= <div style="text-align: left; width: 15em; line-height: 70px; height:70px; background: #FA8072; color: #F8F8FF;"> {{fontcolor|#F8F8FF| [[Mycotic aneurysm|<span style="color:white;">Extracranial mycotic aneurysm </span>]]}} </div> | D06= <div style=" background: #FFFFFF; text-align: left; padding: 5px; color: #999999; height: 100px; line-height: 20px;"> [[Endocarditis resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]</div>}}
{{familytree  | |!| | | |!| | | |!| | | |!| | | |!| | | }}
{{familytree  |boxstyle=background: #FA8072; color: #F8F8FF;| E01 | | E02 | | E03 | | E04 | | E05 | | E01= <div style="text-align: left; width: 15em">❑ Consider [[valve replacement surgery|<span style="color:white;">valve replacement surgery</span>]]<br>❑ [[Acute heart failure resident survival guide|<span style="color:white;">Click here for heart failure resident survival guide</span>]] </div>| E02= <div style="text-align: left; width: 15em">❑ Consider [[valve replacement surgery|<span style="color:white;">valve replacement surgery</span>]] </div>| E03= <div style="text-align: left; width: 15em">❑ [[Stroke resident survival guide|<span style="color:white;">Click here for stroke resident survival guide</span>]] </div>| E04= <div style="text-align: left; width: 15em">❑ Evaluate medical vs surgical intervention</div>| E05= <div style="text-align: left; width: 15em">❑ Consider surgical ligation of the involved artery </div>}}
{{Family tree/end}}
==Complete Diagnostic Approach==
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary | url = http://circ.ahajournals.org/content/early/2014/02/27/CIR.0000000000000029.citation | publisher =  | date =  | accessdate = 4 March 2014 }}</ref><ref name="Baddour-2005">{{Cite journal  | last1 = Baddour | first1 = LM. | last2 = Wilson | first2 = WR. | last3 = Bayer | first3 = AS. | last4 = Fowler | first4 = VG. | last5 = Bolger | first5 = AF. | last6 = Levison | first6 = ME. | last7 = Ferrieri | first7 = P. | last8 = Gerber | first8 = MA. | last9 = Tani | first9 = LY. | title = Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = e394-434 | month = Jun | year = 2005 | doi = 10.1161/CIRCULATIONAHA.105.165564 | PMID = 15956145 }}</ref>
<span style="font-size:85%">'''Abbreviations:''' '''TEE:''' [[Transesophageal echocardiography]]; '''TTE:''' [[Transthoracic echocardiography]] </span>
{{familytree/start |summary=Diagnostic approach}}
{{familytree | A01 | | | | |A01= <div style="float: Left; text-align: left; width: 40em; padding:1em;">'''Characterize the symptoms:'''<br>
❑ Onset of the symptoms<BR>
:❑ Acute
:❑ Subacute
❑ [[Fever]] <BR>
❑ [[Chills]] <BR>
❑ [[Rigors]] <BR>
❑ [[Sweat]]s <BR>
❑ [[Fatigue]] <BR>
❑ [[Pleuritic chest pain]] <BR>
❑ [[Back pain]] <br>
❑ [[Weakness]] <BR>
❑ [[Myalgia]]s <BR>
❑ [[Arthralgia]]s <BR>
❑ [[Anorexia]] <BR>
❑ [[Shortness of breath]] <BR>
❑ [[Hemoptysis]] <BR>
❑ [[Productive cough]] <BR>
❑ [[Flank pain]] (suggestive of [[septic emboli]] or [[glomerulonephritis]])<br>
❑ [[Hematuria]] (suggestive of [[septic emboli]] or [[glomerulonephritis]])<br>
❑ [[Seizures]] (suggestive of [[septic emboli]])<BR>
❑ Focal neurological deficits due to [[stroke]] (suggestive of [[septic emboli]]) or [[mycotic aneurysm]]<BR>
❑ Reversible focal neurological deficits due to [[transient ischemic attack]] (suggestive of [[septic emboli]])<BR>
</div>}}
{{familytree | |!| | | | | |}}
{{familytree | B01 | | | | B01= <div style="float: left; text-align: left; width: 40em; padding:1em;">'''Identify existing risk factors for endocarditis:'''<BR>
❑ History of [[rheumatic heart disease]]<BR>
❑ [[Prosthetic valves]]<BR>
❑ [[Intravenous drug use]]<BR>
:❑ Adulterants used in the mixture, such as talc which increases the vulnerability of the valve to infection<ref name="pmid10671344">{{cite journal| author=Frontera JA, Gradon JD| title=Right-side endocarditis in injection drug users: review of proposed mechanisms of pathogenesis. | journal=Clin Infect Dis | year= 2000 | volume= 30 | issue= 2 | pages= 374-9 | pmid=10671344 | doi=10.1086/313664 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10671344  }} </ref>
:❑ Sharing the equipment
:❑ Use of cotton filters (associated with [[cotton fever]])<ref name="pmid2362114">{{cite journal| author=Harrison DW, Walls RM| title="Cotton fever": a benign febrile syndrome in intravenous drug abusers. | journal=J Emerg Med | year= 1990 | volume= 8 | issue= 2 | pages= 135-9 | pmid=2362114 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2362114  }} </ref>
:❑ The process of cleaning the equipment
❑ Previous [[infective endocarditis]]  <BR>
❑ [[Cardiac transplantation]] with valvular abnormality <BR>
❑ [[Congenital heart diseases]] with a [[shunt]]<BR>
❑ [[Heart disease|Acquired heart diseases]]<BR>
❑ [[Immunodeficiency]] <br>
❑ Medical procedures <br>
❑ Surgical procedures <br>
❑ Indwelling [[prosthesis|prosthetic devices]] <br>
❑ Bleeding during toothbrushing <br>
❑ Recent dental procedure
</div>}}
{{familytree | |!| | | | | }}
{{familytree | C01 | | | | |C01= <div style="float: left; text-align: left; width: 40em; padding:1em;">'''Examine the patient:'''<BR>
'''Vitals'''<BR>
❑ [[Temperature]]
:❑ [[Fever]]<BR>
❑ [[Blood pressure]]
:❑ Wide [[pulse pressure]] (suggestive of [[aortic insufficiency]])<BR>
:❑ Narrow [[pulse pressure]] (suggestive of [[left ventricular failure]])<BR>
'''Skin'''<BR>
<table>
<tr class="v-firstrow"><td>❑ [[Petechiae]] </td><td> [[File:Minor Petechia.jpg|200px]]</td></tr>
<tr><td>❑ [[Splinter hemorrhages]]</td><td>[[File:Splinter hemorrhage.jpg|200px]]</td></tr>
<tr><td>❑ [[Osler's nodes]]</td><td>[[File:Osler's Lesions (Endocarditis).jpg|200px]]</td></tr>
<tr><td>❑ [[Janeway lesions]] </td><td>[[File:Skin janeway.jpg|200px]]</td></tr>
</table>
'''Oral examination'''<br>
❑ Poor oral hygiene<ref name="pmid19797553">{{cite journal| author=Lockhart PB, Brennan MT, Thornhill M, Michalowicz BS, Noll J, Bahrani-Mougeot FK et al.| title=Poor oral hygiene as a risk factor for infective endocarditis-related bacteremia. | journal=J Am Dent Assoc | year= 2009 | volume= 140 | issue= 10 | pages= 1238-44 | pmid=19797553 | doi= | pmc=PMC2770162 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797553  }} </ref><br>
❑ [[Teeth]] looking for [[periodontitis]], [[plaque]] and [[calculus]]<ref name="pmid19797553">{{cite journal| author=Lockhart PB, Brennan MT, Thornhill M, Michalowicz BS, Noll J, Bahrani-Mougeot FK et al.| title=Poor oral hygiene as a risk factor for infective endocarditis-related bacteremia. | journal=J Am Dent Assoc | year= 2009 | volume= 140 | issue= 10 | pages= 1238-44 | pmid=19797553 | doi= | pmc=PMC2770162 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797553  }} </ref><BR>
❑ [[Gingiva]] looking for [[gingivitis]]<ref name="pmid19797553">{{cite journal| author=Lockhart PB, Brennan MT, Thornhill M, Michalowicz BS, Noll J, Bahrani-Mougeot FK et al.| title=Poor oral hygiene as a risk factor for infective endocarditis-related bacteremia. | journal=J Am Dent Assoc | year= 2009 | volume= 140 | issue= 10 | pages= 1238-44 | pmid=19797553 | doi= | pmc=PMC2770162 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797553  }} </ref><BR>
❑ Recent dental procedure
'''Eyes'''<BR>
❑ [[Conjunctival hemorrhage]]<BR>
❑ [[Roth's spot]]s in the [[retina]]<BR>
'''Cardiovascular examination'''<BR>
❑ [[Murmur|Heart murmur]]: New or change in the character of a previous murmur<BR>
:❑ [[Aortic insufficiency]] (early diastolic, decrescendo, best heard in the left sternal border)<BR>
:❑ [[Tricuspid regurgitation]] (holosystolic, best heard over the fourth intercostal area at left sternal border)<BR>
:❑ [[Mitral regurgitation]] (holosystolic, best heard at the apex) <BR>
'''Respiratory examination'''<BR>
❑ [[Rales]] (suggestive of [[heart failure]]) <BR>
'''Abdominal examination'''<BR>


