Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

Infective Endocarditis

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In one line

·Bacteria land on a heart valve, stick there, and grow a clump of germs and clotted blood that damages the valve and scatters pieces into the bloodstream.

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Normal physiology

·The heart has four valves—mitral, tricuspid, aortic, and pulmonic—that open and close in rhythm to keep blood flowing forward and prevent backflow. Each valve is covered by a thin, smooth lining called the endocardium (the inside skin of the heart). This lining is slippery and intact, so bacteria and platelets in the blood slide right past without sticking.

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What goes wrong

·A valve that is already damaged (from past illness, wear and tear, or birth defect) or artificial (mechanical or tissue replacement) loses its smooth surface and becomes rough. At the same time, bacteria enter the bloodstream from a source—dental work, skin infection, injecting drugs with dirty needles, or a medical procedure. Instead of sliding past, the bacteria land on the rough valve and stick. They multiply there, and platelets and fibrin (clotting threads) pile on top, forming a lumpy, fragile clump called a vegetation that damages the valve further and breaks off pieces into the blood.

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Hallmark signs

·Fever that won't quit
·New heart murmur or a murmur that sounds different
·Tiny red or purple spots on the skin (petechiae) or painful red bumps on fingers and toes (Osler nodes)
·Painless red spots on the palms or soles (Janeway lesions)
·Splinter hemorrhages—tiny red lines under the nails
·Sudden stroke or patches of vision loss
·Shortness of breath and swollen ankles (heart failure)
·Night sweats and weight loss you didn't plan

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Red flags · escalate now

·New or worsening heart murmur—means the valve is being destroyed fast
·Sudden weakness, slurred speech, or vision loss—a clump may have hit the brain
·Severe shortness of breath or coughing up pink foam—sign the heart is failing and fluid is flooding the lungs
·Confusion or severe headache—infection may have spread to the brain lining (meningitis) or caused a brain abscess
·Uncontrolled fever despite antibiotics—the infection may be walled off in an abscess or the germ is resistant to the drug

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Workup

·Blood cultures (three sets from different sites, drawn 30 minutes apart before antibiotics)
·Transthoracic echocardiogram (TTE) or transesophageal echocardiogram (TEE, the preferred test)
·Complete blood count (CBC) with differential
·Red blood cell (Erythrocyte) sedimentation rate (ESR) and C-reactive protein (CRP)
·Basic metabolic panel (BMP) and creatinine
·Urinalysis
·Electrocardiogram (ECG)
·Chest X-ray

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Treatment

·Draw three sets of blood cultures from different sites before antibiotics, then start empiric IV antibiotics immediately (vancomycin 15–20 mg/kg every 8–12 hours + ceftriaxone 2 g daily or gentamicin 1 mg/kg every 8 hours)
·Transesophageal echocardiogram (TEE) within 24–48 hours to confirm vegetations and assess valve damage
·Switch to targeted antibiotics once blood culture results and sensitivities return: nafcillin or cefazolin 2 g IV every 4–6 hours for methicillin-sensitive Staphylococcus aureus (MSSA), vancomycin for MRSA, penicillin G 4 million units every 4 hours or ceftriaxone 2 g daily for Streptococcus viridans, ampicillin 2 g every 4 hours + gentamicin for Enterococcus
·Cardiac surgery for valve replacement or repair if: heart failure develops, infection cannot be controlled with antibiotics alone (persistent fever and positive blood cultures after 5–7 days), prosthetic valve is loose or infected, vegetation is very large (>10 mm) with high embolic risk, perivalvular abscess forms, or fungal endocarditis is diagnosed
·Continue IV antibiotics for 4 to 6 weeks total (native valve endocarditis) or 6 to 8 weeks (prosthetic valve endocarditis), with repeat blood cultures to confirm clearance
·Monitor closely for embolic complications (stroke, septic pulmonary traveling clots (emboli), splenic abscess, mycotic aneurysm) and manage supportively: IV fluids for low blood pressure, diuretics (furosemide 20–80 mg IV) for heart failure and fluid overload, inotropes (dobutamine) if the heart is too weak to pump
·Antibiotic prevention (prophylaxis) before dental or surgical procedures for high-risk patients after recovery: those with prosthetic valves, previous endocarditis, or unrepaired turning blue (cyanotic) congenital heart disease (amoxicillin 2 g PO 30–60 minutes before procedure, or clindamycin 600 mg if penicillin-allergic)

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NCLEX trap

·Infective endocarditis can start after dental work (pulling a tooth or deep cleaning), bladder procedures (catheter, scope), skin infections (even a big pimple or cut), or on artificial heart valves. Germs need two things: a way in (dental work, IV line, skin break) and a sticky spot inside the heart (a damaged valve or a plastic one). Any combo of those two can cause it.
·Draw blood cultures BEFORE you give any antibiotic — this is the only way to catch the exact germ and know which medicine kills it best. If you give antibiotics first, the cultures come back empty and you fly blind the whole time.
·New murmur plus fever is infective endocarditis until proven otherwise. Bacteria are eating the valve, throwing off clots, and the patient can die without antibiotics. This never gets better by itself.
·The skin spots are just signs that infected clots are flying through the bloodstream and landing in tiny vessels. The real problem is the bacteria colony growing on the valve. Kill the valve infection and the clots stop.
·Give vancomycin PLUS ceftriaxone (or gentamicin) right away — you need broad coverage while waiting for the culture name. After the lab tells you which germ it is, you can switch to one targeted antibiotic if possible.
·Heart failure in infective endocarditis means the valve is shredded or about to fall apart. The patient may need emergency surgery to replace it — water pills alone will not fix a torn valve. The broken valve is the real problem, not fluid overload.

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