Cram The Pance - S1E18 Endocarditis

Episode Date: April 2, 2021

Endocarditis review for your Pance, Panre and Eor’s.►Paypal Donation Link: https://bit.ly/3dxmTql (Thank you!)--- Support this podcast: https://anchor.fm/scott--shapiro/supportBecome a supporter of this podcast: https://www.spreaker.com/podcast/cram-the-pance--5520744/support.

Okay, so today we're going to be going over endocarditis. Normally when I do these podcasts, I try to knock out a few different topics, but endocarditis, there's so much for you to know that I felt like I should dedicate just one podcast to this. So again, I just wanted to thank everybody for the reviews. I really appreciate it. If you haven't checked out my YouTube channel yet, I feel like you should. It really does help. I have a lot of really good visuals on there.

So if you go to YouTube, just type and cram the pants and you'll find my YouTube channel. Okay, so let's get started with endocarditis. Endocarditis is an infection of the endocardial surface of the heart. So that's the innermost layer of tissue that lines the chambers of the heart. And normally you're going to have an infection of one or more of the valves of the heart, whether it's prosthetic valves, native valves, or even intracardiac devices can get infected. And the most common valve to get infected with infective endocarditis is going to be the mitral valve. So overall, most common valve is the mitral valve unless the patient is an IV drug user.

And then you should be thinking tricuspid valve. So if they're an IV drug user, tricuspid valve is going to be the most common valve to get infected. The way I always remember that is I think of somebody saying want to try drugs, like try TRI drugs. And then that just always made me remember drug use, tricuspid valve, most common valve and IV drug use. Otherwise, Mitral, if they say they're an IV drug user, you should be thinking tricuspid. So much so that actually 90% of patients that have right-sided infectious endocarditis are actually all IV drug users. Obviously, the right side is where the tricuspid is. Now, risk factors should know these because it kind of helps you differentiate on the vignette.

So normally they're going to be an older patient. About half of all cases are patients over 60 years of age. There is a slight male to female predominance, about a three to two male predominance. Ivy drug use, like I already went over as a risk factor. Poor dentition or dental infections can actually lead to endocarditis. History of infective endocarditis, which seems so obvious, but that's obviously a risk factor. history of any kind of structural heart disease, valvular heart disease, and then presence of any type of artificial prosthetic heart valves are all risk factors. Now, there's a few different types of endocarditis,

and really you just need to know a few minor details about each. So let's briefly review the different types. I'm going to give you some different things that I feel like you need to know. Really, there's maybe only like two or three things that you need to know for each different type, but you should be familiar because you need to know the different types to know which, um, type of organism is going to present, which type of treatment and things like that. So let's run through them real quick. The first type of endocarditis is acute bacterial endocarditis. So what do you need to know for acute bacterial endocarditis? So the first thing is that these patients are generally going to have healthy normal valves. Their valves are going to be working fine. They're not going to have any type

of vulnerability. They're healthy valves. No problems with the actual valves of the heart. Now, the organism that's going to be involved in acute endocarditis is going to be a more hostile or virulent organism. And it needs to be because it's infecting otherwise healthy tissue. These valves, like I said, are healthy. There's nothing wrong with them. So they need to be a little bit more aggressive or virulent. So that's the type of organisms you'll see. And generally, the most common organism you're going to see in acute bacterial endocarditis is going to be staphoreus.

Group B strep is another one, but your most common one. and the one that you need to know is going to be staphoreas for acute bacterial endocarditis. I'll give you some ways to remember these a little bit later on. And then the other thing, too, is with acute bacterial endocarditis, it's going to be a sudden onset. It could be hours to days, but generally it's going to be pretty quick the onset. These patients are going to go from feeling fine to pretty crappy over the period of just hours or days. Now, the second type is subacute bacterial endocarditis. So it's subacute compared to acute.

These patients are going to have abnormal valves. they're going to be susceptible, damaged valves. They may have some regurg, things like that. But these valves are not going to be functioning the way they should. They're vulnerable. They're abnormal. Now, the organisms here typically are going to be less aggressive, less furulent. And they don't need to be because, again, they're attacking these compromised abnormal valves.

