Understanding Endocarditis for PANCE Exam

Okay, so today we're going over endocarditis. Normally I like to do a few different topics when we're on a YouTube video, but endocarditis has so much that you need to know for the pants that I felt like it'd be good just to dedicate to one video. So again, really quickly, I always want to thank you so much for all the reviews, the likes on YouTube, the new subscriptions. I really appreciate it. Thank you so much for that. And if you haven't checked out my podcast, I think it's a really good addition to this when you're on the go and you're driving to clinicals and things like that to help out. So if you haven't checked that out yet, definitely go ahead and... check that out on apple podcast or spotify all right so let's go ahead and get started with endocarditis so what is infectious endocarditis so this is going to be an infection of the endocardial surface of the heart which is obviously the inner layer of tissue that lines the the chambers of the heart and usually the the infection is going to be of one or more of the native heart valves it can also be on prosthetic valves as well as intracardiac devices now the most common area the most common valve to be infected is actually going to be the mitral valve as we can see here in this diagram and what you're going to see here is these vegetations or these lesions on the valves so this infection actually lines these valves and causes a lot of different problems as we'll go over later that's what it looks like on uh you know just an animation there again like i went over most common valve is going to be to be involved is going to be the mitral valve now there's an exception unless the patient is an iv drug user in which case the most common valve to be involved in an IV drug user is going to be the tricuspid valve. And actually in 90% of patients with right-sided infectious endocarditis, of course, tricuspid valves on the right, about 90% of patients with right-sided endocarditis are going to be IV drug users. So tricuspid valve, most common in an IV drug user. The way I always remember that, I remembered somebody saying to me, I want to try drugs, like tri, TRI, tricuspid drugs, IV drug users, most common valve is the... tricuspid and IV drug users. Just remember the sentence, we want to try drugs, and then you can think of the tricuspid valve. That's just an easy way to remember it. Now, risk factors. You need to be at least somewhat familiar with these, so you can pick them out on a vignette and kind of, you know, point you to endocarditis. So a few different things as far as risk factors. Normally, it's going to be in older individuals, typically over 60. About half of all cases are patients over 60. There is a slight male to female predominance, about a three to two ratio. IV drug use obviously like we already went over is a is a factor as a risk factor for Dentition or dental infection can actually cause some cases of an infectious card and endocarditis as we'll go over later history of structural heart disease or valvular heart disease can predispose patients and then of course a history of Infectious endocarditis, which is pretty obvious, but it is a is a risk factor Of course and then presence of prosthetic heart valves now the different types I think you should be familiar with the different types because there's a few things, not a lot, there's a few things that you need to know about each individual type that's going to help you as far as choosing treatment, as far as knowing the organisms that are going to be involved, and the presentation, things like that. So let's go over a few things I feel you need to know for each one. So let's start with acute bacterial endocarditis. So these patients with acute bacterial endocarditis are generally going to have normal valves they're not going to have any problems they're not going to have any history of valvular regurgitation anything like that normal healthy valves nothing wrong with the valves in most cases with acute bacterial endocarditis now the most common organism is going to be a more hostile or virulent organism and it has to be because it's healthy tissue that it's infecting it's not vulnerable tissue so it has to be pretty virulent pretty hostile pretty and the most common organism in acute bacterial endocarditis is going to be staph aureus rupee strep is also seen but not as common as staph aureus so that's going to be your most common cause in acute bacterial endocarditis and then this is going to be a sudden onset so it's hours to days pretty quick onset for acute bacterial endocarditis now subacute bacterial endocarditis is a little bit different than you're going to see with acute now with subacute typically the the valves are going to be damaged heart valves abnormal they're going to have regurge different things going on with these valves but they're going to be susceptible they're going to be vulnerable and because of that the organisms are less virulent they're less aggressive compared to the ones we see in acute bacterial endocarditis and actually the most common organism is uh strep viridans and strep viridans is actually part of your normal oral flora so in a normal patient you can have some kind of dental procedure routine dental cleaning it'll cause no problems this bacteria would just be flushed out but in a patient that has these abnormal damaged valves can have a routine dental cleaning they can have a tooth tooth pulled and actually wind up with um subacute bacterial endocarditis so it doesn't need to be as aggressive the most common organism is strep viridans remember that and then the onset is going to be much more indolent it's going to be a slower insidious onset sometimes it can actually take months for these patients to become symptomatic so that's the difference between acute and subacute so remember those things for those Then a couple more that we want to go through. So IV drug use related endocarditis. Usually no underlying valvular abnormalities. And then of course, or actually, Staph aureus can be your most common organism, particularly MRSA in these patients. So methicillin-resistant Staph aureus, but overall Staph aureus, most common organism. And then the most common valve to be infected, again, is the tricuspid valve. Want to try drugs, remember that. And then finally, prosthetic valve endocarditis. This is going to be two different types. There's gonna be your acute and then your late prosthetic valve endocarditis. So. early is going to be less than 60 days from implantation or you know the valve repair less than 60 days and then late prosthetic valve endocarditis is going to be over 60 days from the implantation from the surgery now the organisms involved in both late and early they vary something slightly but generally you're gonna see staph aureus coagulation negative staff and in particular the one that's going to be most common most common generally in early prosthetic valve but also in late is going to be staph epidermitis so overall most common organism is going to be staph epidermitis you're also going to see strap a few different things but the one you really need to know for the boards is going to be staph epidermitis in prosthetic valve endocarditis so those are the the different types now i want you also to be familiar with the organisms so we briefly went over the organisms there's a few that we didn't touch on yet but i'm going to go over those now And then