"Infectious Endocarditis: Diagnosis and Treatment" (A Synopsis)

Infectious Endocarditis: Diagnosis and Treatment
DEBORAH PIERCE, MD, MPH; BETHANY C. CALKINS, MD; and KRISTEN THORNTON, MD, University of Rochester School of Medicine and Dentistry, Rochester, New York
Am Fam Physician. 2012 May 15;85(10):981-986.
http://www.aafp.org/afp/2012/0515/p981.pdf

     Infectious endocarditis occurs when bacterial or fungus attach to endocardium or to a prosthetic valve, and form vegetations and thrombi. Risk factors include dialysis, IVDA, congenital disease, valve disease, and rheumatic heart disease. Early infection occurs within 2 months of a valve replacement or operation. Late infections occur after 12 months. Symptoms include unexplained fever, night sweats, and signs or a systemic infection. The Duke criteria classifies the endocarditis into definite (2 major, 1 major + 3 minor, or 5 minor), possible (1 major + 1-2 minor, or 3 minor), or rejected. 

The major criteria are;
2 separate blood cultures infected with endocarditis bacteria, or
positive blood cultures drawn 12 hours apart, or
positive blood cultures from all 3 or most of 4 cultures drawn an hour apart, or
blood positive for Coxiella burnetii  or IGG ab titer, or
positive findings on echo.

Minor criteria include;
fever of 100.4F or more,
glomerulonephritis, osler nodes, roth spots, RF,
positive blood cultures that don't meet major criteria,
history of IVDA or predisposing heart condition,
vascular phenomenon (arterial emboli, pulmonary infarct, mycotic aneurysm, intracranial hemorrhage, janeway lesions)
     Evaluation starts with a cardiac evaluation. Physical exam may reveal heart failure, a regurgitant murmur, roth spots on the retina, hemorrhagic janeway lesions on the palms or soles, painful osler nodes on the palms or soles, or petechiae on the mucus membranes. Blood cultures should be drawn before antibiotics. Urinalysis may show hematuria, proteinuria, or pyuria. An ECG can be done as a baseline. TEE may be necessary in patients with staphylococcal bacteremia, obesity, mechanical ventilation, or a prosthetic valve that obscures visualization.
     Treatment includes antibiotics. Empiric therapy consists or vancomycin or ampicillin/sulbactam plus an aminoglycoside. Cultures and sensitivity can can help guide therapy. Anticoagulation should be held for the first two weeks of antibiotic therapy.  Patients with fungal infection, aggressive bacterial infection, multiple embolic events, left sided endocarditis, valve dehiscence or rupture, or perivalvular abscess will need a surgical consult.