16.3 Infective Endocarditis, Device Infections & Other Focal Cardiovascular Infections

ABIM Critical Care Medicine Study Guide Exam

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1 Chapter 1: Exam Orientation: Format, Blueprint & Study Strategy

1.1 ABIM Critical Care Medicine Exam: Format, Blueprint & Study Strategy

2 Chapter 2: Acute Respiratory Failure & ARDS

2.1 ARDS Definition, Pathophysiology & Phenotypes 2.2 Lung-Protective Mechanical Ventilation 2.3 Refractory ARDS: Prone Positioning, Neuromuscular Blockade & VV-ECMO

3 Chapter 3: Obstructive Airways, Pulmonary Vascular & Pleural Emergencies

3.1 Severe Asthma & COPD Exacerbations in the ICU 3.2 Massive & Submassive Pulmonary Embolism 3.3 Pulmonary Hypertension & Right Ventricular Failure in the ICU 3.4 Massive Hemoptysis, Complex Pleural Effusions & Thoracic Drainage

4 Chapter 4: Airway, Parenchymal & Nonthrombotic Pulmonary Emergencies

4.1 Airway Management, Upper-Airway Obstruction & Artificial-Airway Complications 4.2 Diffuse Alveolar Hemorrhage, Interstitial Lung Disease, Pulmonary Vasculitis & Noncardiogenic Edema 4.3 Severe Community-Acquired & Viral Pneumonia 4.4 Nonthrombotic Embolism (Air, Fat, Amniotic Fluid, Tumor, Septic) & Acute Chest Syndrome

5 Chapter 5: Mechanical Ventilation Modes, Dyssynchrony & Liberation

5.1 Mechanical Ventilator Modes & Advanced Breath Delivery 5.2 Patient-Ventilator Dyssynchrony & Waveform Analysis 5.3 Ventilator Liberation, Spontaneous Breathing Trials & Post-Extubation Support

6 Chapter 6: Shock Syndromes & Hemodynamic Principles

6.1 Shock Classification, Cellular Pathophysiology & Biomarkers 6.2 Hemodynamic Monitoring: Arterial Lines, CVP & Pulmonary Artery Catheter 6.3 Dynamic Assessment of Fluid Responsiveness & Resuscitation Targets

7 Chapter 7: Vasoactive Therapies & Mechanical Circulatory Support

7.1 Vasopressors & Inotropes: Pharmacology & Clinical Titration 7.2 Temporary Mechanical Circulatory Support: IABP, Impella & TandemHeart 7.3 Venoarterial ECMO (VA-ECMO) & Differential Hypoxemia 7.4 Post-Cardiac Arrest Care, Targeted Temperature Management & Neuroprognostication

8 Chapter 8: Acute Kidney Injury & Renal Replacement Therapy

8.1 KDIGO AKI Classification, Etiologies & Diagnostic Evaluation 8.2 Continuous Renal Replacement Therapy (CRRT) vs Intermittent Hemodialysis 8.3 Indications & Timing for RRT in Critical Illness: AKIKI & STARRT-AKI

9 Chapter 9: Electrolyte, Acid-Base & Endocrine Emergencies

9.1 Severe Dysnatremias: Hyponatremia, Hypernatremia & Osmotic Demyelination 9.2 Potassium, Calcium, Magnesium & Phosphate Disorders 9.3 Complex & Mixed Acid-Base Disorders: Boston vs Copenhagen vs Stewart 9.4 Endocrine Crises: DKA, HHS, Thyroid Storm, Myxedema Coma & Adrenal Crisis

10 Chapter 10: Glycemic Control, Hyperammonemia, Pituitary & Adrenal Disorders

10.1 ICU Glycemic Control & Severe Hypoglycemia 10.2 Non-Hepatic Hyperammonemia & Metabolic Encephalopathy 10.3 Pituitary Emergencies, Adrenal Excess & Critical Illness-Related Corticosteroid Insufficiency

11 Chapter 11: Acute Coronary Syndromes & Cardiac Arrhythmias

11.1 Acute Coronary Syndromes & Mechanical Complications of Myocardial Infarction 11.2 Critical Tachyarrhythmias: Atrial Fibrillation with RVR, VT & VF 11.3 Critical Bradyarrhythmias, Conduction Blocks & Temporary Cardiac Pacing

12 Chapter 12: Acute Heart Failure, Valvular & Pericardial Emergencies

12.1 Acute Decompensated Heart Failure & Cardiogenic Pulmonary Edema 12.2 Acute Valvular Regurgitation & Prosthetic Valve Emergencies 12.3 Pericardial Tamponade & Acute Aortic Syndromes