what I want to do is give you some ways to remember all the organisms because there's a lot. There's Staph aureus, there's Strep viridans, there's a whole bunch that you need to know. And you need to know which ones, which type of endocarditis they go with. So I have some ways for you to remember that. So let's go through those now. So the organisms. First, Staph aureus. Now Staph aureus has an A in aureus. So what does that mean? So when you see Staph aureus, think of A for acute. Most common organism seen in acute endocarditis. And the other A stands for addiction. so think about drugs addiction it's the most common organism seen in iv drug use endocarditis so as soon as you see staph aureus think of that your two a's acute most common organism in acute and addiction most common organism in iv drug use now strep viridans look at that v start thinking of things with v so this is the most common organism in subacute infectious endocarditis which involves these abnormal or vulnerable valves so as soon as you see step viridans think of vulnerable valves and that leads you to the subacute endocarditis remember the vulnerable valves have this less aggressive less virulent organism which is the strep viridans that's that normal oral flora so you see start viridans think of these vulnerable valves and that's strep viridans now steph staff epidermitis this one you're going to think of the epi staff epidermitis and think of it's the most common organism seen in patients with prosthetic valves So you see the EPI and staph epidermitis, you should be thinking enterous prosthetic implants. As soon as you see staph epidermitis, think enterous prosthetic implants. That makes you realize that this is going to be the most common organism seen in patients with prosthetic valves. Okay, moving right along. This one we didn't go over in the different types, but there is an organism known as enterococcus. And when you see enterococcus, think of those first three letters, ENT. This is the most common organism seen in patients with a recent GI exam or GU exam. Now the two exams I want you to think of, obviously it's not only these specific ones, but it helps with the mnemonic, is going to be an enema and terp. Enema and terp, that's your ENT, so N like instead of an just N. So as soon as you see enterococcus, you should be thinking ENT, enema, which is going to be like a GI exam, and terp, which is a transurethral resection of the prostate. So that's going to be your GU exam. So that helps you remember it's seen with GI and GU exams with enema as a GI exam, terp is a GU exam. And then finally, another one is going to be strep bovis. Now strep bovis is most commonly seen in patients with a history of colon cancer or ulcerative colitis. So colon, bovis, bowel. So bovis, B-O, bowel, B-O. So that's how you remember when you see strep bovis, think of bowel because all of the problems with the bowel. Colon cancer, ulcerative colitis. so these are all the organisms and these are the types of endocarditis situations you'll see them in so this is an easy way to remember i think fairly easy to at least help i mean this isn't easy to remember all these different organisms and what you're going to see them in but i think this is at least somewhat helpful hopefully you'll remember a few of these for the exam when you see them and it can help you differentiate on the on the vignettes okay so those are the organisms let's go into clinical manifestations now Now, clinical manifestations, there's a lot of different things you'll see with endocarditis, and there's some that are common and some that are not very common. and a lot of the not very common things you probably never see in real life but they still want you to know them for the boards so let's start to go through them and i'm also going to have a way for you to remember them as well so overall your most common presenting complaint clinical manifestation is going to be fever that's what you're going to see in almost everybody keep in mind though elderly patients immunocompromised patients may have an atypical presentation and not have fever but generally with endocarditis you're going to see fever that's the most common presenting complaint Now the other ones that are common are going to be your other constitutional symptoms. So night sweats, fatigue, myalgias, all of those are pretty common. So fever, all the constitutional symptoms are pretty common. Everything else, including murmurs, are actually pretty rare and they don't happen very frequently. But you still need to know them because you may see it in real life and it's probably going to be on the boards. So let's go over all the other things you're going to see as well so you can pick these out in a vignette. Now, new onset of a murmur or worsening of an existing murmur. And then we got the weird stuff. So weird stuff. And what are the weird things? So let me go over some of the other things that you're generally not going to see in a lot of other conditions that are pretty, I wouldn't say specific, obviously can happen otherwise, but more specific to endocarditis. So Janeway lesions, these are going to be painless. Remember that because it's important to differentiate painless macules or plaques, most commonly seen on the palms or soles. That's what that looks like there. So you can see these little lesions, little plaques that are plaques here that are going to be seen on normally the palms or the soles it's jane way lesions now there's osler nodes which are painful nodules that are normally found on the pads of the fingers and the toes that's what that looks like here you can see these little small areas there on the finger those are painful and those are osler nodes now roth spots are just going to be these pale retinal lesions hemorrhages that are seen on fundoscopy that's what that looks like there obviously you can see all those little hemorrhages in the on the front fundoscopic exam and then splinter hemorrhages which are just really nail bed hemorrhages but they look in a certain way so you can see these little splintering of these the hemorrhaging of the fingernails and i actually saw this on clinical rotation we actually had a patient with this which was really interesting because you'll probably very rarely see this in real life but i did actually get to see it um in one of my er rotations so those are some of the weird things that you'll see um and then you're also going to these patients may have a higher potential for emboli and anemia now how are you going to remember all of these clinical manifestations normally i would say don't but because there's a really good mnemonic for it there's uh there's a way for you to remember all of these so what you're going to remember to remember all of the different things you're going to see in endocarditis you're going to remember i got endocarditis from jane so this isn't my mnemonic i will always admit if it's not mine and it's not original so this is something i learned at pa school but it's great and it always helped me remember this so i got endocarditis from jane from jane stands for fever rothspot oslo nodes murmur and then jane stands for janeway lesions anemia nail bed hemorrhages or splinter hemorrhaging and then emboli so i got endocarditis from jane that's how you remember all of the different clinical manifestations and all the things you'll see because you will see these on a vignette or like in my case i had it on an