Chapter 128: Infective Endocarditis: Toxic Choices Level II

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LEARNING OBJECTIVES

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

• 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.

PATIENT PRESENTATION

Chief Complaint

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

HPI

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.

PMH

• 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)

FH

Father: hypertension, died of myocardial infarction at age 76

SH

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

Meds

• Lisinopril 10 mg PO daily

• Amlodipine 10 mg PO daily

• Rivaroxaban 20 mg PO daily

• Metformin 1,000 mg PO twice daily

All

NKDA

ROS

Noncontributory except for complaints noted in HPI

Physical Examination

Gen

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

VS

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

Skin/Nails

No evidence of rash, lesions, or petechiae

HEENT

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

Neck/Lymph Nodes

No lymphadenopathy, JVD, or thyromegaly

Lungs

Clear to auscultation; no wheezing, rales, or rhonchi

CV

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

Abd

Nontender, nondistended

Genit/Rect

Normal; guaiac-negative stool

Ext