Clinician's Corner: Endocarditis

Summary

In this educational video, Dr. Rishi, the Chief Medical Officer at All Samosas, discusses infective endocarditis, focusing on its signs and symptoms using the acronym FROM Jane. He covers diagnosis criteria like blood cultures and echocardiograms, emphasizing the importance of detecting subtle valve changes. Treatment typically involves antibiotics, with adjustments based on culture results. Dr. Rishi highlights the challenge of treating prosthetic valve infections, often requiring surgical intervention due to the biofilm nature of the infection, which necessitates prolonged antibiotic treatment.

Takeaways

• 🔍 In the script, the speaker, Rishi, introduces infective endocarditis and its signs and symptoms using the acronym FROM JANE.
• 🌡️ 'F' in FROM JANE stands for fevers, which is a common symptom of infective endocarditis.
• 👀 'R' stands for Roth spots, which are found during an eye exam and are indicative of the condition.
• 🎵 'O' represents Osler nodes, which are painful or tender, and are another sign of endocarditis.
• 💓 'M' is for murmur, specifically heart murmur, which is a key diagnostic sign of the disease.
• 👣 'Jane' in the acronym refers to Janeway lesions, which are non-painful and distinct from Osler nodes.
• 👁️ 'A' stands for nail bed or splinter hemorrhages, which can be seen as embolic phenomena on imaging studies.
• 🧬 Diagnosis of infective endocarditis involves Duke's criteria, with major criteria including blood cultures and echocardiograms.
• 🍯 Blood cultures are used to identify the causative organisms, often staphylococci or streptococci.
• 🛠 Echocardiograms are crucial for observing changes in valve movement, which may indicate the presence of endocarditis.
• 💊 Treatment typically involves long-term antibiotic therapy, with the choice of antibiotics depending on the culture results.
• 🔧 In cases of prosthetic valve endocarditis, surgical replacement may be necessary if antibiotic treatment fails, due to the difficulty of treating biofilm infections.

Q & A

What is the main topic discussed in the video script?

The main topic discussed in the video script is infective endocarditis, focusing on its signs, symptoms, diagnosis, and treatment.

What is the acronym 'FROM JANE' used for in the context of endocarditis?

The acronym 'FROM JANE' is used to remember the signs and symptoms of infective endocarditis: Fevers, Roth spots, Osler nodes, Murmurs, Janeway lesions, and Embolic phenomena.

What does 'Roth spots' refer to in the context of the acronym?

Roth spots refer to small, flat, red spots on the retina that can be a sign of endocarditis.

What are 'Osler nodes' mentioned in the acronym?

Osler nodes are small, painful, raised spots that can appear on the fingers, toes, or palms, and are associated with endocarditis.

What are 'Janeway lesions' and how do they differ from 'Osler nodes'?

Janeway lesions are painless, red or purple spots on the palms and soles, distinct from Osler nodes which are painful and typically found on fingers and toes.

What is the significance of 'embolic phenomena' in the context of endocarditis?

Embolic phenomena refer to the small blood clots that can break off from the infected valve and travel to other parts of the body, causing damage.

What are the major criteria for the diagnosis of infective endocarditis according to Duke's criteria?

The major criteria for the diagnosis of infective endocarditis according to Duke's criteria include two positive blood cultures and an echocardiogram showing evidence of endocardial involvement.

What is the typical approach to treating infective endocarditis?

The typical approach to treating infective endocarditis involves administering antibiotics, such as penicillin, gentamicin, or vancomycin, and potentially surgical intervention if the infection involves a prosthetic valve.

Why is the length of treatment for infective endocarditis often longer than other types of infections?

The length of treatment for infective endocarditis is often longer because it is considered a biofilm infection, where antibiotics have difficulty penetrating the mucus layer to reach the bacteria, thus requiring a prolonged treatment period.

What is a clinical pearl mentioned in the script regarding the treatment of prosthetic valve endocarditis?

The clinical pearl mentioned is that treating prosthetic valve endocarditis with antibiotics alone is often challenging due to the nature of the material, which may require surgical replacement of the valve.

What is the role of blood cultures in diagnosing infective endocarditis?

Blood cultures play a crucial role in diagnosing infective endocarditis by identifying the causative organisms, such as Staphylococcus aureus or Streptococcus viridans, through large volume blood samples.

