American Board of Internal Medicine (ABIM) Certification Practice Exam

What indicates that endocarditis is complicated and may require early surgical intervention?

1. Persistent bacteremia after 3 days of therapy

2. Monday morning presentations

3. Fatigue that lasts longer than 1 week

4. Imaging findings of tricuspid regurgitation

The correct answer is: Persistent bacteremia after 3 days of therapy

Persistent bacteremia after 3 days of appropriate antibiotic therapy is a significant concern in the management of endocarditis. This condition typically leads to the expectation of clinical improvement and eradication of bacteria within this time frame when proper antimicrobial treatment is in place. When bacteremia continues beyond this period, it suggests the presence of complications such as a large vegetative mass, abscess formation, or the inability of the antibiotics to penetrate the biofilm often associated with the infective endocarditis. In such instances, the likelihood of further systemic embolic events increases and the risk of heart failure due to valvular dysfunction also becomes more pronounced. Therefore, persistent bacteremia acts as a significant indicator that surgical intervention might be necessary to remove infected tissue or repair the affected valve to improve outcomes and prevent serious complications. This early surgical approach is crucial in handling complicated cases of endocarditis and is supported by various guidelines. The other options do not provide similar urgency or indication for surgical intervention. For instance, fatigue lasting longer than a week, while concerning for the patient's overall clinical picture, does not specifically indicate that endocarditis has complicated to a degree that requires surgery. Similarly, Monday morning presentations could reflect a variety of clinical scenarios without directly linking to complications of