oski i had a patient that had Osler knows that they had anemia Janeway lesions all of these different things on my OSCE and I had to know these things and Remember that it was endocarditis. So remember I got endocarditis from Jane you won't forget that now moving on to the actual diagnosis So the thing with the diagnosis for endocarditis is that it's not a simple Okay, we did an echo and they have a vegetation on one of the valves. They have endocarditis It's actually a combination of a lot of different things. So it's based upon a bunch of different factors clinical manifestations blood cultures echo and anytime you have a diagnosis based upon all of these different factors you're going to have some form of criteria and generally what i say with criteria for the pants is and for real life of course because you can always look these up is not to memorize it there's too much it's a waste of time and you normally won't have to be able to uh to pick these through and like count up and see if you met the criteria so i'm going to go over it but i would not say to memorize it do not waste your time so modified new criteria let's go over it obviously so to meet the criteria it's about 80 specificity if you do meet this criteria that they have endocarditis you need either two major which we'll go over or one major three minor or five minor so you need to add those up and see if you get um the diet meet the diagnosis diagnostic criteria so let's go over the major criteria so major criteria is going to be two separate positive blood cultures Normally you're going to do it from two separate areas of the body so you actually get a blood culture from you know two separate areas of the body. And there's a certain amount of time in between. I can't remember. You won't have to know that for the boards, but two separate positive blood cultures, but positive for organisms that are consistent with infectious endocarditis. So it can't just be any bacteria seen. They have to be organisms that are consistent with infective endocarditis. So some of the ones we went over before, Staph aureus, Staph viridans, any one of those in two separate positive blood cultures. That's one major criteria. the other one is going to be evidence of endocardial involvement confirmed by echo so you can see vegetations present on echo an abscess formation new valvular regurg any one of these things will you know give you evidence that there is some kind of endocardial involvement and if you look at an echo you can see here this is actually the the vegetations on the mitral valve here so these are the vegetations you can see which is just basically the infection present that has these little lumps here on the actual valve. So that's what that looks like on echo. So let's move on to the minor criteria. So minor criteria is pretty easy because a lot of the minor criteria is just all the stuff from Jane. So all the things, fever, Roth spots, Janeway lesions, et cetera, each one of those is going to be a point. And then, excuse me, some of the other minor criteria is going to be either a positive echo that doesn't meet the criteria that we want to refer major. or a positive blood culture that doesn't meet the criteria for major so like the blood culture if you have some bacteria that's not consistent with infectious endocarditis that would be a minor finding and the same thing with the echo if it doesn't meet one of the criteria we went over the the vegetations and the new abscess new um any one of those changes we went over that was for major it's something different that it would be considered a minor criteria so you can have a positive blood culture a positive echo that doesn't meet those findings and it's still meets minor criteria just not major then the other thing is going to be any predisposing factor so ib drug use indwelling catheter all these are going to be a point remember as far as you know you need to add up either two major criteria one major three minor or five minor criteria to diagnose and that's um that's the the modified duke criteria and that's how you diagnose endocarditis now on to treatment so With treatment, it's not going to be very simple. It's multidisciplinary care. You're going to have infectious disease involved, cardiology, cardiac surgeons. There's going to be a bunch of different people handling these patients. But for what you need to know for the boards, you just need to be aware of the fact that a lot of these patients are going to require some kind of surgical intervention, maybe a valve replacement. But really, all you need to know otherwise is going to be the empiric antibiotic treatment. So as far as the empiric antibiotic therapy, I'm going to go over that in a second, but just be aware. that if you have a patient that comes in, they have an acute bacterial endocarditis, they're really sick, this developed fast over a few hours, a couple days, they're really sick, you can't wait for your blood cultures to come back to decide which type of bacteria it is, which antibiotics it's going to be sensitive to, they're very sick, you need to treat them empirically, which means you give these broad spectrum antibiotics to cover a bunch of different things, because you don't know what the bacteria is. Now on the flip side, if you have a patient that has subacute bacterial endocarditis, they've been sick for months, you're going to have time here so you can get your blood cultures back see what type of bacteria it is see what antibiotics it's sensitive to and treat accordingly now on the boards they're not going to give you a culture and say here's the bacteria this is what it's sensitive to because there's your answer so what they're going to want you to know is the empiric antibiotic therapy so you're going to need to memorize these because you need to know when they say okay this patient had a native valve what type of empiric antibiotic therapy you're going to know so these are the things that you need to know now for native valves, so they have their own valve, it hasn't been replaced, the antibiotics that you're going to use is an anti-staphylococcal penicillin, so nafcillin, oxacillin. Use one of those combined with either ceftriaxone or gentamicin. So two meds, you're covering your gram positive with the nafcillin and oxacillin, and then you're covering your gram negative with either the gentamicin or the ceftriaxone. So that's your broad spectrum coverage. So one of these and one of these. Now, the way that I remember that, the sentence only native cardiac gears meaning they only have native cardiac gears like gears as in valves and parts they're native so only native cardiac gears stands for oxacillin nafcillin ceftriaxone and gentamicin so remember you're only picking one of these and then one of these so you can use oxacillin with ceftriaxone nafcillin with gentamicin whatever you want just one from each to cover your gram-negative and gram-positive and remember only native cardiac gears that reminds you oxycillin, nafcillin, ceftriaxone, gentamicin, that's native valve. Now, if you have prosthetic valves, generally these are more complicated patients. They're likely going to need some kind of surgical repair replacement of the valve. But as far as the antibiotics that you need to know, that's really all you need to know. It's going to be vancom. gentamicin and rifampin so those are the three meds that you're going to use for these patients sometimes the rifampin they