1. Fingernails

2. Conjunctiva

3. Skin

4. CT ABDOMEN

5. MRI BRAIN

6. Infective Endocarditis

7. Duke Criteria Definative: 2 major, 1 major and 3 minor, 5 minor
Possible: 1 major and 1 minor OR 3 minor crieria met

8. Duke Criteria Major: Positive Blood culture:
Evidence of endocardial involvement

9. Duke Criteria – Major Positive Blood culture:
Typical microorganism for infective endocarditis from two separate blood cultures
Viridans Streptococci, streptococcus bovis, HACEK group, staph aureas, Community acquired enterococcus in absence of a primary focus OR
Persistently positive blood culture (3/4 cultures or 2 cultures >12 hours apart)
Single positive for coxiella bunetti, or phase I IgG titer of >1:800

10. Duke Criteria – Major Endocardial Involvement Positive Echo:
Oscillating intracardiac mass on valve or supporting structures in the path of regurgitant jet or in implanted material in the absence of an alternative anatomic explanation
Abscess
New partial dehiscence of prosthetic valve
New Valvular Regurgitation
Increase or change in previous murmur not sufficient

11. Duke Criteria – Minor Predisposing condition Fever ≥38.0 C
Abnormal valve (prior endocarditis, rheumatic valvular disease, Aortic Valvular disease, complex cyanotic lesions, prosthesis
Abnormal risk (IVDU, indwelling catheters, poor dentition, hemodialysis, DM
Fever ≥38.0 C
Vascular Phenomena:
Major arterial emboli, septic pulmonary infarctions, mycotic aneurism, intracranial hemorrhage, conjunctival hemorrhages, Janeway lesions

12. Duke Criteria – Minor
Immunologic Phenomena: Glomerulonephritis, Osler;s nodes, Roth’s sports, rheumatoid factor
Microbiologic evidence:
Positive blood culture but not meeting major criteria
Usu: gnr’s
Serologic evidence of active infection with organism consistent with infective endocarditis

13. IE - Acute vs. Subacute Acute More virulent pathogen
Rapid valvular damage
Rapid hematogenous seeding of extracardiac sites
Untreated leads to death in days to weeks
Typical exam findings of vascular phenomenon: Janeway lesions, emboli, mycotic aneurisms

14. IE - Acute vs. Subacute Acute Organisms
Staphylococcus Aureas (MRSA and MSSA)
Beta Hemolytic Streptococcus
Pneumococcus
Enterococcus, Coag negative Staph (less commonly)

15. IE - Acute vs. Subacute Subacute Indolent course.
gradual valvular damage
Rarely has seeding of extracardiac sites
Generally has more signs of rhematologic activation: roth spots, RF+, osler’s nodes, GN

16. IE - Acute vs. Subacute Subacute Organisms Viridan’s Streptococcus
Enterococci
Coagulase negative Staph
HACEK
haemophilus ssp.,
actinobaciullus actinomycetemcomitans,
cadiobacterium hominis,
eikenella corrodens,
kingella ssp.
Strep Bovis with colon cancer.

17. Age old Debate - TTE vs. TEE

18. Cardiac Complications
CHF – 30-40%
Consequence of valvular disease
Perivalvular Abscess
Perivalvular fistula
Pericarditis
Varying degrees of heart block
Mitral: may interrupt the AV node, or bundle of his
Aortic: non-cardiac or right sinus: upper interventricular system.

19. Extra-cardiac Findings
Musculoskeletal
Septic and reative arthritis, bone infarctions, back pain,
Skin
Subungual hemorrhages, janeway lesions, osler’s nodes,
Eyes:
Roth’s spots, conjunctival petichiae,
Neuro:
CVA in up to 40%, aseptic and purulent meningitis, intracranial hemorrhage, seizures, encephalopathy, microabscesses in brain and meninges,
Renal:
Immune complex deposition in GBM, embolic infarcts, abscesses
Embolic:
Any organ can be involved but most often are skin, kidneys, spleen, skeletal system, brain and meninges

20. Treatment Medical Management:
Difficult to eradicate bacteria from the valve.
Should use long course of IV bacteriocidal antibiotics and static antibiotics should be avoided.
Antibiotic management should be held for cultures to be drawn.
Either 4 over the course of an hour, or 2 and 2 12 hours apart.
Even with appropriate management some may continue to spike fevers and have + BC