❑ [[Reduced bowel sounds]] (suggestive of mesenteric [[embolism|embolization]] or [[ileus]])<BR>
❑ [[Abdominal pain]]<BR>
:❑ [[Flank pain]] (suggestive of [[embolus to the kidney]])<BR>
:❑ [[Left upper quadrant pain]] (suggestive of [[splenic infarct]])<BR>
❑ [[Splenomegaly]]<BR>


'''Extremities'''<BR>


{{familytree/start |summary=Definition of Infective Endocarditis According to the Modified Duke Criteria}}
❑ [[Janeway lesion]]s (painless hemorrhagic cutaneous lesions on the [[palms]] and [[soles]])<BR>
{{familytree | | | | | | | | A01 | | | | |A01= '''Definite Infective Endocarditis According to Modified Duke Criteria'''}}
[[Gangrene]] of fingers<BR>
{{familytree | | | | | | | | |!| | | | | |}}
[[Splinter hemorrhage]]s<BR>
{{familytree | | | | | | | | A01 | | | | |A01= <div style="float: left; text-align: left; width: 40em; padding:1em;">'''Pathological Criteria'''
[[Osler's node]]s (painful subcutaneous lesions in the distal fingers)<BR>
:Microorganisms demonstrated by culture or histological examination of a vegetation <br>
 
:Pathological lesions; vegetation or intracardiac abscess confirmed by histological examination showing active endocarditis <br>
'''Neurological examination'''<BR>
'''Clinical Criteria'''
:❑ 2 major criteria; or
:1 major criterion and 3 minor criteria; or
:❑ 5 minor criteria <br>
'''Possible IE'''
:❑ 1 major criterion and 1 minor criterion; or
:❑ 3 minor criteria<BR>
'''Rejected'''  
:❑ Firm alternative diagnosis explaining evidence of IE; or
:❑ Resolution of IE syndrome with antibiotic therapy for 4 days; or
:❑ No pathological evidence of IE at surgery or autopsy, with antibiotic therapy for 4 days; or
:❑ Does not meet criteria for possible IE as above</div>}}
{{familytree/end}}


==Causes==
❑ Full neurological exam
===Life Threatening Causes===
:❑ Focal deficits (suggestive of [[stroke]] or [[brain abscess]])</div>}}
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Endocarditis can be a life-threatening condition if it is left untreated, and it must be treated as such irrespective of the causes.
{{familytree | |!| | | | | |}}
{{familytree | E01 | | | | |E01= <div style="float: left; text-align: left; width: 40em; padding:1em;">'''Order tests:'''<BR>
❑ [[Blood culture]] (at least two sets)<br>
❑ Order a [[TTE]]<br>
❑ Order a [[TEE]] if one or more of the following is present
:❑ Non diagnostic [[TTE]] in a suspected [[infective endocarditis]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]])
:❑ Clinical complications ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]])
:❑ [[ICD|Intracardiac device]] leads ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]])
:❑ [[Staphylococcus aureus]] bacteremia without a known cause ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence B]])
:❑ [[Prosthetic valve]] with persistent [[fever]] without [[bacteremia]] ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence B]])
:❑ [[Prosthetic valve]] with a new [[murmur]] ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence B]])
:❑ Nosocomial [[Staphylococcus aureus]] [[bacteremia]] with known extra-cardiac port of entry ([[ACC AHA guidelines classification scheme|Class IIb, level of evidence B]])
</div>}}
{{familytree | |!| | | | | |}}
{{familytree | D01 | | | | | D01= <div style="float: left; text-align: left; width: 40em; padding:1em;">'''Evaluate the Modified Duke Criteria for infective endocarditis:'''<ref name="pmid10770721">{{cite journal| author=Li JS, Sexton DJ, Mick N, Nettles R, Fowler VG, Ryan T et al.| title=Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. | journal=Clin Infect Dis | year= 2000 | volume= 30 | issue= 4 | pages= 633-8 | pmid=10770721 | doi=10.1086/313753 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10770721  }} </ref> <br>