So the most common organism seen in subacute bacterial endocarditis is going to be streptococcus viridens, which is actually part. of the normal oral flora. And in these patients with abnormal valves, all it really takes is a routine dental cleaning or some kind of dental procedure, like they get a tooth pulled, and this can actually lead to subacute bacterial endocarditis. So it's because they have these more susceptible valves that this less aggressive type of bacteria can cause all of these problems. So again, for subacute bacterial endocarditis, the most common organism is going to be streptocococcus viridens. And then the other thing you need to know about subacute bacterial endocarditis is going to be that it's a more indolent or slow course compared to the acute form. Sometimes it can actually take months for these patients to become symptomatic.

So it's not going to be this acute, you know, a couple of days and they're feeling bad. It's actually going to take a while. And like I said, again, sometimes it could be months before they start presenting with symptoms. The third type that you need to know is IV drug use, which we already briefly went over. In IV drug use, the most common organism is going to be staphoreous. like we saw in acute, again, for IV drug use, it's going to be Staphoreas, again, particularly MRSA, so metacillin-resistant Staphoreas is more common in IV drug users. Usually they're going to have no underlying valvular abnormalities, and then the most common valve,

like we talked about before, is going to be a tricuspid valve. Again, want to try drugs. So I remember, tricuspid valve for IV drug users. Then the last one that you need to know is going to be patients with prosthetic valve, so prosthetic valve endocarditis, which is a small portion of the patient's affected, but there's two different types of prosthetic valve endocarditis. There's early and then late. So early would be within 60 days of these patients having valve implantation.

So within the first couple months, all of a sudden they develop this infection. A lot of times the valves need to be replaced. So in early, less than 60 days, the most common in counterpathogens are normally going to be staphoreous, coagulase negative staff, and in particular, or the one that you really need to know, the one that's going to be the most common, especially in early prosthetic valve endocarditis, is going to be staff epidermis. Staff epidermis, most common cause, particularly for early prosthetic valve endocarditis.

You definitely need to know that one. And again, I have some ways for you to remember these organisms soon, so don't freak out about all this stuff you need to know. And then in late valve, you're going to see like staff species, again, like staff epidermis is going to be epidermitis is going to be seen as well staphoreus streptocockeye species all seen in late valve now let's go over the the different types of of actual organisms so that you can we can go over again each type and just ways for you to remember them and then we'll go over just the differences with them so let's start with staff orius so staff orius really I'm just

going to go over ways for you to remember which one they're tied to. So Staph orius starts with an A. Oreus starts with an A. So when you see Staph aureus, you should be thinking of two things. You should be thinking of acute and you should be thinking of addiction. So Staphoreas organism, acute or addiction, because it starts with an A, acute because it's the most common organism in acute infectious endocarditis. So that's the first day. And then addiction, because remember, IV drug use, addiction. Stafforeas, again, is the most common. common organism in IV drug use. So you see Staphoreas. It starts with an A. A stands for addiction and acute, most common in acute endocarditis, and it's also most common in IV drug use. So addiction,

that helps with that. Now, strepviridins. Strepveridens, if you remember, this is going to be the subacute, the one with the vulnerable or the damaged valves. So strepveridens starts with a V, strepveridens, and it's the most common cause of subacute infectious endocarditis. where it infects damaged or vulnerable valves. So strepviridans starts with a V. So think vulnerable. You have these vulnerable valves that are going to be infected by this, infected by this lesser, you know, less aggressive organism.

So again, step viridans, V stands for vulnerable. Think vulnerable valves, damage. And that's going to be the most common cause of subacute. Okay, moving on. Staff epidermis. Staff epidermis starts with an EPA. Staff epidermis, EPA. So you should be thinking EPI enters prosthetic implants.

So this is the most common organism seen in prosthetic valve endocarditis. So you see staff epidermis, think of the EPI, enters prosthetic implants. That's how you remember. That's the most common organism in prosthetic valve endocarditis. Next, enteroccus species, which we haven't gone over yet. And enterococcus species are normally going to be seen in patients with a recent GI or GU exam. so either GI or GU genital urinary exam.

So how do I remember that? Enteroccus starts with an ENT. ENT stands for enema, like N, or like and, but just the letter N. Terp. If you know what a terp is, it's a transurethral resection of the prostate. So remember, enteroccus is going to be seen with patients with a recent GI or GU exam. And Enema is a GI exam. And a terp is going to be a GU exam.