21. Treatment – Medical Mgmt.
Strep ssp.:
Pen sensitive: Penicillin G, ceftriaxone, vanc for 4 wks, OR penicilin/ceftr plus gent for 2 weeks
Pen resistant: Penicillin G plus gent for 4-6wks OR Vanc 4 weeks
Enterococcus:
Pen g plus gen for 4-6 weeks, OR Amp plus gent for 4-6 weeks, OR vank plus gent for 4-6 weeks
HACEK:
Ceftriaxone for 4 weeks OR Amp/Sulbactam 4 weeks

22. Treatment – Medical Mgmt.
MRSA
Native valve
Vanc for 4-6 weeks
Prosthetic valve
Vanc plus gent plus rifampin for 6-8 weeks
MSSA
Naf/oxacillin/cefazolin 4-6 wks plus gent for 4-5 days, OR vanc for 4-6 weeks
Naf/oxacillin for 6-8 weeks plus gent for 2 weeks plus rifampin for 6-8 weeks

23. Treatment – Surgical When to consider surgical therapy
Emergent (same day):
aortic reguritation and preclosure of mitral valve
sinus of valsalva abscess rupture into right heart
rupture into pericardial sac

24. Treatment – Surgical Urgent (1-2 days):
Valve obstruction by vegitation
Unstable prosthesis
Ao regurgitation with NYHA 3-4 CHF
Septal perforation
Perivalvular infection
Lack of effective antibiotic therapy
Major embolus plus persisting large vegetation (evidence conflicting but concensus opinion)

25. Treatment – Surgical Elective (earlier usually preferred):
Progressive paravalvular prothetic regurgitation
Valve dysfuntion plus persistent infection after 7-10 days of Abx
Fungal endocarditis (specifically mold)
Prosthetic vave:
With staph
<2 moths after preplacement
Fungal
Antibiotic resistant

26. Treatment – Surgical Abx after surgery:
If native valve and uncomplicated with negative valve cultures:
2 weeks of post operative antibiotics OR a total full duration of above regimen whichever is longer
If complicated by perivalvular abscess, partially treated prosthetic valve infection or cases with culture positive valves:
Full course of antibiotics after surgery

27. Complication rate:
Mortality with staph aureas: 70% with medical management - decreases to 25% with surgical intervention
Splenic abscess 3-5%
Should be treated with drain placement
Mycotic aneurisms: 2-15%, 50% in cerebral vasculature
Some resolve with Abx so monitor with cerebral angiography recommended
Persistent enlarging or periferal aneurisms should be resected surgically if possible
Vegitations
50% remain unchanged 3 months after cure is achieved, and 25% have slight improvement

28. Prophylaxis: Indications: Prosthetic heart valves Prior endocarditis
Unrepaired cyanotic congenital heart disease
Completely repaired congential heart disease <6 months after repair)
Incompletely repaired congenital heart diease with residual defects adjacent to prosthetic material
Valvulopathy developing after cardiac transplantation

29. Prophylaxis: Regimens:
Standard: amoxicillin 2.0 g PO 1 hour prior to procedure
If pen allergic:
clarithromycin or azithro 500 mg prior to procedure
Cefalexin 2.0 g PO prior to procedure
Clindamycin 600 mg prior to procedure

30. Bibliography
Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service. American Journal of Medicine. 96(3):200-9, 1994.
Jennifer S. Li, Daniel J. Sexton, Nathan Mick, Richard Nettles, Vance G. Fowler, Jr., Thomas Ryan, Thomas Bashore, G. Ralph Corey . Proposed Modifications to the Duke Criteria for the Diagnosis of Infective Endocarditis. Clinical Infectious Diseases, Vol. 30, No. 4 (Apr., 2000), pp
Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, Loscalzo J. (2008). Harrison's principles of internal medicine (17th ed.). Pp ; New York: McGraw-Hill Medical Publishing Division
Fuster, O’rourke, Walsh, Poole-Wilson. (2008). Hurst’s The heart Manual of Cardiology (12th ed.) New York: McGraw-Hill Medical Publishing Division