===Common Causes===
<table class="wikitable">
*[[Streptococcus viridans]]
<tr class="v-firstrow"><th>Probability of infective endocaritis</th><th> Characteristics </th></tr>
*[[Staphylococcus aureus|Staphylococci]]
<tr><td>'''Definite diagnosis by pathological criteria'''</td><td>❑ Microorganisms demonstrated by culture or histological examination<br> of a vegetation, OR <br>
*[[Enterococcus]].
❑ Pathological lesions; vegetation or intracardiac abscess confirmed by histological<br> examination showing active [[endocarditis]] </td></tr>
<tr><td>'''Definite diagnosis by clinical criteria'''</td><td>❑ 2 [[Endocarditis resident survival guide #Modified Duke Criteria|major criteria]], OR <br>
❑ 1 [[Endocarditis resident survival guide #Modified Duke Criteria|major criterion]] and 3 [[Endocarditis resident survival guide #Modified Duke Criteria|minor criteria]], OR <br>
❑ 5 [[Endocarditis resident survival guide #Modified Duke Criteria|minor criteria]] </td></tr>
<tr><td>'''Possible diagnosis'''</td><td>❑ 1 [[Endocarditis resident survival guide #Modified Duke Criteria|major criterion]] and 1 [[Endocarditis resident survival guide #Modified Duke Criteria|minor criterion]], OR <br>❑ 3 [[Endocarditis resident survival guide #Modified Duke Criteria|minor criteria]] </td></tr>
<tr><td>'''Rejected diagnosis'''</td><td>❑ Firm alternative diagnosis explaining evidence of [[infective endocarditis]], OR <br>
❑ Resolution of [[infective endocarditis]] with [[antibiotic therapy]] for 4 days, OR <br>
❑ No pathological evidence of [[infective endocarditis]] at surgery or [[autopsy]], with [[antibiotic therapy]] for 4 days, OR <br>
❑ Does not meet [[Endocarditis resident survival guide #Modified Duke Criteria|criteria]] for possible [[infective endocarditis]] as above</td></tr>
</table></div>}}
{{familytree | |!| | | | | |}}
{{familytree | E01 | | | | | E01= <div style="float: left; text-align: left; width: 40em; padding:1em;">'''Consider alternative diagnoses:'''<br>
❑ Culture negative endocarditis
:❑ Previous treatment with [[antibiotics]]
:❑ Fastidious bacterial infection
:❑ [[Fungi|Fungal]] infection
:❑ Inappropriate [[blood culture]] technique
❑ [[Marantic endocarditis]]
:❑ Valvular vegetations
:❑ Negative [[blood culture]]
:❑ Hypercoagulable state, [[lupus]] or [[antiphospholipid syndrome]]
❑ [[Cellulitis]] (skin inflammatory skin)<br>
❑ [[Intravascular device related infections|Catheter related infection]] (presence of [[catheter]] associated with associated local erythema and tenderness)<br>
[[Intravascular device related infections|Cardiac device infection]] <br>
❑ [[Prosthetic joint]] infection (localized inflammatory signs) <br>
❑ [[Pneumonia]] <br>
❑ [[Osteomyelitis]]<br>
❑ [[Fever of unknown origin]]
[[Cotton fever]]<ref name="pmid2362114">{{cite journal| author=Harrison DW, Walls RM| title="Cotton fever": a benign febrile syndrome in intravenous drug abusers. | journal=J Emerg Med | year= 1990 | volume= 8 | issue= 2 | pages= 135-9 | pmid=2362114 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2362114  }} </ref></div> }}
{{Familytree/end}}


==Management==
==Treatment==
===Diagnostic Criteria===
Shown below is an algorithm depicting the management of [[infective endocarditis]].<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary | url = http://circ.ahajournals.org/content/early/2014/02/27/CIR.0000000000000029.citation | publisher =  | date =  | accessdate = 4 March 2014 }}</ref><ref name="Baddour-2005">{{Cite journal  | last1 = Baddour | first1 = LM. | last2 = Wilson | first2 = WR. | last3 = Bayer | first3 = AS. | last4 = Fowler | first4 = VG. | last5 = Bolger | first5 = AF. | last6 = Levison | first6 = ME. | last7 = Ferrieri | first7 = P. | last8 = Gerber | first8 = MA. | last9 = Tani | first9 = LY. | title = Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = e394-434 | month = Jun | year = 2005 | doi = 10.1161/CIRCULATIONAHA.105.165564 | PMID = 15956145 }}</ref>
{{Familytree/start}}
{{Familytree | | | | | A01 | | | | | | | | | | | | | | | | | | |A01= '''Duke Criteria'''}}
{{Familytree | | | | | |!| | | | | | | | | | | | | | | | | | | |}}
{{Familytree | | | | | B01 | | | | | | | | | | | | | | | | | | |B01=
<div style="float: left; text-align: left; width: 23em; padding:1em;">The Duke Clinical Criteria for Infective Endocarditis requires either:


❑ Two major criteria, or
<span style="font-size:85%">'''Abbreviations:''' '''TEE:''' [[Transesophageal echocardiography]]; '''TTE:''' [[Transthoracic echocardiography]] </span>