So enterococcus species starts with an E.N.T. enema n-turp so that helps you remember that and then finally the last one we didn't of course go over before as well it's going to be strep bovis b o v i s strep bovis bovis starts with a b o and strep bovis is usually seen in patients with the history of colon cancer or ulcerative colitis so strep bovis bow bow bowels and that's how you remember that one okay so hopefully that helps because it was always hard for me to remember all of these different organisms and which one tied to which different type and all of that. So hopefully that is helpful. All right. Now, let's move on to clinical manifestations. Now, the only common clinical manifestations, there's a lot that you're going to see and there's a lot that you'll probably

need to know. But really the only common clinical manifestations in a patient with endocarditis in real life in clinical settings is going to be your constitutional symptoms, your fever, your night sweats, your fatigue, your myalgia. So the most common symptom, the most common presenting complaint overall with endocarditis is going to be fever. So if you ever asked, what is the most common complaint, most common clinical manifestation, fever, 100%. Most all patients will have a fever with endocarditis.

With the exception, of course, if they're elderly immunocompromised, sometimes these patients may have an atypical presentation and they may not have fever. but overall most common fever and then your other constitutional symptoms are are common as well so again like night sweats fatigue myalgia now there's other things that you need to know and these are really for the boards because these aren't very common but you do need to know them they're just things that that you may see in real life probably not as common but you do need to know them so let's go over some of the other one so a new onset of a murmur or worsening of an existing cardiac murmur it's not very common surprisingly and you would think it is more common but it's actually pretty rare So that's the other thing you may see in endocarditis. So a new onset of a murmur or a worsening of an existing cardiac murmur. The other things I like to know, I like to call them the weird stuff, is something that I remember as from Jane.

That's how I remember all the other weird things you're going to see. So from Jane, F-R-O-M, Jane, J-A-N-E. So these are the other things that you'll see. Actually, one of them is fever, so not all weird. But so some of the other things that you're going to see in endocarditis is going to be Janeway lesions, which are these painless, painless macules or plaques that are most common on the palms and souls, something known as Osler nodes. These are painful nodules, normally found in the pads of the fingers or toes, Roth spots. These are pale retinal hemorrhages or lesions that you can see on phondoscopy.

Splinter hemorrhages, which are just these nail bed hemorrhages that you'll see. Embali, you may see, anemia. These are all the, you know, the less common things that you'll see. And they're probably going to come up in a vignette. So you really need to know them because you're probably going to get a patient with Osler nose or Janeway lesions. You'll definitely get it in your oskies. I remember this was definitely a my oski. So you need to know them, even though they're not common.

So the way you remember is from Jane. I got endocarditis from Jane. Jane gave me endocarditis. So I got endocarditis from Jane. This isn't mine, but this is not original. This is something that I learned in school, but it's really good. So from Jane are the other things you need to know for endocarditis. So from F-R-O-M, F stands for fever, so that's the common one we already went over.

R stands for Rothspots, O stands for Osler nodes, and M-M-R-M-R-M-R-E, stands for J-A-N-E, stands for Jane-J-A-N-E-N-E-L-E-L-E-L-E-L-L-E-L-L-E-L-L-E-L-L-E-L-L-E-L-L-E. So from Jane, fever, Rothspot, Osloids, murmur, Janeway, lesions, anemia, nailbed hemorrhages, or splinter hemorrhages, like we talked about before, an embolide. So those are the other ones that you need to know for endocarditis. That's from Jane. Remember that because you're going to see it at least once or twice. Okay. Now, diagnosis for endocarditis, it's based on a number of different factors. This isn't a straightforward thing where you're going to do an echo and say, okay, they have. endocratitis. It's actually a number of different factors including clinical manifestations, blood cultures, echo, and you have a criteria because it's, again, a number of different factors. So like everything that consists of a number of different things, you're going to have some form of criteria. So the criteria that you need to be familiar with, I would not say to memorize it,

but the criteria that you need to be familiar with is something known as the modified due criteria. So again, don't memorize this, but be familiar with it. And so with that being said, let's at least review it. So you're going to be somewhat familiar with it, and you'll have an idea if you do see it on an exam question. So with modified due criteria, there's going to be major and minor criteria. To diagnose endocarditis, you need either two major criteria or one major and three minor or five minor criteria. That's about an 80% I believe specificity if you do diagnose with that criteria. So again, you need two major, one major and three minor, or five minor criteria to diagnose.