13 Chapter 13: Myocardial Disease, Hypertensive & Cardiac Device Emergencies

13.1 Fulminant Myocarditis, Stress & Peripartum Cardiomyopathy, and Hypertrophic Cardiomyopathy 13.2 Hypertensive Emergencies & Ruptured Abdominal Aortic Aneurysm 13.3 Implanted Cardiac Devices, LVAD Emergencies & Electrical Storm

14 Chapter 14: Sepsis & Systemic Infectious Diseases

14.1 Sepsis-3 Definitions & Surviving Sepsis Campaign 2026 Guidelines 14.2 Refractory Septic Shock & Adjunctive Therapies 14.3 Multidrug-Resistant Pathogens & Antimicrobial Stewardship in the ICU

15 Chapter 15: ICU-Acquired & Severe Focal Infections

15.1 Hospital-Acquired & Ventilator-Associated Pneumonia 15.2 Central Line-Associated Bloodstream Infections & Catheter-Associated UTIs 15.3 Intra-Abdominal Sepsis, Necrotizing Soft Tissue Infections & CNS Infections

16 Chapter 16: Focal, Special-Host & Systemic Infections

16.1 CNS Infections Beyond Bacterial Meningitis: Encephalitis, Brain Abscess & Epidural Abscess 16.2 Infections in the Immunocompromised Host, Tropical & Bioterror Infections 16.3 Infective Endocarditis, Device Infections & Other Focal Cardiovascular Infections 16.4 Antimicrobial Pharmacokinetics, Allergy, Toxicity & Infection Prevention 16.5 Gastrointestinal & Hepatobiliary Infections: Fulminant C. difficile, Typhlitis, CMV Colitis & Abscesses

17 Chapter 17: Neurocritical Care & Coma

17.1 Coma, Altered Mental Status & Acute Delirium in the ICU 17.2 Status Epilepticus & Non-Convulsive Status Epilepticus 17.3 Acute Ischemic Stroke & Intracranial Hemorrhage

18 Chapter 18: Cerebrovascular Syndromes, Encephalopathy & Withdrawal States

18.1 Cerebral Venous Sinus Thrombosis, PRES & Reversible Cerebral Vasoconstriction Syndrome 18.2 Alcohol & Sedative Withdrawal, Wernicke Encephalopathy & Drug-Induced Encephalopathy

19 Chapter 19: Intracranial Hypertension & Neuromuscular Weakness

19.1 Intracranial Pressure Monitoring, Cerebral Perfusion & Tiered ICP Management 19.2 Acute Neuromuscular Respiratory Failure, ICU-Acquired Weakness & Brain Death Determination

20 Chapter 20: Traumatic Brain Injury, Spinal Cord Injury & Toxin-Mediated Paralysis

20.1 Traumatic Brain Injury Management & Paroxysmal Sympathetic Hyperactivity 20.2 Acute Spinal Cord Injury, Neurogenic Shock & Autonomic Dysreflexia 20.3 Toxin-Mediated Paralysis & Neuromuscular Crises: Botulism, Tetanus, Tick Paralysis & Myasthenic Crisis

21 Chapter 21: Gastrointestinal, Hepatic & Abdominal Emergencies

21.1 Acute Upper & Lower Gastrointestinal Bleeding in the ICU 21.2 Acute Liver Failure & Severe Acute Pancreatitis 21.3 Abdominal Compartment Syndrome & Acute Mesenteric Ischemia

22 Chapter 22: Luminal GI Emergencies & Complications of Cirrhosis

22.1 Esophageal, Gastric & Bowel Emergencies: Perforation, Obstruction, Ogilvie Syndrome & Colonic Ischemia 22.2 Complications of Cirrhosis: Alcohol-Associated Hepatitis, Hepatorenal Syndrome & Pulmonary Vascular Syndromes

23 Chapter 23: Trauma, Burns & Perioperative Critical Care

23.1 Polytrauma Resuscitation, Damage Control & Massive Transfusion 23.2 Severe Burn Injury, Inhalation Injury & Environmental Emergencies 23.3 Perioperative Critical Care for High-Risk Surgical Patients

24 Chapter 24: Thoracic Trauma, Environmental Injury & Obstetric Critical Care

24.1 Thoracic Trauma: Flail Chest, Pulmonary Contusion, Great Vessel & Tracheobronchial Injury 24.2 Environmental Injury: Drowning, Diving, Altitude, Heat, Cold, Electrical & Radiation 24.3 Obstetric & Genitourinary Emergencies and the Physiology of Pregnancy

25 Chapter 25: Transplantation, Donor Management & Post-Cardiac Surgery Care

25.1 Solid Organ Transplant Recipients & Deceased Donor Management 25.2 Post-Cardiac Surgery Critical Care: Bleeding, Tamponade, Low Output & Vasoplegia