substitute that with a cephalosporin but most of the time it's going to be rifampin now just a side note it's not really important for your pants but vanco and gentamicin the reason you use gentamicin with vanco is actually because of the synergistic effect they actually work together much better than they do alone so bringing them together the vanco and the gentamicin actually improve their their efficacy and they actually work much better particularly against MRSA so that's why you add the gentamicin with the vanco and then rifampin again you don't need to know this for your board but i like to give you a little clinical knowledge outside of the the board stuff rifampin when you introduce rifampin you don't start it for at least two to three days after starting the the vancomycin and the gentamicin the reason you don't is because if you treat a patient with rifampin right off the bat rifampin actually has a really high rate of causing mutation in the bacteria and resistance. So with rifampin, you treat first with other antibiotics like vancomycin, gentamicin, bring down the actual population of the bacteria. And then once it's somewhat under control, then you can introduce rifampin. And it works really well. And rifampin actually, the reason you use it in this is because it actually can penetrate the biofilm of the pathogens that infect the prosthetic valve. There's actually this biofilm on some of the the uh the organisms and rifampic can penetrate it really well but keep in mind again about two to three days after you start the vancogen to mice sorry a little bit got sidetracked there but i feel like it's important for you to know once you start actually practicing what you do with these beds and why okay so treatment the way i remember that is going to be valves generally repaired replaced replicated whatever you want to think of to remember that it's a prosthetic valve it's not their original it was repaired or replaced at some point so remember the sentence valves generally repaired that helps me remember vancomycin gentamicin and rifampin valves generally repaired or replaced replicated whatever are you want to use here to remember that the valves are not their own they've been replaced or replicated whatever so that's the sentence i remember for prosthetic valve impaired treatment and then fungal really really easy fungal infection is just going to be amphotericin b for about six to eight weeks and with the native valve and the prosthetic valve treatment the antibiotics they're typically going to be for about four to six weeks you're going to treat as far as the empiric antibiotic therapy. So that's your treatment. That's really all you need to know. There is one more thing that you need to be familiar with, and that's the antibiotic prophylaxis. Now, antibiotic prophylaxis with endocarditis, you're not going to use in every patient. You're really only going to use in patients where you feel like there's a patient that has a high likelihood of some kind of adverse outcome if they did wind up getting endocarditis. So there's certain patients that are going to be more predisposed. And in patients with a history of, let's go over that now. And again, do not memorize this. This is not something you need to memorize. Be somewhat familiar with it. Hear it as I'm talking to you about it. Maybe read it once, but don't memorize it. There's just way too much and it's not worth it. It's not high yield. But if a patient does have a history of infectious endocarditis, they have an unrepaired cyanotic congenital heart disease, heart repairs using prosthetic material, not including stents, repaired congenital heart disease. disease or defects with the residual shunts, prosthetic patches or devices, valvular regurg due to a structurally abnormal valve in a transplanted heart. Those are all the patients. And again, it's ridiculous to try to memorize that. But anytime you see like a patient that has some kind of congenital heart disease, they have some valvular regurg, some kind of problem with a heart, you may want to start thinking, okay, maybe this patient needs to be prophylaxed for endocarditis. Now, the procedures you're going to prophylax for are going to be dental procedures. If there's any type of manipulation perforation of the gingival tissue So if they have like a really aggressive cleaning you may need to actually use prophylaxis If they have a tooth pulled a dental abscess anything like that where there's any manipulation of the gingival tissue You want to go ahead and use prophylaxis if they have a respiratory tract procedure But only procedures involving an incision or a biopsy so say they have a bronchoscopy, but no biopsy. You don't need to use prophylaxis But if they have a bronchoscopy and they have a biopsy, then you need to use antibiotics to prophylax. And then finally, any skin or soft tissue procedures of infected skin. Anytime you're manipulating the skin or the soft tissue, you want to have prophylaxis. So again, be familiar with these, but do not memorize it. This is an absolute waste of time for something that's very low yield. The one thing you should memorize is the actual antibiotics you need to use. And really, there's only a couple. The main antibiotic that you want to use for prophylaxis and endocarditis is going to be amoxicillin. 2 grams 30 to 60 minutes prior to the procedure that's the preferred antibiotic the only reason you're not going to use amoxicillin is if they have a penicillin allergy in which case you would use clindamycin 600 milligrams just if they have a penicillin allergy so Memorize the amoxicillin the clindamycin if you need to without the allergy, but don't remember all the other stuff. It's a waste of time Okay, so that is endocarditis I try to get through the stuff pretty quickly only stick to the high-yield stuff and hopefully that was helpful Let's do five quick questions just to see how much you've retained of what I went over So what is the most common valve involved in a patient who is an IV drug user? Hopefully you remember this because you want to think of do you want to try drugs try cuspid valve? So that's the most common valve in a patient who's an IV drug user one to try drugs tricuspid valve what is the most common organism seen in subacute endocarditis which remember infects those damaged or vulnerable valves vulnerable valves most common organism strep viridans that's going to be most common remember the v viridans vulnerable valves what are roth spots roth spots are retinal hemorrhages or lesions seen on fundoscopy you can also remember roth spot starts with an r retina starts with an r might help you What is the empiric treatment regimen for a patient with a prosthetic valve endocarditis? So prosthetic valve endocarditis, hopefully you remember the mnemonic, vancomycin, gentamicin, rifampin, and that is going to be the treatment regimen that you're going to use. So what is the most common clinical manifestation seen in patients with endocarditis? So most common clinical manifestation seen in patients with endocarditis is going to be a fever. So that's your most common clinical manifestation. okay so thank you so much um for listening to the the video i hope it was helpful thank you again for all the reviews it really does make my day when i see those i'm so happy to see that that is helping you guys so thank you again and good luck in pa school good luck on your pants your pantry and your eors