One major and three minor criteria, or
{{familytree/start |summary=Treatment}}
{{familytree | | | G01 | | | | | G01=<div style="float: left; text-align: left; width: 40em; padding:1em;">'''Once the diagnosis of infective endocarditis is confirmed, initiate the treatment:'''
❑ Begin [[Endocarditis antimicrobial treatment|antibiotic treatment]]<br>
❑ Order [[blood cultures]] every 24-48 hours until no [[bacteremia]] can be detected<br>
❑ Temporarily discontinue [[anticoagulation]] if one of the following is present
:❑ Signs and symptoms of [[CNS]] involvement consistent with [[embolism]] or [[stroke]] ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence B]])
:❑ [[Vitamin K antagonist]] administration ([[ACC AHA guidelines classification scheme|Class IIb, level of evidence B]])
❑ Remove the [[pacemaker]] of the [[defibrillator|defibrillator system]] if one of the following is present
:❑ Documented infection of the device or leads ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]])
:❑ Valvular [[infective endocarditis]] by [[Staphylococcus aureus]] or [[fungi]] in the absence of documented infection of the device or leads ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence B]])
:❑ Patient scheduled for [[valve surgery]] ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])
:❑ Persistent vegetations and recurrent [[emboli]] despite the [[antibiotic]] regimen ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence B]])
❑ Manage the patient with a multidisciplinary team<br>
:❑ Consult an infectious disease specialist
:❑ Consult a cardiologist
:❑ Consult a cardiac surgeon </div> }}
{{familytree | | | |!| | | | | |}}
{{familytree | | | D02 | | D02= <div style="float: left; text-align: left; width: 40em; padding:1em;">'''Does the patient have any of the following conditions that require an early [[valve replacement surgery]] during hospitalization?'''<br>
❑ [[Heart failure]] due to the valve dysfunction ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) <br>
❑ Left sided [[infective endocarditis]] due to [[staphylococcus aureus]], fungal or highly resistant organisms ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) <br>
❑ [[Heart block]], annular or aortic [[abscess]] or destructive lesions ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) <br>
❑ Persistent [[bacteremia]] or [[fever]] 5 to 7 following the initiation of the [[antibiotics]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]])<br>
❑ Relapse of the infection depsite a complete course of [[antibiotics]] in prosthetic valve endocarditis when no portal of infection can be identified ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])<br>
❑ Recurrent [[emboli]] and persistent vegetations despite antibiotic therapy ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence B]]) <br>
❑ Mobile vegetations with a length more than 10 mm in native valve endocarditis([[ACC AHA guidelines classification scheme|Class IIb, level of evidence B]])
</div>}}
{{familytree | | |,|^|.| | |}}
{{familytree | D03 | | D04 | D03= '''Yes'''| D04= '''No'''}}
{{familytree | | |!| |!| | |}}
{{familytree | D05 | |!| | |D05= ❑ Schedule for early surgery}}
{{familytree | | |!| |!| | |}}
{{familytree | | | F01 | | | | | F01=<div style="float: left; text-align: left; width: 40em; padding:1em;"> '''Follow up the patient:'''<br>
❑ Repeat [[TTE]] before discharge<br>
❑ Refer for cessation of [[drug abuse]] (if applicable) <br>
❑ Educate the patient about the signs and symptoms of infective endocarditis <br>
❑ Recommend a thorough dental examination <br>
❑ Monitor for complications
:❑ Relapse ([[fever]], [[chills]])
:❑ New or worsening [[heart failure]]
:❑ [[Antibiotic]] toxicity
::❑ Vestibular toxicity
::[[Diarrhea]] or [[colitis]]
</div>}}
{{familytree | | | |!| | | | | |}}
{{familytree | | | G01 | | | | | G01=<div style="float: left; text-align: left; width: 40em; padding:1em;"> '''Reevaluate the patient with TTE and/or TEE if one of the following is present:'''<br>
❑ Change in clinical signs and symptoms
:❑ New [[murmur]]
:❑ [[Embolism]]
:❑ Persistent [[fever]]
:❑ [[Heart failure]]
:❑ [[Abscess]]
:❑ [[Atrioventricular heart block]]
❑ High risk of complications
:❑ Large vegetations on [[echocardiogram]]
:❑ [[Staphylococcus]], [[enterococcus|enterecoccal]], or [[fungi|fungal]] infections
</div>}}
{{familytree/end}}


❑ Five minor criteria</div>}}
===Antibiotic Regimens===
A complete list of pathogen specific antibiotics regimens with appropriate dosages and duration of treatment is available '''[[Endocarditis antimicrobial treatment|here]]'''.


{{Familytree | | |,|-|-|^|-|-|.|}}
===Modified Duke Criteria===
{{Familytree | | D01 | | | | D02 | | | | | | | |D01='''Major Criteria'''|D02='''Minor criteria'''}}
Shown below is a table summarizing the major and minor Modified Duke Criteria.<ref name="pmid10770721">{{cite journal| author=Li JS, Sexton DJ, Mick N, Nettles R, Fowler VG, Ryan T et al.| title=Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. | journal=Clin Infect Dis | year= 2000 | volume= 30 | issue= 4 | pages= 633-8 | pmid=10770721 | doi=10.1086/313753 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10770721  }} </ref> <br>
{{Familytree | | |!| | | | | |!| | | | | | | |}}
{{Familytree | | E01 | | | | E02 | | | | | | |E01=<div style="float: left; text-align: left; width: 23em; padding:1em;">'''Positive Blood Culture for Infective Endocarditis'''<BR>
*Typical microorganism consistent with infective endocarditis from 2 separate blood cultures, as noted below:<BR>


{| style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center colspan="2"| {{fontcolor|#FFF|Modified Duke Criteria}}
|-
| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Major criteria'''||style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Minor criteria'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |'''''1- Positive Blood Culture for Infective Endocarditis'''''<br>
❑ Typical microorganism consistent with infective endocarditis from 2 separate blood cultures, in the absence of a primary focus:<BR>
:❑ [[Viridans streptococci]], [[streptococcus bovis]]<BR>
:❑ [[Viridans streptococci]], [[streptococcus bovis]]<BR>
:❑ [[HACEK organism|HACEK group]]<BR>
:❑ [[HACEK organism|HACEK group]]<BR>
:❑ Community-acquired [[staphylococcus aureus]]
:❑ Community-acquired [[staphylococcus aureus]]
:❑[[Enterococci]], in the absence of a primary focus, or<BR>
:❑ [[Enterococci]] <br>
<br>OR<br><br>
❑ Microorganisms consistent with [[infective endocarditis]] from persistently positive [[blood cultures]] defined as:<BR>
:❑ At least 2 positive cultures of blood samples drawn >12 hours apart, or<BR>
:❑ All of 3 or a majority of 4 separate cultures of blood (with first and last sample drawn 1 hour apart)<br>
<br>OR<br><br>
❑ Single positive [[blood culture]] for [[Coxiella burnetii]] or anti–phase 1 IgG antibody titer >1:800<br>
<br>
-----
'''''2-Echocardiographic evidence of endocardial involvement''''' <br>
❑ Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomic explanation, or<br>
❑ [[Abscess]], or<BR>
❑ New partial dehiscence of [[prosthetic valve]], or<BR>
❑ New [[valvular disease|valvular regurgitation]]
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''1- Predisposition'''''<br>
❑ Predisposing heart condition or intravenous drug use<BR>
<br>
----
'''2- Fever'''<br>
❑ Temperature > 38.0° C (100.4° F)<BR>
<br>
----
'''''3- Vascular phenomena'''''<br>
❑ [[Embolism|Major arterial emboli]] <br>
❑ Septic pulmonary infarcts <br>
❑ [[Mycotic aneurysm]] <br>
❑ [[Intracranial hemorrhage]] <br>
❑ [[Conjunctival hemorrhage]] <br>
❑ [[Janeway lesions]]<BR>
<br>
----
'''''4- Immunologic phenomena''''' <br>
❑ [[Glomerulonephritis]] <br>
❑ [[Osler's nodes]] <br>
❑ [[Roth spot]]s <br>
❑ [[Rheumatoid factor]]<BR>
<br>
----
'''''5- Microbiological evidence''''' <br>
❑ Positive [[blood culture]] but does not meet a major criterion as noted above<br>
<br>OR<br><br>
❑ Serological evidence of active infection with organism consistent with [[infectious endocarditis]]<BR>
|-
|}
|}
<br>
 