26 Chapter 26: Hematologic Emergencies, Toxicology, Critical Ultrasound & ICU Liberation

26.1 Hematologic Emergencies in the ICU: HIT, DIC, TMA & Anticoagulant Reversal 26.2 Critical Care Toxicology, Toxidromes & Specific Antidotes 26.3 Critical Care Point-of-Care Ultrasound (POCUS) 26.4 ICU Liberation, Analgosedation, Goals of Care & Critical Care Ethics

27 Chapter 27: Transfusion Medicine, Hematologic & Oncologic Disorders

27.1 Transfusion Medicine: Products, Thresholds, Reactions & Apheresis 27.2 Red and White Cell Disorders, Hemoglobinopathies, Factor Deficiencies & Hypercoagulable States 27.3 Oncologic Emergencies, Hematopoietic Cell Transplant Complications & Cellular Therapy Toxicity

28 Chapter 28: Clinical Pharmacology, Adverse Drug Reactions & Specific Poisonings

28.1 Pharmacokinetic Principles, Dose Adjustment & Drug Interactions in Critical Illness 28.2 Adverse Drug Reactions: Anaphylaxis, Severe Cutaneous Reactions & Hyperthermic Syndromes 28.3 Specific Poisonings: Sodium-Channel Blockers, Lithium, Valproate, Theophylline, Iron, Sulfonylureas & Methemoglobinemia

29 Chapter 29: Ethics, Research Methods, Administration & Abdominal Ultrasound

29.1 Advance Care Planning, Nonbeneficial Treatment, Informed Consent & Confidentiality 29.2 Critical Care Research Methods, Statistics, IRB Oversight & Quality Improvement 29.3 Abdominal, Vascular & Procedural Point-of-Care Ultrasound

16.3 Infective Endocarditis, Device Infections & Other Focal Cardiovascular Infections

Key Takeaways Explain This Topic AI

Early surgery is indicated in infective endocarditis for heart failure from valve dysfunction, uncontrolled infection such as abscess or persistent bacteremia, and vegetations larger than 10 mm with embolism (or very large vegetations).

In the 2012 EASE trial, surgery within 48 hours for large vegetations reduced embolic events (3% vs 23%) without changing mortality.

Anticoagulation is generally avoided or interrupted after embolic stroke in endocarditis because of hemorrhagic transformation risk, especially with Staphylococcus aureus.

Cardiac implantable device infection requires complete hardware extraction; antibiotics alone fail, and transesophageal echocardiography assesses lead vegetations.

Purulent pericarditis is a surgical drainage problem; pericardiocentesis alone often fails because the exudate is loculated and thick.

Last updated: October 2026

Infective Endocarditis: Diagnosis

The 2023 Duke-ISCVID criteria updated the classic Duke framework. The essential logic remains:

Major microbiologic criteria :

Typical organisms in at least two separate blood cultures: viridans streptococci, Streptococcus gallolyticus (formerly bovis ), HACEK organisms, S. aureus , Enterococcus faecalis .

Persistent bacteremia with organisms that are less typical.

Positive serology or PCR for Coxiella burnetii , Bartonella , and Tropheryma whipplei .

Major imaging criteria :

Echocardiographic vegetation, abscess, pseudoaneurysm, intracardiac fistula, valve perforation, or new prosthetic dehiscence.

18F-FDG PET/CT abnormal activity around a prosthetic valve or device (now a major criterion), and CT evidence of paravalvular involvement.

Minor criteria include predisposing heart disease or injection drug use, fever, vascular phenomena (septic emboli, mycotic aneurysm, intracranial hemorrhage, Janeway lesions), immunologic phenomena (glomerulonephritis, Osler nodes, Roth spots, rheumatoid factor), and microbiologic findings that do not meet major criteria.

Practical approach :

Draw at least three sets of blood cultures from separate sites before antibiotics.

Transthoracic echocardiography first, then transesophageal echocardiography when the transthoracic study is negative or inadequate, when a prosthesis or device is present, or when complications are suspected.

Add cardiac CT for paravalvular extension, brain MRI for silent emboli, and PET/CT for prosthetic material.

S. gallolyticus bacteremia mandates colonoscopy (association with colonic neoplasia).

S. aureus bacteremia always deserves an echocardiogram and a careful search for metastatic foci.

Treatment and the Surgical Decision

Empiric therapy in a critically ill patient covers S. aureus (including MRSA), streptococci, and enterococci: vancomycin plus ceftriaxone , or vancomycin plus gentamicin for prosthetic valves with rifampin added once the organism is known. Definitive therapy is organism-directed for 4 to 6 weeks, usually intravenous, with cardiology, cardiac surgery, and infectious diseases co-managing.

Indications for early surgery :

Heart failure from valve regurgitation or obstruction (the strongest indication).

Uncontrolled infection : abscess, fistula, pseudoaneurysm, heart block, or persistent bacteremia and fever beyond 5 to 7 days despite appropriate antibiotics.