Outlines

00:00

🏥 Infective Endocarditis Overview

In this paragraph, Rishi, the Chief Medical Officer, introduces the topic of infective endocarditis, a serious heart condition. He discusses the signs and symptoms using the acronym 'CHAINS', which stands for fevers (F), Roth spots (R), Osler nodes (O), heart murmur (M), Janeway lesions (J), and nail bed or splinter hemorrhages (A). He also touches on the importance of blood cultures and echocardiograms in diagnosing the condition, emphasizing the subtle changes in valve movement that can indicate the presence of endocarditis. Additionally, he mentions the common organisms causing the infection, such as staph aureus or staph epi, and the challenges of treating prosthetic valves due to their plastic nature and the difficulty for antibiotics to penetrate.

05:02

🛠️ Treatment and Biofilm Infection Insights

The second paragraph delves into the treatment of infective endocarditis, highlighting the use of antibiotics like unison and gentamicin, or vancomycin with ciprofloxacin, especially in cases involving prosthetic valves. Rishi explains that the treatment duration is often lengthy, which is a clinical pearl he shares, due to the biofilm nature of the infection. Biofilms are described as a protective layer of mucus that makes it difficult for antibiotics to reach the bacteria, necessitating prolonged antibiotic therapy. This approach allows for the antibiotic concentration to eventually kill the bacteria over time. The paragraph concludes with a brief mention of Osmosis, an educational platform, inviting viewers to start a free trial.

Keywords

💡Infective Endocarditis

Infective endocarditis is an infection of the inner lining of the heart, typically affecting the heart valves. It is a serious condition that can lead to complications such as heart failure. In the video, the speaker focuses on this condition, discussing its signs, symptoms, diagnosis, and treatment, making it the central theme of the presentation.

💡Acronym - FROM JANE

The acronym FROM JANE is a mnemonic device used to remember the signs and symptoms of infective endocarditis. Each letter stands for a different symptom: Fevers (F), Roth spots (O), Osler nodes (M), Janeway lesions (J), Aneurysms (A), and Embolic phenomena (E). The speaker uses this acronym to help viewers recall the various indicators of the condition.

💡Roth Spots

Roth spots are small, round, white or pale spots on the retina that can be a sign of infective endocarditis. They are named after the ophthalmologist Leon Roth, who first described them. In the script, the speaker mentions Roth spots as part of the FROM JANE acronym, indicating their relevance in diagnosing the condition.

💡Osler Nodes

Osler nodes are small, painful, raised spots that can appear on the hands and feet and are associated with infective endocarditis. They are named after the physician William Osler. The speaker refers to Osler nodes in the context of the FROM JANE acronym, emphasizing their diagnostic importance.

💡Janeway Lesions

Janeway lesions are painless, red or purple spots that can appear on the palms and soles and are another sign of infective endocarditis. They are named after the cardiologist Thomas Lewis, who first described them as 'Janeway's spots.' The speaker distinguishes these from Osler nodes by noting their painless nature.

💡Echo

An echo, short for echocardiogram, is a test that uses sound waves to create images of the heart's structure and function. In the video, the speaker discusses the importance of echocardiograms in diagnosing infective endocarditis by identifying changes in valve movement or the presence of vegetations.

💡Blood Cultures

Blood cultures involve taking samples of blood to identify the presence of microorganisms causing an infection. The speaker mentions that blood cultures are crucial for diagnosing infective endocarditis by identifying the specific bacteria, such as Staphylococcus aureus or Streptococcus, that may be causing the infection.

💡Antibiotics

Antibiotics are medications used to treat bacterial infections. In the context of the video, the speaker discusses the use of antibiotics for the treatment of infective endocarditis, mentioning specific drugs like vancomycin and gentamicin, and the importance of adjusting treatment based on culture results.

💡Prosthetic Valve

A prosthetic valve is an artificial heart valve that has been surgically implanted to replace a damaged or diseased valve. The speaker addresses the unique challenges of treating infective endocarditis in patients with prosthetic valves, noting that antibiotics alone may not be effective and that surgical replacement may be necessary.

💡Biofilm

A biofilm is a community of microorganisms embedded within a protective matrix of extracellular polymeric substances. The speaker uses the term 'biofilm infection' to explain why the treatment of infective endocarditis often requires long-term antibiotic therapy, as biofilms can protect bacteria from the effects of antibiotics.

💡Treatment Duration

Treatment duration refers to the length of time a patient is on a specific treatment regimen. The speaker emphasizes the importance of long-term antibiotic therapy in treating infective endocarditis, particularly in the context of biofilm infections, where a prolonged duration allows for higher antibiotic concentrations to reach and kill the bacteria.

Highlights

Introduction to Infective Endocarditis by Rishi, the Chief Medical Officer at All Samosas.

Discussion on signs and symptoms of Infective Endocarditis using the acronym CHAIN.

Explanation of the CHAIN acronym: Fevers (F), Roth spots (R), Osler nodes (O), Heart murmur (M), and Janeway lesions (A).

Clarification that Infective Endocarditis is not contagious.