So the major criteria, the major criteria consists of either two separate positive blood cultures for organisms consistent with infectious endocarditis. So you get two separate positive blood cultures from different areas in the body, a certain amount of time spread apart between them. don't worry about that. And they have to be organisms that are consistent with infectious endocarditis. So staphoreas, strepviridans, the ones we already went over. They can't just be any random organism or it won't qualify for major criteria. And then the second criteria and major criteria is evidence of endocardial involvement. And this can be confirmed with an echo that's going to

show either lesions or vegetations on the endocardium, abscess formation, new valvular regurgitation, a new partial dehiscence of a prosthetic valve. So something that you see, one of those findings on an echo. So you have this evidence of endocardial involvement. So those are the major criteria. So either going to have two positive separate blood cultures for infectious endocarditis specific organisms or evidence of endocardial involvement that's seen on echo. That's a major criteria.

Now, minor criteria, the minor criteria is the first one is from Jane. anything from jane so your osler nodes your dainway lesions your roth spots any of those all count as one for minor so remember anything from jane is going to be part of the minor criteria each one is going to be one and there's a couple other one that are minor criteria so either a positive echo that doesn't meet the that doesn't meet the criteria for major or a positive blood culture that doesn't meet the criteria for major so this can be um you get an echo done and it's shows, you know, I can't remember exactly the specific criteria that wouldn't fall in, but anything that didn't qualify, anything that wasn't major criteria that we went over for

an echo. And then if you get a positive blood culture, but it doesn't have one of the organisms specific to infectious endocarditis, that's a minor criteria. So so far, for minor, we have anything from Jane, positive blood culture that doesn't match the organisms for infectious endocarditis or an echo that doesn't meet the criteria that we went over for major. And then another minor criteria is just a predisposing factor. So IV drug use in dwelling catheter, one of those. Any type of predisposing factor can be another point for minor criteria. So again, for the modified due criteria, you need two major, one major,

three minor or five minor. And again, major is going to be two positive blood cultures with known infectious endocardis organisms, endocardial involvement established with echo, with the criteria you went over before. Miner is going to be from Jane, a predisposing factor, and then a positive echo or positive blood culture, not meeting the requirements for major. That is your diagnostic criteria. Do not memorize it.

Just be familiar enough if on a vignette, you see somebody that has a fever, they have a new murmur, something like that, you should be thinking endocarditis. Normally they're not going to give you all of the different things, expect you to count it out and say, does this patient have endocarditis? It just really doesn't normally happen on exam questions. So just be familiar with it,

but do not memorize it. There's too much else for you to memorize. Okay, now treatment. Again, treatment's going to be this multidisciplinary care. You're going to have infectious disease. You're going to have cardiology. You're going to have cardiac surgery specialist working on these patients. It's not just going to be the ER doctor.

So, but for the pants, really all you need to know for treatment is going to be the antibiotics that you're going to use. You don't need to know all these other things. Now, you need to understand that a lot of these patients will need surgical intervention. So be aware of this. that and a lot of times they'll need a valve replace and things like that. But as far as what you need to know for the pants, you just need to know the antibiotics that you're going to use. So what you're going to memorize for the pants is the empiric antibiotic therapy. So generally, if you have a patient that comes in and they have an acute episode of infective endocarditis, they're really sick. It's come on

quickly, this acute case, you're going to treat them empirically. You're not going to have time for the blood cultures to come back, wait all these hours. days and then see what bacteria they're susceptible to. These patients are really sick. You won't have that amount of time. So you're going to treat them empirically, which means you're going to use antibiotics that are presumed, the presumed infectious organisms. You'll use antibiotics. You believe will attack those because you don't have time to wait. Now, if they're a sub-acupation, it's more of an insidious onset, it's been, it's been going over for months, then you can wait for cultures to come back and see which organisms are positive and treat accordingly. They're not

going to ask you it that way in the pants because that's too easy. They're not going to give you, you know, a culture and say these are the antibiotics, it's, or these are the organisms, these are antibiotics, it's sensitive to because then there's your answer. So really, they're going to give you a question. They're going to ask you, what is the empiric antibiotic treatment for these patients for endocarditis? You really need to know the empiric antibiotics. That's the main ones you need to know. Now, the empiric antibiotics vary. It all depends on the type of valve involved, and it depends on the type of organism, whether it's fungal. So let's go over. So let's go over. over the different empiric therapies that you need to know for each.

So for native valve, so that means, you know, it hasn't been replaced. It's their native valve that they have in their heart. The empiric therapy, for native, you're going to use a combo of two different medications. So one of the medications will be an antistaphylocococcal penicillin, and that's going to be your grand positive coverage. Again, remember this is empiric therapy, you're covering a bunch of different things because you don't know what it is yet. So the anti-staphyphalococcal penicillin, you're going to choose one of these. It's either going to be nafcylin, oxysillin.

