REBEL Core Cast 27.0 – Endocarditis

Take-Home Points

Endocarditis can have vague and varied presentations and has high morbidity and mortality. Be on the lookout in patients with risk factors including:
1. Congenital heart disease
2. Cardiac prosthesis or devices
3. Immunocompromise
4. IV drug use
5. Recent invasive procedure
6. 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.
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:
1. For patients with native valve disease a good starting regimen is:
  1. Vancomycin 25-30 mg/kg IV loading dose followed by 15-20 mg/kg twice daily AND
  2. Cefepime 2 g IV TID
2. For patients with prosthetic valve disease, we have to go a bit bigger:
  1. Vancomycin 25-30 mg/kg IV loading dose followed by 15-20 mg/kg IV twice daily AND
  2. Rifampin 300 mg PO/IV TID AND
  3. Gentamicin 1 mg/kg IV TID AND
  4. Some recommendations include the Cefepime 2 g IV TID

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

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

Most of the time patient will present with fever (90%)
Other nonspecific symptoms
- Malaise
- Anorexia
- Weight loss
- myalgia
- Arthralgia
Acute and Subacute presentations with severity being quite broad.
- Acute IE presentations tend to have more impressive presentations.
New Murmur
- 50-80% of patients presented with this symptom
AV nodal conduction abnormalities
- Prolonged PR interval, heart block
Heart failure
Valvular insufficiency
- The most common complication of IE

Osler Nodes
- Tender lesions found on finger pulps and thenar/hypothenar eminences
Janeway Lesion
- Non tender macular papules on palm or sole
Splinter Hemorrhages
- Small blood spots that appear underneath nail
Petechiae
Clubbing
Roth Spots
- Emboli in the eye causing boat-shaped hemorrhages with pale centers

Based on a combination of clinical findings, microbiological findings and echocardiogram using the modified Duke Criteria

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

Shownotes Written By: Miguel Reyes, MD (Twitter: @miguel_reyesMD)

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

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