Description of nail bed or splinter hemorrhages as evidence of embolic phenomenon.

Importance of Duke's criteria in the diagnosis of Infective Endocarditis.

Emphasis on blood cultures and echocardiograms as major diagnostic tools.

Common organisms causing Infective Endocarditis, such as Staphylococcus aureus and Streptococcus.

The subtle signs in echocardiograms that may indicate Infective Endocarditis.

Prosthetic valve dehiscence as a major criterion for the diagnosis of Infective Endocarditis.

Treatment of Infective Endocarditis typically involves long-term antibiotic therapy.

The challenge of treating prosthetic valve infections with antibiotics alone.

Surgical replacement as a necessary step in some cases of prosthetic valve infections.

Endocarditis as a biofilm infection and its implications for treatment duration.

The rationale behind the extended use of antibiotics in treating biofilm infections.

Conclusion summarizing the clinical aspects of Infective Endocarditis and its treatment.

Invitation to start a free trial at Osmosis for further learning.

Transcripts

all right how are you feeling today hey

guys I'm Rishi decide the chief medical

officer here at all samosas and I want

to talk a little bit about infective

endocarditis today so we're gonna talk

about a few different topics the first

one being signs and symptoms of

endocarditis specifically infective

endocarditis so there's an acronym a

handy acronym to kind of go through this

and it is from chain so just think maybe

you got in a car that is from Jane

although it's not contagious

so from Jane f stands for fevers from R

stands for Roth spots just think of the

eye exam o stands for Osler notes so I

think of ow

Osler al being because of painful or

tender M is murmur so heart murmur

Jane so Jay AME chain is Janeway lesions

and I think I'll just change weight

meaning oh just they're not painful

they're just Janeway lesions so they're

distinct from the also notes which are

al Osler a frenemy a-- and for nail bed

hemorrhages so I'm showing my nails but

nail bed or splinter hemorrhages are

sometimes called

an e fret embolize so sometimes you'll

see embolic phenomenon on CT scan or MRI

or something like that and that's often

evidence again of something cuts kind of

spewing off of your valve and kind of

seating 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 there's

Dukes pressure and many of the things

that I just went over our part of these

criteria specifically minor criteria but

for the major criteria the big things

you want to think about our two blood

cultures an echo so the blood cultures

basically get large volume blood

cultures you see if anything grows out

typically it's gonna be you know

something like staph aureus or staph epi

or Andrew Cox is dr. Cox IED so those

are the most common organisms there are

some very uncommon organisms

that are very uncommon but you should

kind of keep a lookout for yellow

being one of them that often kind of

people will mention because it's tested

using titers but anyway those are the

blood cultures so you see what the lot

grows out the other one being the echo

and the echo is actually kind of

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

change in the way that the valve moves

maybe there's a new regurgitation or

sometimes it's literally just the way

it's moving is a little bit more stiffer

or it's not kind of moving as flexibly

as it was on a prior echo and sometimes

people at 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 if it's or if there's a prosthetic

valve dehiscence of the prosthesis is a

classic example of what an accord itis

will do so there's any evidence of

dehiscence then you want to make sure

that you would invest the effort and the

carditis

so those are the keys run diagnosis and

then treatment classically it's going to

be bacterial right so it's gonna be

impaired treatment with antibiotics and

specifically something like unison and

gent or you know if you're thinking

about vancomycin it might be Bank gent

and cipro or sometimes where Fantin is

added on especially around prosthetic

valves so it's gonna be some combination

of those antibiotics and usually this is

just for a few days until you actually

get a culture back and once you see the

culture and the susceptibilities you can

say okay 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 sometimes you have to treat for

a long time and with prosthetic valves

in particular it's something to do 3 for

a long time it still won't work and

you'll have to get a surgical

replacement done and so just keep in

mind that with prostheses I often think

of prosthesis is being kind of like

plastic in a way and antibiotics don't

treat plastic very well as you can

imagine plastic doesn't blood vessels

phantom products 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 usually end up having to take

out that valve and and surgically

replacing it so anytime there's

prosthetist it prostheses 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 on one I kind of

leave you with is just thinking about

endocarditis as being a biofilm

infection so you think about biofilms is

being bacteria and then there's stuff in

this mucus right so 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 key there is just a length

of treatment you end up giving

antibiotics for weeks and weeks 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

defuses what we're kind of waiting on is

we just let it last for a long time and

over time the concentration of

antibiotic one of the bacteria gets high

enough to where the bacteria will die so

that's why the length of treatment for

endocarditis is so long now is 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

helped you understand some clinical

aspects of infective endocarditis

Thanks five bye bye start your free

trial today at osmosis org

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