Take-Home Points
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Endocarditis can have vague and varied presentations and has high morbidity and mortality. Be on the lookout in patients with risk factors including:
- Congenital heart disease
- Cardiac prosthesis or devices
- Immunocompromise
- IV drug use
- Recent invasive procedure
- Hx of prior IE
- Patients may present with fever, sepsis of unclear source or may have manifestations of emboli to the skin, eyes, brain, lungs, spleen or kidney.
- Diagnosis is based on the modified Duke Criteria and workup should include THREE good sets of blood cultures.
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ED management includes consultation with ID and cardiothoracic surgery and starting antibiotics based on whether the patient has a native or prosthetic valve. Basic starting antibiotic regimen includes:
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For patients with native valve disease a good starting regimen is:
- Vancomycin 25-30 mg/kg IV loading dose followed by 15-20 mg/kg twice daily AND
- Cefepime 2 g IV TID
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For patients with prosthetic valve disease, we have to go a bit bigger:
- Vancomycin 25-30 mg/kg IV loading dose followed by 15-20 mg/kg IV twice daily AND
- Rifampin 300 mg PO/IV TID AND
- Gentamicin 1 mg/kg IV TID AND
- Some recommendations include the Cefepime 2 g IV TID
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For patients with native valve disease a good starting regimen is:
REBEL Core Cast 27.0 – Endocarditis
Click here for Direct Download of Podcast
Endocarditis
- Infection of the endocardial surface of the heart, heart valves or both
- Micro damage to the endothelium from rheumatic heart disease or congenital heart disease can lead to colonization and infection
Incidence
- 40,000 to 50,000 new cases of endocarditis in the US each year.
- In-hospital mortality 14-22%
- 1-year mortality of 20-40%
Risk Factors
- Be suspicious when patient presents with fever or sepsis and has these risk factors
- Congenital heart disease
- Cardiac prosthesis or devices
- Immunocompromise
- IV drug use
- Recent invasive procedure
- Prior history of infectious endocarditis
Clinical Presentation
- Most of the time patient will present with fever (90%)
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Other nonspecific symptoms
- Malaise
- Anorexia
- Weight loss
- myalgia
- Arthralgia
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Acute and Subacute presentations with severity being quite broad.
- Acute IE presentations tend to have more impressive presentations.
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New Murmur
- 50-80% of patients presented with this symptom
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AV nodal conduction abnormalities
- Prolonged PR interval, heart block
- Heart failure
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Valvular insufficiency
- The most common complication of IE
Extracardiac Manifestations
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Osler Nodes
- Tender lesions found on finger pulps and thenar/hypothenar eminences
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Janeway Lesion
- Non tender macular papules on palm or sole
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Splinter Hemorrhages
- Small blood spots that appear underneath nail
- Petechiae
- Clubbing
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Roth Spots
- Emboli in the eye causing boat-shaped hemorrhages with pale centers
Complications from Emboli
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Cerebral emboli
- Acute CVA presentations
- Meningitis
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Pulmonary emboli
- More common in IVDU, tricuspid almost always involved
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Splenic Emboli
- Can present with flank pain or diaphragmatic irritation
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Renal Emboli
- Present with flank pain, pyuria and hematuria
Work Up
- CBC
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UA
- Hematuria could indicate renal emboli
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ESR/CRP
- Elevated in >90% of cases
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Blood Cultures
- 3 sets from different sites
Imaging
- Get imaging based on symptoms
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Respiratory symptoms
- CXR
- Chest CT
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AMS / Headache
- Noncontrast head CT
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Abdominal symptoms
- Abdominal CT
Diagnosis
- Based on a combination of clinical findings, microbiological findings and echocardiogram using the modified Duke Criteria
Treatment
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Antibiotics
- Native valve – Vancomyin 25-30mg/kg IV loading dose & Cefepime 2g IV
- Prosthetic valve – Vancomycin 25-30 mg/kg IV, Rifampin 300mg and Gentamicin 1 mg/kg
- Surgery for source control
References
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REBEL EM: Endocarditis
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Core EM: Infective Endocarditis
- LITFL: Infective endocarditis
- SMACC Dublin: Endocarditis Will Also F*ck You Up
- CorePendium: Endocarditis
Shownotes Written By: Miguel Reyes, MD (Twitter: @miguel_reyesMD)
Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)
The post REBEL Core Cast 27.0 – Endocarditis appeared first on REBEL EM - Emergency Medicine Blog.