1. Infective endocarditis

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

3. 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

4. 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

5. 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.

6. 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

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

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

9. 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

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

11. 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)

12. 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

13. 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

14. Protocol

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

16. 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