Those are the most common ones. And then one of, for gram-negative coverage, is either going to be Cephtriaxone or agenemicin. So again, remember, for your gram-positive coverage, you're going to use an antistaphylococcal penicillin. So nafcillin, oxysillin, and then combine one of those with your gram-negative coverage, which is either going to be seftriaxone or gentomycin. You normally treat for about four to six weeks with these. Now, how do you remember the meds that you need to know?

remember it was oxycinacin nafcyl and one of those and then one of either seftrioxin or gentemycin. I remember the sentence, only native cardiac gears. Only native cardiac gears, meaning these patients only have their native cardiac gears, like the gears of the heart. Nothing is artificial or prosthetic. So only native cardiac gear stands for oxycin, nafcyl and sefthriaxone or gentimicin. Remember, you pick one on each side. So either oxycin or nafcyline plus either seftrioxone or gentomycin, only native cardiac ears.

And then just as a side note, if for some reason you believe these patients do have MRSA, you're going to use vanco instead of either the oxycin or the nafcylyn or the nafcylyn. You would replace that with vanco. But that ruins by mnemonic, so I can't say that. But generally, you're going to use either oxycin, nefcyl or sefriaxon or gentimicin, unless they say this patient has MRSA. And then you just remember use vanco instead of. oxacillin and afsillum. Okay, so that's native valve. Let's move on to prosthetic valves. So

Prostatic valve, antibiotic therapies, it's a little bit more complicated. Often the valves will actually have to be replaced. But generally, you're trying to cover staff enterococci, gram-negative bacilli, and the regimen is going to consist of vancomycin, gentimicin, and refampin. That's typically the three medications you're going to use for prosthetic valves. So vancomycin, gentimic. So vancomycin, gentimicin and refampin. And just as a side note, you don't really need to know this for the pants. But the reason you use gentomycin with vanco is actually because of the synergistic effect of gentimicin with vanco.

The gentimicent actually makes the vanco work better and vice versa. So they both kind of work off of each other and improve the coverage, particularly for Mercer. So remember again, Vanco, Genta, refampin. And the reason you use refampin, it actually can penetrate. When you have these prosthetic valves, the pathogens sometimes develop this biofilm that's hard for the antibiotics to penetrate. And the refampin actually can penetrate the biofilm. That's the reason you use refampin.

And then one other thing I wanted to mention too, I always like to give you a little bit more clinical knowledge. The refampin, a lot of times with most bacterial infections with refampin, you don't start refampin day one. So normally you're going to use vancogenogenomycin for a couple days, two to three days, to kind of of drop down the the amount of infectious organisms, the amount of staff, whatever you're treating. Because if you use refampin right away, Fampin actually has a really high potential for mutation. And a lot of times these bacteria, when they're exposed to refampin, develop resistance almost within days. But if you give it a couple days, you treat with other antibiotics first bring down the actual

amount of bacteria. Raphon works really well, and this resistance isn't seen as commonly. So again, you don't need to know that for the pants, but it's always better just to know a little bit more about the meds that you're going to use once you use them in real life. Now, how do you remember the meds that you need to know for prosthetic valves? So remember again, they're Vanco, Gentomicin, or Phampin. I remember the sentence. Valves generally replicated, recreated, reproduced, whatever word you want to use for R. Use one of those.

But remember, these valves aren't, they're not native valves. They've been replicated. They've been reproduced. They've been recreated. they're recreating the native valves of the body. So I remember the sentence, valves generally recreated. And that reminds me all those letters, vancogenomycin refampin. So valves generally recreated, vancogenitimicin refampin.

And then, like I said before, with all of these antibiotic therapies, whether it's prosthetic or native, you're going to do it for about four to six weeks. And then the last one, this is the easiest. If it turns out it's a fungal infection, you're just going to treat with Amphotarison B for about six to eight weeks. And that's going to be your treatment for fungal infection. So that one's super easy. Just amphotericin B for about six to eight weeks.

Okay, so this is the last thing you need to know about endocarditis. I wish we were done, but we're not. You actually need to know a little bit about the prophylactic regimen. So the only time you're going to use antibiotics prophylactically to prevent infectious endocarditis is if you have a patient that has a very high likelihood of an adverse outcome, if they did wind up getting endocarditis. So the patients you're going to use prophylactic antibiotics on will be one of the following. Again, don't memorize this, but just kind of be familiar with this.

