Infective endocarditis

Definitions 感染性心內膜炎即microorganisms在endocardium內生長

Nonbacterial thrombotics endocarditis Transient bacteremia IE Pathophysiology Endothelium injury Perexisting valvular or congenital heart defects IDU (injected drug user) Nonbacterial thrombotics endocarditis Hypercoagulable states Transient bacteremia IE

Prolonged unexplained fever 2-D echo reveal vagitation 什麼人要懷疑 IE Fever with Pre-existing valvular abnormalities (Table 152-1) IDUs Prosthetic Valve endocarditis Prolonged unexplained fever 2-D echo reveal vagitation

course Acute Subacute 多為S. aureus 感染 快速進展 High fever and rigors 破壞心臟結構且易轉移至遠端 Death within days to weeks if no treat Subacute 緩慢的病程, 其常見的complication embolic event ruptured mycotic aneurysm heart failure.

Clinical symptoms and sign (Tintinalli table 145-2) Fever 80% Chills 40 Weakness dyspnea Anorexia 25 cough Malaise Skin lesion 20 Headache stroke Chest apin 15 Abd. pain Fever 90% Heart murmur 85 New murmur 3~5 Changing murmur 5~10 Skin表現 18~50 Oslar node 10~23 Splinter hemorrhage 15 Petechiae 20-40 Janeway lesion <10 Embolic phenomena >50 Septic complication 20 Mycotic aneurysm splenomegaly 20~57

Diagnosis: Duke criteria major criteria Positive blood culture for I.E. Evidence of endocardial involvement Positve echocardiogram finding for I.E. New valvular regurgitation

Duke Criteria Minor criteria Predisposition Fever: > 38.0 C predisposing heart condition I.V drug use Fever: > 38.0 C Vascular phenomena: septic emboli, mycotic aneurysm, ICH, Janeway lesions Immunologic phenomena: glomerulonephritis, Osler nodes, Roth spots Microbiologic evidence : consistent Echocardiogram : consistent

Definite infective endocarditis : Duke criteria Definite infective endocarditis : Pathologic criteria Clinical criteria (sensitivity: 90%) 2 major 1 major + 3 minor criteria 5 minor criteria possible infective endocarditis (介於中間) Rejected Firm alternate diagnosis Resolution of manifestations of IE within 4 days after ABx treatment Surgery or autopsy: no evidence of IE

Lab and exam EKG CXR CBC/DC, SMA ESR U/A 2D-echo TTE or TEE

Initial stabilization Stroke: standard protocol Treatment Initial stabilization Stroke: standard protocol Acute cardiac decompensation Afterload reduction IABP for MV rupture (不能用在AV rupture)

Antibiotics for 4~6 weeks Native (多streptococcus) Treatment Antibiotics for 4~6 weeks Native (多streptococcus) Penicillin 3 MU st and q4h + Gentamycin 1mg/kg st and q8h IV drug abuser (多S. aureus) Oxacillin 2g st and q4h + Gentamycin 1mg/kg st and q8h Prosthetic vulve: Vancomycin 15mg/kg q12h+ Gentamycin 1mg/kg q8h+ Rifampin 300 mg q8h po

Indications for cardiac surgery in Native IE Severe valvular dysfunction hemodynamic instability or acute heart failure Relapsing prosthetic valve endocarditis Major embolic complications New conduction defects or arrhythmias Unresponsive infection fungal / G(-) bacillus endocarditis persistent bacteremia paravalvular invasion & abscess

Protocol

Reference 1.Internal medicine , Harrison 16th edition 2.Uptodate :infective endocarditis 3.Emergency Medicine: A Comprehensive Study Guide 6th edition, Chapter: infective endocarditis

Practice 46 y/o male, cachexia status Visited LMD 3 days ago due to general weakness, fever and left side weakness LMD treatment with hydration and UTI (RBC: 250/HPF, WBC: 120/HPF) Progressively SOB  intubation after treatment  transfer to our ER Vital sign: HR: 150/min, BP: 90/60, RR: 36/min