1. Endocarditis Tutoring
By Alaina Darby

2. A defect in which valve would put a patient at the most risk for endocarditis?
Aortic
Tricuspid
Pulmonic
Mitral d

3. GR is a 21 yo WF who had a mitral defect at birth that couldn’t be totally repaired. Which of the following would put her at least risk for endocarditis?
Wisdom tooth extraction
Gum tissue graft
Tooth brushing
Upper airway procedure c

4. If a patient presents with fever, a new murmur, and pulmonary infarct, what pathogen should you most likely suspect?
Strep mutans
Strep bovis
Staph aureus
Pseudomonas c

5. BG is a 34 yo WF who is suspected to have endocarditis
BG is a 34 yo WF who is suspected to have endocarditis. She injects heroin sometimes when with friends. Which valve is most likely infected?
Aortic
Tricuspid
Pulmonic
Mitral b

6. BG is a 34 yo WF who is suspected to have endocarditis
BG is a 34 yo WF who is suspected to have endocarditis. She injects heroin sometimes when with friends. Which sign/symptom would most likely not be seen?
New murmur
Chills
Splenomegaly
Weight loss c

7. BG is a 34 yo WF who is suspected to have endocarditis
BG is a 34 yo WF who is suspected to have endocarditis. She injects heroin sometimes when with friends. Which vascular complication would be more likely in this patient?
Pulmonary infarct
Janeway lesions
Conjunctival hemorrhage
Arterial emboli a

8. DM is a 45 yo WM who comes in complaining of pain in his leg and seems somewhat confused. What would you not want to do immediately?
ECHO
Get blood cultures
Take history
Bolus fluids
Vitals:
RR 26
Temp 38.3
HR 64
BP 115/76 d

9. DM is a 45 yo WM who comes in complaining of pain in his leg and seems somewhat confused. When taking cultures, how many tubes of blood should you get?
At least 2
At least 3
At least 4
At least 5
Vitals:
RR 26
Temp 38.3
HR 64
BP 115/76 c

10. ER has a positive ECHO with cultures positive for E. coli
ER has a positive ECHO with cultures positive for E. coli. He also has a preexisting murmur. How would you diagnose him?
Definite IE
Possible IE
Rejected
Vitals:
RR 26
Temp 37.8
HR 64
BP 115/76 b

11. JD has a positive ECHO with cultures positive for Coxiella
JD has a positive ECHO with cultures positive for Coxiella. He also has a preexisting murmur. How would you diagnose him?
Definite IE
Possible IE
Rejected
Vitals:
RR 26
Temp 37.8
HR 64
BP 115/76 b

12. Remember your bugs! Strep (viridans, bovis) Staph (aureus)
HACEK (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)
Enterococci
Coxiella b

13. JD has a positive ECHO with cultures positive for Coxiella
JD has a positive ECHO with cultures positive for Coxiella. When would you want to get another culture if there is no primary focus found?
1 hour
12 hours
24 hours
Not necessary
Vitals:
RR 26
Temp 37.8
HR 64
BP 115/76 d

14. FR has a positive ECHO with 2 cultures (one positive and one negative) for S. aureus. The cultures were taken 3 hours apart How would you diagnose?
Definite IE, no more cultures needed
Possible IE, another culture 1 hour from last
Possible IE, at least 2 more cultures 1 hour apart
Reject IE, look for another cause of symptoms
Vitals:
RR 26
Temp 37.8
HR 64
BP 115/76 c

15. Time your cultures appropriately!
1 culture… Coxiella ONLY!
2 cultures… 12 hours apart
3 cultures… all positive, 1 hour apart
4 cultures… most positive, 1 hour apart b

16. Which bug(s) should you also consider in an IVDU with left-sided IE but not in other populations?
S. aureus
HACEK
Pseudomonas
No special considerations d

17. JR presents with a new murmur and positive ECHO but his cultures are negative. He has a bite wound on his hand. How should you treat him?
Penicillin
Ceftriaxone
Vancomycin
Rifampin b