==Do's==
* Elicit a full medical history to identify the minor Duke criteria for the diagnosis.
* Consider alternative diagnoses for [[bacteremia]] and [[fever]] by searching for the cause of the infection.
* Initiate [[antibiotic therapy]] after withdrawing [[blood]] for culture ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]).<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary | url = http://circ.ahajournals.org/content/early/2014/02/27/CIR.0000000000000029.citation | publisher =  | date =  | accessdate = 4 March 2014 }}</ref>


*Microorganisms consistent with infective endocarditis from persistently positive blood cultures defined as:<BR>
* If the [[blood cultures]] are negative in a patient suspected to have [[infective endocarditis]], suspect [[HACEK]] infection and ask the laboratory to retain the [[blood cultures]] for more than two weeks.<ref name="Baddour-2005">{{Cite journal  | last1 = Baddour | first1 = LM. | last2 = Wilson | first2 = WR. | last3 = Bayer | first3 = AS. | last4 = Fowler | first4 = VG. | last5 = Bolger | first5 = AF. | last6 = Levison | first6 = ME. | last7 = Ferrieri | first7 = P. | last8 = Gerber | first8 = MA. | last9 = Tani | first9 = LY. | title = Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = e394-434 | month = Jun | year = 2005 | doi = 10.1161/CIRCULATIONAHA.105.165564 | PMID = 15956145 }}</ref>


:❑ 2 positive cultures of blood samples drawn >12 hours apart, or<BR>
* If [[HACEK]] bacteremia is detected without any focus of infection, suspect the presence of infective endocarditis even in the absence of the typical signs and symptoms.<ref name="Baddour-2005">{{Cite journal  | last1 = Baddour | first1 = LM. | last2 = Wilson | first2 = WR. | last3 = Bayer | first3 = AS. | last4 = Fowler | first4 = VG. | last5 = Bolger | first5 = AF. | last6 = Levison | first6 = ME. | last7 = Ferrieri | first7 = P. | last8 = Gerber | first8 = MA. | last9 = Tani | first9 = LY. | title = Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = e394-434 | month = Jun | year = 2005 | doi = 10.1161/CIRCULATIONAHA.105.165564 | PMID = 15956145 }}</ref>
:❑ All of 3 or a majority of 4 separate cultures of blood (with first and last sample drawn 1 hour apart)<BR>
'''Echocardiographic evidence of endocardial involvement'''<BR>
:❑ Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or<BR>
:❑ On implanted material in the absence of an alternative anatomic explanation, or<BR>
:❑ Abscess, or<BR>
:❑ New partial dehiscence of prosthetic valve, or<BR>
:❑ New valvular regurgitation (worsening or changing of preexisting murmur not sufficient)</div>|E02=<div style="float: left; text-align: left; width: 23em; padding:1em;">
*'''Predisposition:'''
:❑ Predisposing heart condition or intravenous drug use<BR>
*'''Fever:'''
:❑ Temperature > 38.0° C (100.4° F)<BR>
*'''Vascular phenomena:'''
:❑ [[Embolism|Major arterial emboli]]
:❑ Septic pulmonary infarcts
:❑ [[Mycotic aneurysm]]
:❑ [[Intracranial hemorrhage]]
:❑ [[Conjunctival hemorrhage]]
:❑ [[Janeway lesions]]<BR>
*'''Immunologic phenomena:'''
:❑ [[Glomerulonephritis]]
:❑ [[Osler's nodes]]
:❑ [[Roth spot]]s
:❑ [[Rheumatoid factor]]<BR>
*'''Microbiological evidence:'''
:❑ Positive blood culture but does not meet a major criterion as noted above
:❑ Serological evidence of active infection with organism consistent with infectious endocarditis<BR>
*'''Echocardiographic findings:'''
:❑ Consistent with infectious endocarditis but do not meet a major criterion as noted above</div>}}


{{Familytree/end}}
* Do a [[transesophageal echocardiography]] intraoperatively among patients scheduled for valve surgery for [[infective endocarditis]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]).<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary | url = http://circ.ahajournals.org/content/early/2014/02/27/CIR.0000000000000029.citation | publisher =  | date =  | accessdate = 4 March 2014 }}</ref>


==Diagnostic approach==
* Consider ordering a cardiac [[CT scan]] when [[echocardiography]] does not provide clear details about the cardiac anatomy in the context of suspected paravalvular infections ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence B]]).<ref name="circ.ahajournals.org">{{Cite web  | last = | first = | title = 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary | url = http://circ.ahajournals.org/content/early/2014/02/27/CIR.0000000000000029.citation | publisher =  | date =  | accessdate = 4 March 2014 }}</ref>


* Suspect intraventricular septal [[abscess]] as a complication of endocarditis when the [[ECG]] is significant for a gradual increase in the [[PR interval]] or a new [[left bundle branch block]].<ref name="pmid3516105">{{cite journal| author=Weinstein L| title=Life-threatening complications of infective endocarditis and their management. | journal=Arch Intern Med | year= 1986 | volume= 146 | issue= 5 | pages= 953-7 | pmid=3516105 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3516105  }} </ref>


Shown below is an algorithm summarizing the approach to <nowiki>Endocarditis</nowiki>.
==Don'ts==
{{Familytree/start}}
* Don't administer [[Endocarditis antibiotic prophylaxis|prophylaxis for infective endocarditis]] in patients with valvular heart disease who are at risk infective endocarditis for procedures such as [[TEE|transesophageal echocardiography]], [[cystoscopy]], [[esophagogastroduodenoscopy]] or [[colonoscopy]] without any evidence of active infection (Class III; level of evidence B).<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary | url = http://circ.ahajournals.org/content/early/2014/02/27/CIR.0000000000000029.citation | publisher =  | date =  | accessdate = 4 March 2014 }}</ref>


