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Bacterial endocarditis

  • Modified Duke criteria

    • Major:
      • Typical bug in 2 separate blood cultures (strep viridans, strep bovis, HACEK, staph aureus, enterococci)
      • Persistently positive blood culture
      • Coxiella burnetii
      • Echo shows oscillating intracardiac mass, abscess or dehiscence of prosthetic valve
      • New regurgitation murmur
    • Minor:
      • Predisposing heart condition or IV drug use
      • Fever > 38 C
      • Embolism (arterial emboli, pulm infarcts, Janeway lesion, conjunctival hemorrhage)
      • Immunologic phenomena (Glomerulonephritis, Osler's nodes, Roth spots)
      • Positive blood culture or serologic evidence of infection, but doesn't meet major criterion
  • Admission orders

    • Admit: Telemetry
    • Diagnosis: Bacterial Endocarditis
    • Condition: Serious
    • Vital Signs: q 4 hours until afebrile for 24 hours, then per routine
    • Allergies:
    • Nursing: Daily weights, Strict I/Os
    • Diet: Regular
    • Activity: As Tolerated
    • Labs:
      • CBC (initially with diff) qday until WBC normalized
      • Chem qday
      • LFTs
      • Rheumatoid factor, ESR
      • Blood cultures x 3 (from different sites)
      • urinalysis
      • CXR
      • EKG
      • echocardiogram
    • IV: As Needed
    • Special: consult cardiology, ID, cardiac surgery (HF, abscess, vegetation, emboli, atypical bugs, refractory to tx)
    • Medications:
      • Vancomycin 1 g IV q 12 hours
      • If not MRSA, substitute Vanc for nafcillin IV 1.5g q4h
      • Gentamicin 1 mg/kg IV q 8 hours
      • Tylenol 325-650 mg PO q 4-6 hours prn for fever; max 4 g in 24 hours (or 2 g in 24 hours if end-stage liver disease)
  • Discharge

    • outpt IV antibiotics at infusion center or nursing home
  • Pimp Qs

    • mitral regurgitation if mitral prolapse or rheumatic fever
    • tricuspid regurgitation if IV drugs

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