And if you haven't checked out my podcast, I think it's a really good addition to this when you're on the go and you're driving to clinicals and things like that to help out. So if you haven't checked that out yet, definitely go ahead and... check that out on apple podcast or spotify all right so let's go ahead and get started with endocarditis so what is infectious endocarditis so this is going to be an infection of the endocardial surface of the heart which is obviously the inner layer of tissue that lines the the chambers of the heart and usually the the infection is going to be of one or more of the native heart valves it can also be on prosthetic valves as well as intracardiac devices now the most common area the most common valve to be infected is actually going to be the mitral valve as we can see here in this diagram and what you're going to see here is these vegetations or these lesions on the valves so this infection actually lines these valves and causes a lot of different problems as we'll go over later that's what it looks like on uh you know just an animation there again like i went over most common valve is going to be to be involved is going to be the mitral valve now there's an exception unless the patient is an iv drug user in which case the most common valve to be involved in an IV drug user is going to be the tricuspid valve.

And actually in 90% of patients with right-sided infectious endocarditis, of course, tricuspid valves on the right, about 90% of patients with right-sided endocarditis are going to be IV drug users. So tricuspid valve, most common in an IV drug user. The way I always remember that, I remembered somebody saying to me, I want to try drugs, like tri, TRI, tricuspid drugs, IV drug users, most common valve is the...

tricuspid and IV drug users. Just remember the sentence, we want to try drugs, and then you can think of the tricuspid valve. That's just an easy way to remember it.

Now, risk factors. You need to be at least somewhat familiar with these, so you can pick them out on a vignette and kind of, you know, point you to endocarditis. So a few different things as far as risk factors.

Normally, it's going to be in older individuals, typically over 60. About half of all cases are patients over 60. There is a slight male to female predominance, about a three to two ratio. IV drug use obviously like we already went over is a is a factor as a risk factor for Dentition or dental infection can actually cause some cases of an infectious card and endocarditis as we'll go over later history of structural heart disease or valvular heart disease can predispose patients and then of course a history of Infectious endocarditis, which is pretty obvious, but it is a is a risk factor Of course and then presence of prosthetic heart valves now the different types I think you should be familiar with the different types because there's a few things, not a lot, there's a few things that you need to know about each individual type that's going to help you as far as choosing treatment, as far as knowing the organisms that are going to be involved, and the presentation, things like that. So let's go over a few things I feel you need to know for each one.

So let's start with acute bacterial endocarditis. So these patients with acute bacterial endocarditis are generally going to have normal valves they're not going to have any problems they're not going to have any history of valvular regurgitation anything like that normal healthy valves nothing wrong with the valves in most cases with acute bacterial endocarditis now the most common organism is going to be a more hostile or virulent organism and it has to be because it's healthy tissue that it's infecting it's not vulnerable tissue so it has to be pretty virulent pretty hostile pretty and the most common organism in acute bacterial endocarditis is going to be staph aureus rupee strep is also seen but not as common as staph aureus so that's going to be your most common cause in acute bacterial endocarditis and then this is going to be a sudden onset so it's hours to days pretty quick onset for acute bacterial endocarditis now subacute bacterial endocarditis is a little bit different than you're going to see with acute now with subacute typically the the valves are going to be damaged heart valves abnormal they're going to have regurge different things going on with these valves but they're going to be susceptible they're going to be vulnerable and because of that the organisms are less virulent they're less aggressive compared to the ones we see in acute bacterial endocarditis and actually the most common organism is uh strep viridans and strep viridans is actually part of your normal oral flora so in a normal patient you can have some kind of dental procedure routine dental cleaning it'll cause no problems this bacteria would just be flushed out but in a patient that has these abnormal damaged valves can have a routine dental cleaning they can have a tooth tooth pulled and actually wind up with um subacute bacterial endocarditis so it doesn't need to be as aggressive the most common organism is strep viridans remember that and then the onset is going to be much more indolent it's going to be a slower insidious onset sometimes it can actually take months for these patients to become symptomatic so that's the difference between acute and subacute so remember those things for those Then a couple more that we want to go through. So IV drug use related endocarditis.

Usually no underlying valvular abnormalities. And then of course, or actually, Staph aureus can be your most common organism, particularly MRSA in these patients. So methicillin-resistant Staph aureus, but overall Staph aureus, most common organism.

And then the most common valve to be infected, again, is the tricuspid valve. Want to try drugs, remember that. And then finally, prosthetic valve endocarditis. This is going to be two different types.

There's gonna be your acute and then your late prosthetic valve endocarditis. So. early is going to be less than 60 days from implantation or you know the valve repair less than 60 days and then late prosthetic valve endocarditis is going to be over 60 days from the implantation from the surgery now the organisms involved in both late and early they vary something slightly but generally you're gonna see staph aureus coagulation negative staff and in particular the one that's going to be most common most common generally in early prosthetic valve but also in late is going to be staph epidermitis so overall most common organism is going to be staph epidermitis you're also going to see strap a few different things but the one you really need to know for the boards is going to be staph epidermitis in prosthetic valve endocarditis so those are the the different types now i want you also to be familiar with the organisms so we briefly went over the organisms there's a few that we didn't touch on yet but i'm going to go over those now And then what I want to do is give you some ways to remember all the organisms because there's a lot.

There's Staph aureus, there's Strep viridans, there's a whole bunch that you need to know. And you need to know which ones, which type of endocarditis they go with. So I have some ways for you to remember that.

So let's go through those now. So the organisms. First, Staph aureus.

Now Staph aureus has an A in aureus. So what does that mean? So when you see Staph aureus, think of A for acute.