* Do not administer infective endocarditis prophylaxis for the following dental procedures:
** Anesthetic injections in noninfected tissue
** Dental radiographs
** Shedding of deciduous teeth
** Placement of orthodontic brackets
** Placement or removal of prosthodontic or orthodontic appliances
** Adjustment of orthodontic appliances
** [[Bleeding]] following [[trauma]] to the [[oral mucosa]] or [[lips]]<ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>


{{Familytree | | | | | | | | A01 | | | | | | | | | | | | | | | | | | |A01= A1 Box 1 in Row 1}}
* Do not administer [[Endocarditis antibiotic prophylaxis|prophylaxis for infective endocarditis]] for procedures involving the [[respiratory tract]] unless they involve incision of the respiratory tract [[mucosa]].<ref name="pmid18820172">{{cite journal| author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD et al.| title=2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=Circulation | year= 2008 | volume= 118 | issue= 15 | pages= e523-661 | pmid=18820172 | doi=10.1161/CIRCULATIONAHA.108.190748 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18820172  }} </ref>
{{Familytree | | | | | | | | |!| | | | | | | | | | | | | | | | | | | |}}
{{Familytree | | | | | | | | B01 | | | | | | | | | | | | | | | | | | |B01= B1 Box 1 in Row 2}}
{{Familytree | | | | | | | | |!| | | | | | | | | | | | | | | | | | | |}}
{{Familytree | | | | | | | | C01 | | | | | | | | | | | | | | | | | | |C01= C1 Box 1 in Row 3}}
{{Familytree | | |,|-|-|-|-|-|+|-|-|-|-|-|-|-|-|-|-|-|.| | | | | | | |}}
{{Familytree | | D01 | | | | D02 | | | | | | | | | | D03 | | | | | | | |D01=Box 4 in row 4|D02=Box 5 in row 4|D03=Box 6 in row 4}}
{{Familytree | | | | | | | | |!| | | | | | | | | | | |!| | | | | | | |}}
{{Familytree | | | | | | | | E01 | | | | | | | | | | E02 | | | | | | |E01=Box 7 in row 5|E02=Box 8 in row 5}}
{{Familytree | | |,|-|-|-|-|-|+|-|-|-|.| | | | |,|-|-|^|-|-|-|-|-|.| |}}
{{Familytree | | F01 | | | | F02 | | F03 | | | F04 | | | | | | | | F05 |F01=box 9 in row 6|F02=box 10 in row 6|F03=Box 11 in row 6|F04=Box 12 in row 6|F05=Box 13 in row 6}}
{{Familytree | | |!| | | | | |!| |,|-|^|-|.| | |!| | | | | | | | | |!| |}}
{{Familytree | | G01 | | | | |!| G03 | | G04 | G05 | | | | | | | | G06 |}}
{{Familytree/end}}


* Do not administer [[cephalosporins]] in subjects with a previous history of [[anaphylaxis]], [[angioedema]], or [[urticaria]] following [[penicillin]] or [[ampicillin]] use.


==Do's==
==Dont's==
==References==
==References==
{{Reflist|2}}


[[Category:Help]]
[[Category:Disease]]
[[Category:Projects]]
[[Category:Cardiology]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Resident survival guide]]
[[Category:Templates]]


{{WikiDoc Help Menu}}
{{WikiDoc Help Menu}}
{{WikiDoc Sources}}
{{WikiDoc Sources}}
</div>

Latest revision as of 14:15, 19 August 2020

For infective endocarditis prevention resident survival guide click here.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farman Khan, MD, MRCP [2]; Mohamed Moubarak, M.D. [3]; Rim Halaby, M.D. [4]

Infective endocarditis Resident Survival Guide Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

Infective endocarditis is an infection in the endothelium of the heart, including but not limited to the valves. While acute bacterial endocarditis is caused by an infection with a virulent organism such as staphylococcus aureus, group A or other beta-hemolytic streptococci, subacute bacterial endocarditis is an indolent infection with less virulent organisms like streptococcus viridans. Patients with unexplained fever for more than 48 hours and who are at high risk for infective endocarditis and patients among whom valve regurgitation is newly diagnosed should undergo a diagnostic workup to rule out endocarditis. The diagnosis of endocarditis depends on a thorough history and physical exam as well as the results of blood cultures and the findings on transthoracic echocardiogram or transesophageal echocardiogram. The modified Duke criteria is used to establish the diagnosis of endocarditis. Endocarditis is initially treated with empiric antibiotic therapy until the causative agent is identified.[1][2]

Causes

Life Threatening Causes

Acute endocarditis is a life-threatening condition and must be treated as such irrespective of the underlying cause.

Common Causes

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.[1][3]

Boxes in salmon color signify that an urgent management is needed.

Abbreviations: CT: Computed tomography ; CTA: Computed tomography angiography; MRA: Magnetic resonance angiography; MRI: Magnetic resonance imaging; TEE: Transesophageal echocardiography; TTE: Transthoracic echocardiography

 
 
 
 
Identify cardinal signs and symptoms that increase the pretest probability of endocarditis

❑ Persistent fever
❑ New valvular regurgitation murmur
Bacteremia
Janeway lesion
Osler's node
Roth's spots
Glomerulonephritis
❑ New AV block
❑ High risk factors

❑ Pre-existing cardiac abnormality
Prosthetic valve
❑ Recent surgical or medical procedures
❑ Intravenous drug use
❑ Recent bacterial infection
❑ History of previous endocarditis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Order blood cultures (at least 2 sets)
❑ Order TTE, or

❑ Order a TEE if one or more of the following is present

❑ Non diagnostic TTE in a suspected infective endocarditis
❑ Clinical complications
Intracardiac device leads
Staphylococcus aureus bacteremia without a known cause
Prosthetic valve with persistent fever without bacteremia
Prosthetic valve with a new murmur
❑ Nosocomial Staphylococcus aureus bacteremia with known extra-cardiac port of entry

❑ Evaluate the modified Duke criteria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any findings suggestive of complications of endocarditis that require urgent intervention?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes, the patient has cardiac complications
 
 
 
 
 
 
 
 
Yes, the patient has extra cardiac complications
 
 
 
 
No, the patient does not have any complications
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dyspnea
Edema
❑ Decreased ejection fraction
 
Severe valvular insufficiency
❑ Valvular abscess
❑ Valvular dehiscence
❑ Valvular rupture
❑ Valvular fistula
❑ Periannular extension of the infection
 
 
 
Focal neurological deficits
Facial droop
Unilateral hemiparesis
Aphasia
Neglect
Hemianopsia
Headache
Altered mental status
 
 
 
