Management of Endocarditis
Infective endocarditis most commonly affects patients with structural heart disease or select sociodemographic risk factors. The Modified Duke Criteria are recommended to establish a diagnosis of endocarditis. Medical treatment consists of early empiric b
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Janek Manoj Senaratne and Sean van Diepen
Case Presentation A 56 year old male with a history of hypertension presented with a 2 month history of fevers, chills, anorexia, and weight loss with a 2 week history of worsening dyspnea and pedal edema. At the time of presentation, he had a blood pressure of 90/27 mmHg, with a heart rate of 80 beats per min, temperature of 38.0 °C, and required 8 L/min of oxygen to maintain saturations of 94 %. On exam, his jugular venous pressure was 7 cm above the sternal angle. He had bilateral lung crackles, a grade III/VI decrescendo diastolic murmur along the left lower sternal border, and bilateral pitting edema. His white blood cell count was 14,000 cells/μL. Two sets of blood cultures were drawn and empiric vancomycin, gentamicin, and ciprofloxacin were initiated. At 9 h, blood cultures were positive for pansensitive Streptococcus oralis and his antimicrobial t herapy was changed to
Electronic supplementary material The online version of this chapter (doi:10.1007/978-3-319-43341-7_19) contains supplementary material, which is available to authorized users. J.M. Senaratne Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada S. van Diepen (*) Department of Critical Care Medicine, Division of Cardiology, University of Alberta, Edmonton, AB, Canada e-mail: [email protected]
c eftriaxone. A transthoracic echocardiogram reported a mildly dilated left ventricle with normal systolic function, a trileaflet aortic valve with severe aortic insufficiency, and a large 15 mm aortic valve vegetation (Fig. 19.1, Videos 19.1 and 19.2). A computed tomography (CT) scan of his head reported a left frontal subacute infarction with associated petechial hemorrhage. Question How should this patient’s native valve infective endocarditis (IE) be managed? Answer Antimicrobial therapy and aortic valve replacement. All patients with IE should be initiated on early empiric guideline-recommended antibiotic therapy, and antimicrobials should be further guided by culture and sensitivities. Patients with severe mitral or aortic insufficiency causing congestive heart failure should be referred for early cardiac surgery to repair or replace the incompetent valve. Prior to surgery, this patient underwent a coronary CT scan, which reported a calcium score of 0. This test was done instead of a coronary angiogram to reduce the risk of dislodging the vegetation. A dental consultation excluded an oral abscess source. On post- admission day 2, he developed shock (blood pressure 70/20 mmHg) and flash pulmonary edema (Fig. 19.2). The patient was stabilized with non-invasive mechanical ventilation and vasopressors. Dopamine was selected to increase
© Springer International Publishing Switzerland 2017 R.C. Hyzy (ed.), Evidence-Based Critical Care, DOI 10.1007/978-3-319-43341-7_19
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J.M. Senaratne and S. van Diepen
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Fig. 19.1 Transthoracic echocardiogram documenting an aortic valve vegetation and severe aortic insufficiency in the parasternal long axis view and the 5-chamber
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