Infective Endocarditis

  • CC: Fever, bacteremia, murmur

  • PP: Night sweats, weight loss, chills, embolic phenomena, back pain, stroke-like symptoms, petechiae

  • PN: No alternative source of bacteremia, no focal pneumonia/UTI/SSTI unless present

  • pertinent SHx: IVDU, dental procedures, indwelling lines, recent hospitalization

  • Etiology: Infection of native/prosthetic valve or intracardiac device

  • risk factors: Prosthetic valve, prior endocarditis, IVDU, hemodialysis, cardiac device, structural valve disease, persistent bacteremia

  • initial DATA: Blood cultures x3 sets before antibiotics if stable, CBC, CMP, ESR/CRP, UA, EKG, TTE

  • pending DATA: Blood culture speciation/susceptibilities, repeat blood cultures, TEE if TTE negative but suspicion high

  • prior data: Prior valve/device history, prior micro

  • MEDS: Recent antibiotics, anticoagulation, immunosuppression

  • COURSE:

Plan:

  • Obtain 3 sets blood cultures from separate sites before antibiotics if stable

  • consult ID

  • Antibiotics:

    • Native valve, severe/unstable: Vancomycin + Cefepime

    • Prosthetic valve/device concern: Vancomycin + Cefepime ± Gentamicin/Rifampin per ID

  • Repeat blood cultures q24–48h until negative

  • TTE first; TEE if:

    • Prosthetic valve/device

    • S. aureus bacteremia

    • Persistent bacteremia

    • Poor TTE windows

    • High suspicion despite negative TTE

  • Consult ID

  • Consult cardiology/CT surgery if:

    • Heart failure

    • Abscess

    • Large vegetation/embolization

    • Persistent bacteremia

    • Fungal/prosthetic valve infection

  • Trend CBC/CMP, fever curve, renal function

  • Monitor for stroke, splenic/renal infarct, vertebral osteo, heart block

  • Duration: usually 4–6 weeks from first negative blood culture depending organism/valve