18. JR presents with a new murmur and positive ECHO but his cultures are negative. He has a bite wound on his hand. What is the most likely pathogen?
Haemophilus
Aggregatibacter
Cardiobacterium
Eikenella d

19. PB has a prosthetic valve that was placed 9 months ago
PB has a prosthetic valve that was placed 9 months ago. He presents with symptoms diagnostic of IE. How should you treat him empirically?
Vanc + cefepime + gent + rifampin
Vanc + augmentin
Vanc + ceftriaxone
Vanc + cefepime a

20. PB has a prosthetic valve that was placed 9 months ago
PB has a prosthetic valve that was placed 9 months ago. He presents with symptoms diagnostic of IE. What are your major concerns with this regimen?
Hepatic failure
Kidney failure
Hemolysis
Hearing loss b

21. PB (70kg) has a prosthetic valve that was placed 9 months ago
PB (70kg) has a prosthetic valve that was placed 9 months ago. He presents with symptoms diagnostic of IE. Cultures come back with penicillin susceptible S. viridans. How should you treat?
Ceftriaxone 2g Q24 x 6 weeks
Ceftriaxone 2g Q24 + gentamicin 200mg x 2 weeks
Ceftriaxone 2g Q24 + gentamicin 200mg x 4 weeks
Ceftriaxone 2g Q24 + gentamicin 200mg x 6 weeks a

22. PB (70kg) has a prosthetic valve that was placed 9 months ago
PB (70kg) has a prosthetic valve that was placed 9 months ago. He presents with symptoms diagnostic of IE. Cultures come back with penicillin susceptible S. viridans. You decide to use ceftriaxone 2g Q24 x 6 weeks. If you add gentamicin, how should you dose it?
100mg Q12 x 2 weeks
200mg Q24 x 2 weeks
100mg Q12 x 6 weeks
200mg Q24 x 6 weeks b

23. To which patient would you not consider adding gentamicin?
Native valve strep
Native valve staph
Prosthetic valve strep
Prosthetic valve staph b

24. Which of the following should be added for an IVDU, most likely?
Vancomycin
Ampicillin
Gentamicin
Zosyn d

25. Prosthetic (> 6 weeks)
Dosing is important!!
Strep
Staph
Native (2-4 weeks)
Prosthetic (6 weeks)
Native (6 weeks)
Prosthetic (> 6 weeks)
*PCN million U/day
Nafcillin 12 g/day
*Nafcillin 12 g/day
*Ceftriaxone 2 g/day
Cefazolin 6 g/day
*Rifampin 900 g/day
Vanc 30 mg/kg/day
*Vanc 30 mg/kg/day
This is total daily dose… some are divided into multiple doses
These are just the basics… be able to differentiate treatment in MRSA vs MSSA
*May add gent for 2 weeks

26. PB (70kg) has a native valve that was placed 9 months ago
PB (70kg) has a native valve that was placed 9 months ago. He presents with symptoms diagnostic of IE. Cultures come back with enterococcus. Which should be used?
Ceftriaxone 2 g IV q12 hours
Ceftriaxone 2 g IV q24 hours
Ampicillin 2 g IV q4 hours
PCN-G 8 million units IV 6x per day c

27. JF has IE and a prosthetic valve that was placed 9 months ago
JF has IE and a prosthetic valve that was placed 9 months ago. Cultures come back with enterococcus. He has been treated with ampicillin for 7 days now and his cultures came back clear 5 days ago. How long should therapy continue?
21 days
23 days
37 days
42 days c

28. Which drug should not be used for MRSA?
Vancomycin
Daptomycin
Vanco + Nafcillin
Linezolid D

29. Who should receive prophylaxis?
Prosthetic cardiac valve undergoing dental surgery
Repaired CHD undergoing dental surgery
Prosthetic cardiac valve undergoing GI surgery
Repaired CHD undergoing GI surgery a

30. Your patient is allergic to PCN and needs prophylaxis for a dental procedure. What is preferred?
Amoxicillin 2 g PO
Ceftriaxone 1 g IM
Clindamycin 600 mg PO
Azithromycin 500 mg PO c