Clinician's Corner: Endocarditis

All right. How are you feeling today?

Hey guys, I'm Ride the Chief medical officer here at osmosis. And I want to talk a little bit about infective endocarditis today.

So we're gonna talk about a few different uh topics. The first one being signs and symptoms of endocarditis.

This is infective endocarditis. So uh there's an acronym, a handy acronym to kind of go through this and it is from Jane.

So just think uh maybe you got endocarditis from Jane, although it's not contagious. So from Jane, F stands for fevers, from R stands for rot spots.

Just think of the eye exam. O stands for Osler nodes.

So, uh I think of ow Osler ow being because they're painful or tender. Uh M is murmur.

So heart murmur. Uh Jane, uh so J A ne Jane is Janeway lesions and uh I think, oh, just Janeway meaning, oh, just they're not painful.

They're just Janeway lesions. So they're distinct from the O nodes which are Osler uh A for anemia.

Uh N for nail bed hemorrhages. So I'm showing my nails but nail bed or splinter hemorrhages.

They are sometimes called an E for emboli. So sometimes you'll see embolic phenomenon on uh CT scan or MRI or something like that.

And that's often evidence again of something that's kind of spewing off of your valve and kind of seeding other parts of your body.

So, from Jane are the signs and symptoms. Next, let's move down to diagnosis and for diagnosis you really want to.

And there's Duke's criteria and uh many of the things that I just went over are part of Duke's criteria, specifically minor criteria.

But so the major criteria, the big things you want to think about are two blood cultures and echo. So the blood cultures, basically, you get large volume blood cultures, you see if anything grows out, typically, it's going to be, you know, something like staph aureus or staph uh epi or uh enterococci or streptococci.

So, those are your most common organisms. There are some very uncommon organisms that uh that are very uncommon.

Um But you should kind of keep a lookout for uh Coxiella being one of them that often kind of people will mention uh because it's tested using titers.

But anyway, those are the uh blood cultures. So you to see what the lab grows out, the other one being the echo and the echo is actually kind of the interesting one from my perspective because I always thought it would be a vegetation on the valve that you're looking at and that would be like, oh endocarditis oftentimes it's something that's much more subtle.

So it's like a, a change in the way that the valve moves. Maybe there's a new regurgitation or sometimes it's, it's literally just the way it's moving is a little bit more stiff or, or it's not kind of moving as flexibly as it was on a prior echo.

And sometimes people have prior echoes if they've had cardiac surgery or something. So you can kind of compare and contrast and say, hey, is this valve looking the same as the previous one.

So those are the kind of two keys that you want to look at. And then uh if it's there, if there's a prosthetic valve, uh dehiscence of the prosthesis is a classic example of what uh endocarditis will do.

So if there's any evidence of dehiscence, then you want to make sure that uh you investigate for endocarditis. So those are the keys on diagnosis and the treatment classically, it's gonna be bacterial, right?

So, uh it's going to be impaired treatment with antibiotics and specifically something like Unison and Gent or um you know, if you're thinking about Vancomycin, it might be Vanc Gent and Cipro or uh sometimes rifAMPin is added on, especially on prosthetic valves.

So it's going to be some combination of those antibiotics. And usually that's just for a few days until you actually get a culture back.

And once you see the culture and the susceptibilities, you can say, ok, let's just change the antibiotic regimen accordingly.

That's all well and good. The key though is the length of treatment.

And I say the key because, uh sometimes you have to treat for a long time and with proce valves, in particular, sometimes you'll treat for a long time and it still won't work.

Uh, and you'll have to get a surgical replacement done. And so just keep in mind, um, that with prosthesis, I often think of prosthesis as being kind of like plastic in a way.

And antibiotics don't treat plastic very well as you can imagine, plastic doesn't have blood vessels. So antibiotics can't get to plastic.

So if there's a infection of any prosthetic material, it's very hard to treat with antibiotics alone. So you usually end up having to take out that valve and uh and surgically replacing it.

So anytime there's pros prosthesis, antibiotics are usually going to be tried at first and oftentimes it fails and then you have to just surgically replace.

So that's the keys on treatment. And then one clinical pearl I want to kind of leave you with is just thinking about endocarditis as being a biofilm infection.

So you think about biofilms as being bacteria and then there's stuff in this mucus, right? So um essentially what happens is antibiotics have a hard time getting through that mucus to get down to this bacteria that may be at the bottom.

So the the key there is just a length of treatment you end up giving antibiotics for weeks and weeks. Uh as opposed to, let's say, a UTI or something where you give it for maybe three days or five days with a biofilm infection, usually giving antibiotics for a long period of time.

Because the way that we essentially try to counter the fact that diffusion is what we're kind of waiting on is we just let it last for a long time.

And over time, the concentration of antibiotic run, the bacteria gets high enough to where the bacteria will die. So that's why the length of treatment for endocarditis is so long.

And I always kind of wondered about that is essentially because the biofilm infection is what we're dealing with. So anyway, I will leave you with that and I hope that helps you understand some clinical uh aspects of infective endocarditis.

Thanks a lot. Bye bye.

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