❑ Tender pulsatile mass
Hematemesis, hemobilia, jaundice (suggestive of involvement of the hepatic artery)
Hypertension
Hematuria (suggestive of involvement of the renal artery)
❑ Massive bloody diarrhea (suggestive of involvement of a bowel artery)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Order non contrast head CT scan
❑ Order MRA or CTA
 
 
 
❑ Order abdominal CT scan or MRI
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Embolism to the brain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Evaluate medical vs surgical intervention
 
❑ Consider surgical ligation of the involved artery
 

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[1][2]

Abbreviations: TEE: Transesophageal echocardiography; TTE: Transthoracic echocardiography

Characterize the symptoms:

❑ Onset of the symptoms

❑ Acute
❑ Subacute

Fever
Chills
Rigors
Sweats
Fatigue
Pleuritic chest pain
Back pain
Weakness
Myalgias
Arthralgias
Anorexia
Shortness of breath
Hemoptysis
Productive cough
Flank pain (suggestive of septic emboli or glomerulonephritis)
Hematuria (suggestive of septic emboli or glomerulonephritis)
Seizures (suggestive of septic emboli)
❑ Focal neurological deficits due to stroke (suggestive of septic emboli) or mycotic aneurysm
❑ Reversible focal neurological deficits due to transient ischemic attack (suggestive of septic emboli)

 
 
 
 
 
 
 
 
 
 
 
 
Identify existing risk factors for endocarditis:

❑ History of rheumatic heart disease
Prosthetic valves
Intravenous drug use

❑ Adulterants used in the mixture, such as talc which increases the vulnerability of the valve to infection[4]
❑ Sharing the equipment
❑ Use of cotton filters (associated with cotton fever)[5]
❑ The process of cleaning the equipment

❑ Previous infective endocarditis
Cardiac transplantation with valvular abnormality
Congenital heart diseases with a shunt
Acquired heart diseases
Immunodeficiency
❑ Medical procedures
❑ Surgical procedures
❑ Indwelling prosthetic devices
❑ Bleeding during toothbrushing
❑ Recent dental procedure

 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

Vitals
Temperature

Fever

Blood pressure

❑ Wide pulse pressure (suggestive of aortic insufficiency)
❑ Narrow pulse pressure (suggestive of left ventricular failure)

Skin

Petechiae
Splinter hemorrhages
Osler's nodes
Janeway lesions

Oral examination
❑ Poor oral hygiene[6]
Teeth looking for periodontitis, plaque and calculus[6]
Gingiva looking for gingivitis[6]
❑ Recent dental procedure

Eyes

Conjunctival hemorrhage
Roth's spots in the retina

Cardiovascular examination

Heart murmur: New or change in the character of a previous murmur

Aortic insufficiency (early diastolic, decrescendo, best heard in the left sternal border)
Tricuspid regurgitation (holosystolic, best heard over the fourth intercostal area at left sternal border)
Mitral regurgitation (holosystolic, best heard at the apex)

Respiratory examination

Rales (suggestive of heart failure)

Abdominal examination

Reduced bowel sounds (suggestive of mesenteric embolization or ileus)
Abdominal pain

Flank pain (suggestive of embolus to the kidney)
Left upper quadrant pain (suggestive of splenic infarct)

Splenomegaly

Extremities

Janeway lesions (painless hemorrhagic cutaneous lesions on the palms and soles)
Gangrene of fingers
Splinter hemorrhages
Osler's nodes (painful subcutaneous lesions in the distal fingers)

Neurological examination

❑ Full neurological exam

❑ Focal deficits (suggestive of stroke or brain abscess)
 
 
 
 
 
 
 
 
 
 
 
 
Order tests:

Blood culture (at least two sets)
❑ Order a TTE
❑ Order a TEE if one or more of the following is present

❑ Non diagnostic TTE in a suspected infective endocarditis (Class I, level of evidence B)
❑ Clinical complications (Class I, level of evidence B)
Intracardiac device leads (Class I, level of evidence B)
Staphylococcus aureus bacteremia without a known cause (Class IIa, level of evidence B)
Prosthetic valve with persistent fever without bacteremia (Class IIa, level of evidence B)
Prosthetic valve with a new murmur (Class IIa, level of evidence B)
❑ Nosocomial Staphylococcus aureus bacteremia with known extra-cardiac port of entry (Class IIb, level of evidence B)
 
 
 
 
 
 
 
 
 
 
 
 
Evaluate the Modified Duke Criteria for infective endocarditis:[7]
Probability of infective endocaritis Characteristics
Definite diagnosis by pathological criteria❑ Microorganisms demonstrated by culture or histological examination
of a vegetation, OR
❑ Pathological lesions; vegetation or intracardiac abscess confirmed by histological
examination showing active endocarditis
Definite diagnosis by clinical criteria❑ 2 major criteria, OR

❑ 1 major criterion and 3 minor criteria, OR

❑ 5 minor criteria
Possible diagnosis❑ 1 major criterion and 1 minor criterion, OR
❑ 3 minor criteria
Rejected diagnosis❑ Firm alternative diagnosis explaining evidence of infective endocarditis, OR

❑ Resolution of infective endocarditis with antibiotic therapy for 4 days, OR
❑ No pathological evidence of infective endocarditis at surgery or autopsy, with antibiotic therapy for 4 days, OR

❑ Does not meet criteria for possible infective endocarditis as above
 
 
 
 
 
 
 
 
 
 
 
 
Consider alternative diagnoses:

❑ Culture negative endocarditis

❑ Previous treatment with antibiotics
❑ Fastidious bacterial infection
Fungal infection
❑ Inappropriate blood culture technique

Marantic endocarditis

❑ Valvular vegetations
❑ Negative blood culture
❑ Hypercoagulable state, lupus or antiphospholipid syndrome

Cellulitis (skin inflammatory skin)
Catheter related infection (presence of catheter associated with associated local erythema and tenderness)
Cardiac device infection
Prosthetic joint infection (localized inflammatory signs)
Pneumonia
Osteomyelitis
Fever of unknown origin

Cotton fever[5]
 
 
 
 

Treatment

Shown below is an algorithm depicting the management of infective endocarditis.[1][2]

Abbreviations: TEE: Transesophageal echocardiography; TTE: Transthoracic echocardiography

 
 
Once the diagnosis of infective endocarditis is confirmed, initiate the treatment:

❑ Begin antibiotic treatment
❑ Order blood cultures every 24-48 hours until no bacteremia can be detected
❑ Temporarily discontinue anticoagulation if one of the following is present

❑ Signs and symptoms of CNS involvement consistent with embolism or stroke (Class IIa, level of evidence B)
Vitamin K antagonist administration (Class IIb, level of evidence B)

❑ Remove the pacemaker of the defibrillator system if one of the following is present

❑ Documented infection of the device or leads (Class I, level of evidence B)
❑ Valvular infective endocarditis by Staphylococcus aureus or fungi in the absence of documented infection of the device or leads (Class IIa, level of evidence B)
❑ Patient scheduled for valve surgery (Class IIa, level of evidence C)
❑ Persistent vegetations and recurrent emboli despite the antibiotic regimen (Class IIa, level of evidence B)

❑ Manage the patient with a multidisciplinary team

❑ Consult an infectious disease specialist
❑ Consult a cardiologist
❑ Consult a cardiac surgeon
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any of the following conditions that require an early valve replacement surgery during hospitalization?