Most common organism seen in acute endocarditis. And the other A stands for addiction. so think about drugs addiction it's the most common organism seen in iv drug use endocarditis so as soon as you see staph aureus think of that your two a's acute most common organism in acute and addiction most common organism in iv drug use now strep viridans look at that v start thinking of things with v so this is the most common organism in subacute infectious endocarditis which involves these abnormal or vulnerable valves so as soon as you see step viridans think of vulnerable valves and that leads you to the subacute endocarditis remember the vulnerable valves have this less aggressive less virulent organism which is the strep viridans that's that normal oral flora so you see start viridans think of these vulnerable valves and that's strep viridans now steph staff epidermitis this one you're going to think of the epi staff epidermitis and think of it's the most common organism seen in patients with prosthetic valves So you see the EPI and staph epidermitis, you should be thinking enterous prosthetic implants.

As soon as you see staph epidermitis, think enterous prosthetic implants. That makes you realize that this is going to be the most common organism seen in patients with prosthetic valves. Okay, moving right along.

This one we didn't go over in the different types, but there is an organism known as enterococcus. And when you see enterococcus, think of those first three letters, ENT. This is the most common organism seen in patients with a recent GI exam or GU exam. Now the two exams I want you to think of, obviously it's not only these specific ones, but it helps with the mnemonic, is going to be an enema and terp.

Enema and terp, that's your ENT, so N like instead of an just N. So as soon as you see enterococcus, you should be thinking ENT, enema, which is going to be like a GI exam, and terp, which is a transurethral resection of the prostate. So that's going to be your GU exam.

So that helps you remember it's seen with GI and GU exams with enema as a GI exam, terp is a GU exam. And then finally, another one is going to be strep bovis. Now strep bovis is most commonly seen in patients with a history of colon cancer or ulcerative colitis. So colon, bovis, bowel.

So bovis, B-O, bowel, B-O. So that's how you remember when you see strep bovis, think of bowel because all of the problems with the bowel. Colon cancer, ulcerative colitis. so these are all the organisms and these are the types of endocarditis situations you'll see them in so this is an easy way to remember i think fairly easy to at least help i mean this isn't easy to remember all these different organisms and what you're going to see them in but i think this is at least somewhat helpful hopefully you'll remember a few of these for the exam when you see them and it can help you differentiate on the on the vignettes okay so those are the organisms let's go into clinical manifestations now Now, clinical manifestations, there's a lot of different things you'll see with endocarditis, and there's some that are common and some that are not very common. and a lot of the not very common things you probably never see in real life but they still want you to know them for the boards so let's start to go through them and i'm also going to have a way for you to remember them as well so overall your most common presenting complaint clinical manifestation is going to be fever that's what you're going to see in almost everybody keep in mind though elderly patients immunocompromised patients may have an atypical presentation and not have fever but generally with endocarditis you're going to see fever that's the most common presenting complaint Now the other ones that are common are going to be your other constitutional symptoms.

So night sweats, fatigue, myalgias, all of those are pretty common. So fever, all the constitutional symptoms are pretty common. Everything else, including murmurs, are actually pretty rare and they don't happen very frequently.

But you still need to know them because you may see it in real life and it's probably going to be on the boards. So let's go over all the other things you're going to see as well so you can pick these out in a vignette. Now, new onset of a murmur or worsening of an existing murmur. And then we got the weird stuff. So weird stuff.

And what are the weird things? So let me go over some of the other things that you're generally not going to see in a lot of other conditions that are pretty, I wouldn't say specific, obviously can happen otherwise, but more specific to endocarditis. So Janeway lesions, these are going to be painless.

Remember that because it's important to differentiate painless macules or plaques, most commonly seen on the palms or soles. That's what that looks like there. So you can see these little lesions, little plaques that are plaques here that are going to be seen on normally the palms or the soles it's jane way lesions now there's osler nodes which are painful nodules that are normally found on the pads of the fingers and the toes that's what that looks like here you can see these little small areas there on the finger those are painful and those are osler nodes now roth spots are just going to be these pale retinal lesions hemorrhages that are seen on fundoscopy that's what that looks like there obviously you can see all those little hemorrhages in the on the front fundoscopic exam and then splinter hemorrhages which are just really nail bed hemorrhages but they look in a certain way so you can see these little splintering of these the hemorrhaging of the fingernails and i actually saw this on clinical rotation we actually had a patient with this which was really interesting because you'll probably very rarely see this in real life but i did actually get to see it um in one of my er rotations so those are some of the weird things that you'll see um and then you're also going to these patients may have a higher potential for emboli and anemia now how are you going to remember all of these clinical manifestations normally i would say don't but because there's a really good mnemonic for it there's uh there's a way for you to remember all of these so what you're going to remember to remember all of the different things you're going to see in endocarditis you're going to remember i got endocarditis from jane so this isn't my mnemonic i will always admit if it's not mine and it's not original so this is something i learned at pa school but it's great and it always helped me remember this so i got endocarditis from jane from jane stands for fever rothspot oslo nodes murmur and then jane stands for janeway lesions anemia nail bed hemorrhages or splinter hemorrhaging and then emboli so i got endocarditis from jane that's how you remember all of the different clinical manifestations and all the things you'll see because you will see these on a vignette or like in my case i had it on an oski i had a patient that had Osler knows that they had anemia Janeway lesions all of these different things on my OSCE and I had to know these things and Remember that it was endocarditis. So remember I got endocarditis from Jane you won't forget that now moving on to the actual diagnosis So the thing with the diagnosis for endocarditis is that it's not a simple Okay, we did an echo and they have a vegetation on one of the valves.