Prevention of embolism : a vegetation larger than 10 mm with a prior embolic event, or very large vegetations (above about 15 mm). In the EASE trial, early surgery (within 48 hours) for large vegetations reduced embolic events from 23% to 3% without changing mortality.

Difficult organisms : fungal endocarditis, multidrug-resistant organisms, S. aureus prosthetic valve endocarditis.

Prosthetic valve endocarditis with dehiscence, obstruction, or relapse.

Anticoagulation : endocarditis itself is not an indication. In a patient already anticoagulated (for example, a mechanical valve), the risk of hemorrhagic transformation after a septic embolic stroke, particularly with S. aureus , usually leads to interrupting anticoagulation for about 2 weeks after a significant embolic stroke, with individualized multidisciplinary decisions. Avoid aspirin as adjunctive therapy, which did not reduce embolism and increased bleeding.

Neurologic complications : ischemic stroke is common, and mycotic aneurysms can rupture. Image the brain vessels when there is hemorrhage, focal headache, or unexplained deterioration. Thrombolysis is contraindicated in stroke caused by endocarditis; mechanical thrombectomy can be considered.

Right-Sided Endocarditis

Usually S. aureus in people who inject drugs, or device- and catheter-related.

Presents with fever, bacteremia, and septic pulmonary emboli (multiple peripheral cavitating nodules) rather than systemic emboli.

Many cases respond to antibiotics alone; surgical indications include right heart failure, persistent bacteremia, very large vegetations, and recurrent pulmonary emboli. Tricuspid valve repair is preferred to replacement when possible.

Treat the substance use disorder as part of the plan; relapse drives recurrent endocarditis.

Cardiac Implantable Electronic Device Infection

Pocket infection : erythema, swelling, erosion, or discharge over the generator. Do not aspirate the pocket.

Lead endocarditis or device-related bacteremia : S. aureus or coagulase-negative staphylococci.

Management : complete removal of the generator and all leads , culture of the hardware, 2 to 6 weeks of antibiotics depending on bacteremia and vegetations, and reimplantation on the contralateral side after clearance. Antibiotics without extraction relapse in most cases.

S. aureus bacteremia in a device carrier mandates transesophageal echocardiography even without local signs.

Purulent Pericarditis and Myocardial Abscess

Purulent pericarditis arises from contiguous pneumonia or empyema, bacteremia, thoracic surgery, or trauma, typically with S. aureus , S. pneumoniae , or gram-negative organisms. Patients present with sepsis and often tamponade .

Pericardial fluid shows a very high white cell count with low glucose and high LDH.

Treatment requires drainage , usually surgical (pericardiotomy or pericardiectomy) because the purulent exudate loculates and thickens; needle pericardiocentesis alone frequently fails. Give prolonged intravenous antibiotics, and consider intrapericardial fibrinolysis to prevent constriction.

Tuberculous pericarditis presents subacutely; adjunctive corticosteroids are used selectively, and constrictive physiology may follow.

Head, Neck and Orbital Infections With Critical Care Implications

Infection Features Management

Septic cavernous sinus thrombosis Spread from sinusitis or facial or dental infection: proptosis, chemosis, periorbital edema, cranial nerves III, IV, V1, V2, and VI palsies, often bilateral MRI or CT venography; prolonged high-dose antibiotics covering S. aureus and anaerobes; drainage of the source; anticoagulation is often used despite limited evidence; steroids for cranial neuropathy are debated

Orbital cellulitis and abscess Proptosis, pain with eye movement, reduced vision Imaging, antibiotics, surgical drainage; distinguish from preseptal cellulitis

Ludwig angina Submandibular space infection with tongue elevation and airway compromise Early airway control, broad-spectrum antibiotics, surgical drainage

Lemierre syndrome Internal jugular septic thrombophlebitis after pharyngitis, usually Fusobacterium necrophorum , with septic pulmonary emboli Beta-lactam-beta-lactamase inhibitor or carbapenem, or metronidazole plus a cephalosporin; anticoagulation individualized

Epiglottitis Rapidly progressive sore throat, drooling, muffled voice, stridor in adults Airway control in a controlled setting with surgical backup, ceftriaxone plus anti-staphylococcal coverage

Invasive fungal sinusitis Diabetes with ketoacidosis or neutropenia; black necrotic turbinates, facial numbness Emergent surgical debridement plus liposomal amphotericin B

Deep neck space abscess Trismus, neck swelling, dysphagia; retropharyngeal extension to the mediastinum CT with contrast, drainage, broad-spectrum antibiotics; watch for descending necrotizing mediastinitis

Bone and joint infections also reach the ICU: septic arthritis needs joint aspiration before antibiotics and urgent drainage (arthroscopic or open), and large-joint involvement with S. aureus bacteremia often signals endocarditis or another deep focus. Vertebral osteomyelitis presents with back pain and bacteremia and frequently accompanies epidural abscess.