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Repeat blood cultures now
17%
2/12
Repeat blood cultures 24 hours after initial cultures were drawn
33%
4/12
Repeat blood cultures 36 hours after initial cultures were drawn
0%
0/12
Repeat blood cultures 48 hours after initial cultures were drawn
8%
1/12
Do not repeat blood cultures
42%
5/12
Select Answer to see Preferred Response
The patient’s clinical presentation is concerning for acute infective endocarditis. The most appropriate next step to aid in diagnosis is to repeat blood cultures now. Infective endocarditis involves infection of the heart valves or intracardiac hardware, and should be highly suspected in any patient with a history of intravenous drug use and a heart murmur. The Duke criteria are widely used for diagnosing endocarditis. Major criteria include presence of an intracardiac mass on echocardiogram and positive bacterial or fungal growth in either (A) two blood cultures drawn more than 12 hours apart, or (B) at least 3 out of 4 separate blood cultures drawn at least 1 hour apart. Minor criteria include recent fever, predisposing heart condition or intravenous drug use, and immunologic and/or vascular stigmata of endocarditis. As reviewed by Pierce, infective endocarditis results from bacterial or fungal infection. Common causative organisms include Staphylococcal aureus, Strep. viridans, enterococci, and coagulase-negative staphylococcus. Risk factors include intravenous drug use, prosthetic heart valves, structural or congenital heart disease, and recent invasive procedures. Uncommon, but specific exam findings include Janeway lesions (erythematous, on palms and soles), Osler nodes (tender nodules on hands and feet), and Roth spots (exudative retinal hemorrhages). Treatment for infective endocarditis involves antibiotic therapy and surgical intervention. Due to the high morbidity and mortality of infective endocarditis, optimal timing of surgical intervention remains unclear. According to a meta-analysis by Narayanan et al. involving 21 studies with a total of 11,048 patients, all-cause mortality was significantly lower in those who had earlier surgical intervention (at 20 days or less) compared to those who were conservatively managed. These findings suggest that earlier surgical intervention may be associated with lower mortality. Illustration A is a table of the modified Duke Criteria including the major and minor criteria used for diagnosing acute infective endocarditis. Incorrect Answers: Answers 2-5: None of these choices would aid in fulfilling the Duke criteria.
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