They have endocarditis It's actually a combination of a lot of different things. So it's based upon a bunch of different factors clinical manifestations blood cultures echo and anytime you have a diagnosis based upon all of these different factors you're going to have some form of criteria and generally what i say with criteria for the pants is and for real life of course because you can always look these up is not to memorize it there's too much it's a waste of time and you normally won't have to be able to uh to pick these through and like count up and see if you met the criteria so i'm going to go over it but i would not say to memorize it do not waste your time so modified new criteria let's go over it obviously so to meet the criteria it's about 80 specificity if you do meet this criteria that they have endocarditis you need either two major which we'll go over or one major three minor or five minor so you need to add those up and see if you get um the diet meet the diagnosis diagnostic criteria so let's go over the major criteria so major criteria is going to be two separate positive blood cultures Normally you're going to do it from two separate areas of the body so you actually get a blood culture from you know two separate areas of the body. And there's a certain amount of time in between.

I can't remember. You won't have to know that for the boards, but two separate positive blood cultures, but positive for organisms that are consistent with infectious endocarditis. So it can't just be any bacteria seen.

They have to be organisms that are consistent with infective endocarditis. So some of the ones we went over before, Staph aureus, Staph viridans, any one of those in two separate positive blood cultures. That's one major criteria. the other one is going to be evidence of endocardial involvement confirmed by echo so you can see vegetations present on echo an abscess formation new valvular regurg any one of these things will you know give you evidence that there is some kind of endocardial involvement and if you look at an echo you can see here this is actually the the vegetations on the mitral valve here so these are the vegetations you can see which is just basically the infection present that has these little lumps here on the actual valve. So that's what that looks like on echo.

So let's move on to the minor criteria. So minor criteria is pretty easy because a lot of the minor criteria is just all the stuff from Jane. So all the things, fever, Roth spots, Janeway lesions, et cetera, each one of those is going to be a point. And then, excuse me, some of the other minor criteria is going to be either a positive echo that doesn't meet the criteria that we want to refer major. or a positive blood culture that doesn't meet the criteria for major so like the blood culture if you have some bacteria that's not consistent with infectious endocarditis that would be a minor finding and the same thing with the echo if it doesn't meet one of the criteria we went over the the vegetations and the new abscess new um any one of those changes we went over that was for major it's something different that it would be considered a minor criteria so you can have a positive blood culture a positive echo that doesn't meet those findings and it's still meets minor criteria just not major then the other thing is going to be any predisposing factor so ib drug use indwelling catheter all these are going to be a point remember as far as you know you need to add up either two major criteria one major three minor or five minor criteria to diagnose and that's um that's the the modified duke criteria and that's how you diagnose endocarditis now on to treatment so With treatment, it's not going to be very simple.

It's multidisciplinary care. You're going to have infectious disease involved, cardiology, cardiac surgeons. There's going to be a bunch of different people handling these patients. But for what you need to know for the boards, you just need to be aware of the fact that a lot of these patients are going to require some kind of surgical intervention, maybe a valve replacement.

But really, all you need to know otherwise is going to be the empiric antibiotic treatment. So as far as the empiric antibiotic therapy, I'm going to go over that in a second, but just be aware. that if you have a patient that comes in, they have an acute bacterial endocarditis, they're really sick, this developed fast over a few hours, a couple days, they're really sick, you can't wait for your blood cultures to come back to decide which type of bacteria it is, which antibiotics it's going to be sensitive to, they're very sick, you need to treat them empirically, which means you give these broad spectrum antibiotics to cover a bunch of different things, because you don't know what the bacteria is.

Now on the flip side, if you have a patient that has subacute bacterial endocarditis, they've been sick for months, you're going to have time here so you can get your blood cultures back see what type of bacteria it is see what antibiotics it's sensitive to and treat accordingly now on the boards they're not going to give you a culture and say here's the bacteria this is what it's sensitive to because there's your answer so what they're going to want you to know is the empiric antibiotic therapy so you're going to need to memorize these because you need to know when they say okay this patient had a native valve what type of empiric antibiotic therapy you're going to know so these are the things that you need to know now for native valves, so they have their own valve, it hasn't been replaced, the antibiotics that you're going to use is an anti-staphylococcal penicillin, so nafcillin, oxacillin. Use one of those combined with either ceftriaxone or gentamicin. So two meds, you're covering your gram positive with the nafcillin and oxacillin, and then you're covering your gram negative with either the gentamicin or the ceftriaxone. So that's your broad spectrum coverage.

So one of these and one of these. Now, the way that I remember that, the sentence only native cardiac gears meaning they only have native cardiac gears like gears as in valves and parts they're native so only native cardiac gears stands for oxacillin nafcillin ceftriaxone and gentamicin so remember you're only picking one of these and then one of these so you can use oxacillin with ceftriaxone nafcillin with gentamicin whatever you want just one from each to cover your gram-negative and gram-positive and remember only native cardiac gears that reminds you oxycillin, nafcillin, ceftriaxone, gentamicin, that's native valve. Now, if you have prosthetic valves, generally these are more complicated patients. They're likely going to need some kind of surgical repair replacement of the valve.

But as far as the antibiotics that you need to know, that's really all you need to know. It's going to be vancom. gentamicin and rifampin so those are the three meds that you're going to use for these patients sometimes the rifampin they substitute that with a cephalosporin but most of the time it's going to be rifampin now just a side note it's not really important for your pants but vanco and gentamicin the reason you use gentamicin with vanco is actually because of the synergistic effect they actually work together much better than they do alone so bringing them together the vanco and the gentamicin actually improve their their efficacy and they actually work much better particularly against MRSA so that's why you add the gentamicin with the vanco and then rifampin again you don't need to know this for your board but i like to give you a little clinical knowledge outside of the the board stuff rifampin when you introduce rifampin you don't start it for at least two to three days after starting the the vancomycin and the gentamicin the reason you don't is because if you treat a patient with rifampin right off the bat rifampin actually has a really high rate of causing mutation in the bacteria and resistance.