Heart failure due to the valve dysfunction (Class I, level of evidence B)
❑ Left sided infective endocarditis due to staphylococcus aureus, fungal or highly resistant organisms (Class I, level of evidence B)
Heart block, annular or aortic abscess or destructive lesions (Class I, level of evidence B)
❑ Persistent bacteremia or fever 5 to 7 following the initiation of the antibiotics (Class I, level of evidence B)
❑ Relapse of the infection depsite a complete course of antibiotics in prosthetic valve endocarditis when no portal of infection can be identified (Class I, level of evidence C)
❑ Recurrent emboli and persistent vegetations despite antibiotic therapy (Class IIa, level of evidence B)
❑ Mobile vegetations with a length more than 10 mm in native valve endocarditis(Class IIb, level of evidence B)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
❑ Schedule for early surgery
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Follow up the patient:

❑ Repeat TTE before discharge
❑ Refer for cessation of drug abuse (if applicable)
❑ Educate the patient about the signs and symptoms of infective endocarditis
❑ Recommend a thorough dental examination
❑ Monitor for complications

❑ Relapse (fever, chills)
❑ New or worsening heart failure
Antibiotic toxicity
❑ Vestibular toxicity
Diarrhea or colitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Reevaluate the patient with TTE and/or TEE if one of the following is present:

❑ Change in clinical signs and symptoms

❑ New murmur
Embolism
❑ Persistent fever
Heart failure
Abscess
Atrioventricular heart block

❑ High risk of complications

❑ Large vegetations on echocardiogram
Staphylococcus, enterecoccal, or fungal infections
 
 
 
 

Antibiotic Regimens

A complete list of pathogen specific antibiotics regimens with appropriate dosages and duration of treatment is available here.

Modified Duke Criteria

Shown below is a table summarizing the major and minor Modified Duke Criteria.[7]

Modified Duke Criteria
Major criteria Minor criteria
1- Positive Blood Culture for Infective Endocarditis

❑ Typical microorganism consistent with infective endocarditis from 2 separate blood cultures, in the absence of a primary focus:

Viridans streptococci, streptococcus bovis
HACEK group
❑ Community-acquired staphylococcus aureus
Enterococci


OR

❑ Microorganisms consistent with infective endocarditis from persistently positive blood cultures defined as:

❑ At least 2 positive cultures of blood samples drawn >12 hours apart, or
❑ All of 3 or a majority of 4 separate cultures of blood (with first and last sample drawn 1 hour apart)


OR

❑ Single positive blood culture for Coxiella burnetii or anti–phase 1 IgG antibody titer >1:800


2-Echocardiographic evidence of endocardial involvement
❑ Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomic explanation, or
Abscess, or
❑ New partial dehiscence of prosthetic valve, or
❑ New valvular regurgitation

1- Predisposition

❑ Predisposing heart condition or intravenous drug use


2- Fever
❑ Temperature > 38.0° C (100.4° F)


3- Vascular phenomena
Major arterial emboli
❑ Septic pulmonary infarcts
Mycotic aneurysm
Intracranial hemorrhage
Conjunctival hemorrhage
Janeway lesions


4- Immunologic phenomena
Glomerulonephritis
Osler's nodes
Roth spots
Rheumatoid factor


5- Microbiological evidence
❑ Positive blood culture but does not meet a major criterion as noted above

OR

❑ Serological evidence of active infection with organism consistent with infectious endocarditis


Do's

  • If HACEK bacteremia is detected without any focus of infection, suspect the presence of infective endocarditis even in the absence of the typical signs and symptoms.[2]

Don'ts

  • Do not administer infective endocarditis prophylaxis for the following dental procedures:
    • Anesthetic injections in noninfected tissue
    • Dental radiographs
    • Shedding of deciduous teeth
    • Placement of orthodontic brackets
    • Placement or removal of prosthodontic or orthodontic appliances
    • Adjustment of orthodontic appliances
    • Bleeding following trauma to the oral mucosa or lips[8]

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary". Retrieved 4 March 2014.
  2. 2.0 2.1 2.2 2.3 2.4 Baddour, LM.; Wilson, WR.; Bayer, AS.; Fowler, VG.; Bolger, AF.; Levison, ME.; Ferrieri, P.; Gerber, MA.; Tani, LY. (2005). "Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America". Circulation. 111 (23): e394–434. doi:10.1161/CIRCULATIONAHA.105.165564. PMID 15956145. Unknown parameter |month= ignored (help)
  3. 3.0 3.1 Weinstein L (1986). "Life-threatening complications of infective endocarditis and their management". Arch Intern Med. 146 (5): 953–7. PMID 3516105.
  4. Frontera JA, Gradon JD (2000). "Right-side endocarditis in injection drug users: review of proposed mechanisms of pathogenesis". Clin Infect Dis. 30 (2): 374–9. doi:10.1086/313664. PMID 10671344.
  5. 5.0 5.1 Harrison DW, Walls RM (1990). ""Cotton fever": a benign febrile syndrome in intravenous drug abusers". J Emerg Med. 8 (2): 135–9. PMID 2362114.
  6. 6.0 6.1 6.2 Lockhart PB, Brennan MT, Thornhill M, Michalowicz BS, Noll J, Bahrani-Mougeot FK; et al. (2009). "Poor oral hygiene as a risk factor for infective endocarditis-related bacteremia". J Am Dent Assoc. 140 (10): 1238–44. PMC 2770162. PMID 19797553.
  7. 7.0 7.1 Li JS, Sexton DJ, Mick N, Nettles R, Fowler VG, Ryan T; et al. (2000). "Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis". Clin Infect Dis. 30 (4): 633–8. doi:10.1086/313753. PMID 10770721.
  8. 8.0 8.1 Bonow RO, Carabello BA, Chatterjee K; et al. (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Unknown parameter |month= ignored (help)


Template:WikiDoc Sources