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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Identify major and minor diagnostic criteria for infective endocarditis.

  • Select an appropriate empiric antibiotic regimen for presumed infective endocarditis.

  • Design a pharmacotherapy regimen for endocarditis that takes into account patient-specific factors such as medication allergies, comorbidities, social history, and financial status.

  • Recognize severe adverse reactions experienced by a patient receiving therapy for infective endocarditis and revise the therapeutic plan.

  • Establish monitoring parameters for a selected drug therapy in the treatment of a patient with infective endocarditis.

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PATIENT PRESENTATION

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Chief Complaint

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“I thought I’d feel a lot better after this surgery.”

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HPI

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Bob Williams is a 66-year-old man who presents for a follow-up appointment six months after aortic valve replacement surgery for severe aortic stenosis. He reports that he’s been compliant with his cardiac rehabilitation and has been taking all of his prescribed medications. However, he still feels weak and has experiencing fevers (temperatures not taken) over the last two weeks.

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PMH

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  • Aortic stenosis, s/p AVR with bioprosthetic valve (diagnosed 2 years ago, surgery 6 months ago)

  • Hypertension (diagnosed 10 years ago)

  • Diabetes, Type 2 (diagnosed 2 years ago)

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FH

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Father: hypertension, died of myocardial infarction at age 76

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SH

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Previous tobacco 1/2 ppd quit 8 years ago; no illicit drugs or EtOH

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Meds

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  • Lisinopril 10 mg PO daily

  • Amlodipine 10 mg PO daily

  • Rivaroxaban 20 mg PO daily

  • Metformin 1,000 mg PO twice daily

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All

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NKDA

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ROS

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Noncontributory except for complaints noted in HPI

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Physical Examination

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Gen
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Patient is a Caucasian man in no apparent distress, alert and oriented

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VS
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BP 152/92, P 90, RR 22, T 38.9°C; Wt 92 kg, Ht 6′0″

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Skin/Nails
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No evidence of rash, lesions, or petechiae

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HEENT
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PERRLA, EOMI, anicteric sclerae, no Roth spots, normal oral mucosa and palate

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Neck/Lymph Nodes
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No lymphadenopathy, JVD, or thyromegaly

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Lungs
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Clear to auscultation; no wheezing, rales, or rhonchi

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CV
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RRR, normal S1 and S2, S3 present, III/VI holosystolic murmur

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Abd
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Nontender, nondistended

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Genit/Rect
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Normal; guaiac-negative stool

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Ext
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Reflexes bilaterally 5/5 UE, 4/5 LE; no edema

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Neuro
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Nonfocal; alert and oriented ...

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