So with rifampin, you treat first with other antibiotics like vancomycin, gentamicin, bring down the actual population of the bacteria. And then once it's somewhat under control, then you can introduce rifampin. And it works really well. And rifampin actually, the reason you use it in this is because it actually can penetrate the biofilm of the pathogens that infect the prosthetic valve.

There's actually this biofilm on some of the the uh the organisms and rifampic can penetrate it really well but keep in mind again about two to three days after you start the vancogen to mice sorry a little bit got sidetracked there but i feel like it's important for you to know once you start actually practicing what you do with these beds and why okay so treatment the way i remember that is going to be valves generally repaired replaced replicated whatever you want to think of to remember that it's a prosthetic valve it's not their original it was repaired or replaced at some point so remember the sentence valves generally repaired that helps me remember vancomycin gentamicin and rifampin valves generally repaired or replaced replicated whatever are you want to use here to remember that the valves are not their own they've been replaced or replicated whatever so that's the sentence i remember for prosthetic valve impaired treatment and then fungal really really easy fungal infection is just going to be amphotericin b for about six to eight weeks and with the native valve and the prosthetic valve treatment the antibiotics they're typically going to be for about four to six weeks you're going to treat as far as the empiric antibiotic therapy. So that's your treatment. That's really all you need to know. There is one more thing that you need to be familiar with, and that's the antibiotic prophylaxis.

Now, antibiotic prophylaxis with endocarditis, you're not going to use in every patient. You're really only going to use in patients where you feel like there's a patient that has a high likelihood of some kind of adverse outcome if they did wind up getting endocarditis. So there's certain patients that are going to be more predisposed.

And in patients with a history of, let's go over that now. And again, do not memorize this. This is not something you need to memorize.

Be somewhat familiar with it. Hear it as I'm talking to you about it. Maybe read it once, but don't memorize it.

There's just way too much and it's not worth it. It's not high yield. But if a patient does have a history of infectious endocarditis, they have an unrepaired cyanotic congenital heart disease, heart repairs using prosthetic material, not including stents, repaired congenital heart disease. disease or defects with the residual shunts, prosthetic patches or devices, valvular regurg due to a structurally abnormal valve in a transplanted heart. Those are all the patients.

And again, it's ridiculous to try to memorize that. But anytime you see like a patient that has some kind of congenital heart disease, they have some valvular regurg, some kind of problem with a heart, you may want to start thinking, okay, maybe this patient needs to be prophylaxed for endocarditis. Now, the procedures you're going to prophylax for are going to be dental procedures.

If there's any type of manipulation perforation of the gingival tissue So if they have like a really aggressive cleaning you may need to actually use prophylaxis If they have a tooth pulled a dental abscess anything like that where there's any manipulation of the gingival tissue You want to go ahead and use prophylaxis if they have a respiratory tract procedure But only procedures involving an incision or a biopsy so say they have a bronchoscopy, but no biopsy. You don't need to use prophylaxis But if they have a bronchoscopy and they have a biopsy, then you need to use antibiotics to prophylax. And then finally, any skin or soft tissue procedures of infected skin.

Anytime you're manipulating the skin or the soft tissue, you want to have prophylaxis. So again, be familiar with these, but do not memorize it. This is an absolute waste of time for something that's very low yield. The one thing you should memorize is the actual antibiotics you need to use.

And really, there's only a couple. The main antibiotic that you want to use for prophylaxis and endocarditis is going to be amoxicillin. 2 grams 30 to 60 minutes prior to the procedure that's the preferred antibiotic the only reason you're not going to use amoxicillin is if they have a penicillin allergy in which case you would use clindamycin 600 milligrams just if they have a penicillin allergy so Memorize the amoxicillin the clindamycin if you need to without the allergy, but don't remember all the other stuff.

It's a waste of time Okay, so that is endocarditis I try to get through the stuff pretty quickly only stick to the high-yield stuff and hopefully that was helpful Let's do five quick questions just to see how much you've retained of what I went over So what is the most common valve involved in a patient who is an IV drug user? Hopefully you remember this because you want to think of do you want to try drugs try cuspid valve? So that's the most common valve in a patient who's an IV drug user one to try drugs tricuspid valve what is the most common organism seen in subacute endocarditis which remember infects those damaged or vulnerable valves vulnerable valves most common organism strep viridans that's going to be most common remember the v viridans vulnerable valves what are roth spots roth spots are retinal hemorrhages or lesions seen on fundoscopy you can also remember roth spot starts with an r retina starts with an r might help you What is the empiric treatment regimen for a patient with a prosthetic valve endocarditis? So prosthetic valve endocarditis, hopefully you remember the mnemonic, vancomycin, gentamicin, rifampin, and that is going to be the treatment regimen that you're going to use.

So what is the most common clinical manifestation seen in patients with endocarditis? So most common clinical manifestation seen in patients with endocarditis is going to be a fever. So that's your most common clinical manifestation.

okay so thank you so much um for listening to the the video i hope it was helpful thank you again for all the reviews it really does make my day when i see those i'm so happy to see that that is helping you guys so thank you again and good luck in pa school good luck on your pants your pantry and your eors

Transcript for:Understanding Endocarditis for PANCE Exam

Transcript for:
Understanding Endocarditis for PANCE Exam