So the patients that you're going to treat prophylactically for endocarditis to prevent it is going to be one, a patient with a history of infective endocarditis, obviously. A patient who has an unrepaired cyanotic congenital heart disease like the etiology of philoh. If you did the congenital heart disease podcast, you remember anything that starts with a tea, It's going to be cyanotic. A patient that has heart repairs that uses prosthetic materials. It doesn't include stents, but any other prosthetic material of the heart, you're going to prophylactically treat these patients. Also prosthetic heart valves.

Any patient that has repaired congenital heart disease or defects with either residual shunts, prosthetic patches or any types of prosthetic devices, or any patient that has valvular regurgitation due to structurally abnormal valve. and transplanted hearts. So it's ridiculous to memorize that. But just be familiar. If this patient has some kind of cardiac history, they have some kind of congenital heart disease, they have some kind of prosthetic valve.

Remember, if they have a procedure done, that will go over next. You're probably going to treat them prophylactically. Now, what are the procedures that you need to treat them prophylactically for? So the procedures that these patients need prophylaxis for is either a dental procedure, which is going to be anytime they're having any kind of, manipulation of or perforation of the gingerly tissue, any tooth extractions, drainage of a dental abscess, you know, if it's just a routine exam, the dentist's looking at the teeth, you don't

need to give these patients antibiotics. But you more invasive things. Anytime they're having a respiratory track procedure, now it has to be a procedure, a respiratory tract procedure that involves an incision or a biopsy. So if they're just having an endoscopy done, they don't need prophylaxis. if they're having a bronchoscopy done, they don't need prophylaxis. But if they're having a bronchoscopy with a biopsy, then they do. If they're having a tonsillectomy, anything where we're cutting, you know, taking out tissue, cutting something out of the respiratory tract, make sure that they do receive endocarditis prophylaxis.

And then finally, any time you're doing any time of skin or soft tissue procedure with infected skin, so any kind of surgical procedure repair of the skin with infected. tissue, they need prophylaxis. So this is why I said not to memorize this because it's too much, but you should at least hear it once or twice read it. Now the antibiotics, you should memorize these because it's pretty easy. So the preferred antibiotic, if they say what is the first line treatment for a patient prophylactically for infective endocarditis, unless they specify any allergies, it's going to be amoxicillin. You normally use about two grams. You do it about 30 to 60 minutes prior to the procedure. So super easy moxacinin. That's going to be a prophylactic treatment about

two grams 30 to 60 minutes prior to the procedure. If they do mention a penicillin allergy, then you would use clindomycin about 600 milligrams. So prophylaxis, again, moxicillin, two grams, or penicillin allergy, clindamison, 600 milligrams. Okay, so that's endocarditis. You can see why I only put one thing onto this podcast because it is a lot for endocarditis. Let's do five quick questions and then we'll wrap it up. So what is the most common valve involved in a patient who is an IV drug user? Most common valve. involved in a patient who is an IV drug user, tricuspid valve. Want to try drugs?

What is the most common organism seen in subacute endocarditis, which again, remember, infects the damaged or vulnerable valves. So remember vulnerable valves, strep viradans, vulnerable valves, viradans, strep viradans. What are Roth spots? Roth spots are retinal hemorrhages or lesions. Just a quick way to remember that Rothspart starts with an RRDANs. so think retina, retinal hemorrhages or lesions. Those are rough spots. What is the normal empiric treatment regimen for a patient with prosthetic valve endocarditis?

Normal treatment regimen, empiric treatment regimen for a patient with prosthetic valve endocarditis. Okay, remember valves generally recreated, repaired. So that's vancomycin, gentomycin, refampin. Prostetic valve, vancomycin, gentomycin, refampin, valves generally recreated, repaired, however you want to remember that. And then finally, what is the most common clinical manifestation seen in patients with endocarditis? Most common clinical manifestation symptom seen in patients with endocarditis. It's going to be fever. That's your most common clinical presentation that you'll see in a patient with endocarditis. Okay, so that was endocarditis. About 30 minutes, not too bad. It is a lot to know,

and you should, you know, be pretty familiar, at least with some of the things I went over. Hopefully the pneumonics helped. And as always, Thank you so much for listening to my podcast. Please leave me a review if it's helping you. And good luck in PA school. Good luck on your pants, your panery, and your EORs.