Some Points on Acute Endocarditis from the Talk
- Keep Endocarditis on the radar for all febrile patients without a source
- Examine your febrile-listen for murmur and look at teeth
- Ask about teeth cleaning in past 2 weeks
- Even though we were taught about Janeway lesions and Osler’s nodes in medical school, the reality is that these peripheral manifestations of endocarditis occur in only about 10% of patients. Listening for heart murmurs which are present in about 90% of patients with endocarditis is one of the most important physical exam maneuvers in patients who present with fever
- Various Ways to Categorize
- Native Valve | Prosthetic Valve | IV Drug User
- Right vs. Left-sided
- Acute vs. Subacute
- Acute Endocarditis may present so acutely that a murmur has not yet developed despite the patient being quite ill
- Oh so fastidious, the HACEK organisms are Haemophilus species, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae
- Endocarditis should be on your radar for any patient with valvular heart disease who presents to the ED whether they are febrile or not, especially if they are vaguely unwell
- Ideal cultures: 3 sets at 3 sites with an hour between first and last, each with a bunch of blood
- Coag-Negative Staph Aureus positive blood culture in a patient with valvular disease is endocarditis until proven otherwise, even though the majority of Coag Negative Staph Aureus positive blood cultures are contaminants. A blood culture positive for a particular type of Coag-Negative Staph Aureus called SLUG (Staphylococus lugdunensis) should raise the possibility of endocarditis even in patients without valvular heart disease
- Get nervous when the bacteria doesn't fit the crime
- No ED/ICU procedure requires prophylaxis
- 2/3 of L-sided emboli will be CNS. Brain emboli will be in the MCA territory
- Be scared of new-onset of CHF and CHF in young patients
- Look at the ECG for new heart blocks in patients with fever (Even 1st Degree HB) – Consider Valvular Abscess
- Antibiotic coverage-your empiric sepsis antibiotics + sepsis-dose Vanco will cover everything you need to worry about. Vanco alone will get the job done in almost every case
Indications for Operation
From David's EM:RAP Episode (2/22)
- Groups of patients that should raise suspicion for endocarditis include:
- Usual suspects
- Patients with intravenous drug use (IVDU).
- IVDU + fever = 15% chance of endocarditis.
- IVDU + fever = 25-40% chance of bacteremia.
- Patients with valve replacements
- Risk of approximately 4% within 1st year of replacement and 1% cumulative risk per year.
- They may present with fever or generalized weakness or “not feeling well.”
- Patients with intravenous drug use (IVDU).
- Unusual suspects, which lend themselves to nonbacterial endocarditis
- Marantic endocarditis: seen in patients with cancer particularly those with adenocarcinoma.
- Libman-Sacks Endocarditis: seen in patients with lupus.
- Usual suspects
- Fever “plus” Syndromes
- Fever + stroke
- Approximately 65% of embolic phenomena are neurological in nature, and 23% of the time stroke is the initial manifestation of endocarditis.
- Consider endocarditis in any stroke patient with a fever.
- Fever + back pain
- Should raise concern for osteomyelitis of the spine and spinal epidural abscess. Typically indicates hematogenous spread.
- Consider endocarditis in any patient with these infections.
- Fever + congestive heart failure (CHF)
- Acute aortic insufficiency can result from endocarditis leading to new-onset congestive heart failure (CHF).
- More commonly seen in young patients without prior disease.
- Fever + new AV block
- Conduction changes like 1st, 2nd, or 3rd degree block suggest perivalvular abscess.
- This is highly suggestive of endocarditis.
- Fever + stroke
- Importance of blood cultures in the emergency department
- Often patients get blood cultures sent from the ED but are discharged home or outpatient blood cultures are obtained and EM physicians are notified about positive findings.
- Most common bacteria are Streptococcus and Staphylococcus species.
- There are also uncommon bacteria that cause endocarditis that we may not be familiar with. In this situation, it is reasonable to call an infectious disease consultant to discuss whether the bacteria is a concerning one.
- Coagulase-negative Staphylococcus
- Typically a contaminant in blood culture results (82%)
- It is also the second most common cause of endocarditis in patients with intracardiac devices (eg. valve replacement).
- Staphylococcus lugdunensis(“Slug”)
- Virulent form of coagulase negative staphylococcus that can cause endocarditis even in patients without intracardiac devices.
- In the ED if endocarditis is suspected, obtain at least 3 cultures from different places spaced at least 30-60 minutes apart in time.
- Treatment
- If the patient is ill-appearing or septic, start antibiotics immediately.
- A vast majority of cases are from gram positive bacteria.
- Vancomycin is a good first-line agent.
- Native valve endocarditis
- Vancomycin: 15-20 mg/kg IV q12h (max: 2 g/dose)
- Gentamicin: 1 mg/kg/dose IV q8h
- Prosthetic valve endocarditis
- Vancomycin: 15-20 mg/kg IV q12h (max: 2 g/dose)
- Gentamicin: 1 mg/kg/dose IV q8h
- Rifampin: 300 mg IV or PO q8h
- Native valve endocarditis
- If there is concern for gram negative endocarditis (uncommon) ceftriaxone can be added.
- Most patients will not be ill-appearing or septic.
- Can either start vancomycin after cultures are obtained or consult infectious diseases regarding when it is appropriate to start antibiotics.
- Consult cardiology and cardiothoracic surgery.
- About 25% of patients will require surgery.
- If the patient is ill-appearing or septic, start antibiotics immediately.
More Information
- Dave Carr on Anton Helman's Show
- Dave Carr from SMACC
- The AHA Guidelines (but highly recommend placing toothpicks under your eyelids before reading)
Additional New Information
More on EMCrit
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Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Great episode. High index of suspicion definitely key…had a GUCH patient a while back who returned from Thailand with a fever and kind of dengue-ish rash and some lung infiltrates, admitted for work up under ID, who diagnosed a RLL pneumonia. Turned out to have subacute IE. From the way it’s told it sounds like the nurse in the strep viridans case had 3 sets of cultures taken – somebody presumably thinking IE?
Just want to clarify for everyone that when you are referring to coagulase-negative Staphylococcus that is not the same as Staphylococcus aureus. There are more than 20 species of coagulase-negative Staphylococcus (e.g., Staphylococcus epidermis). Staphylococcus is the genus name and the second name is the species.
Luis
How timely. Here is an endocarditis lawsuit that was just settled in the Bangor area. The case turned on whether or not the PCP was informed of the positive blood cultures and there was a comparative negligence reduction in the award due to the patient being informed of the result and electing not to act on it. The assertion by the hospital that when the blood cultures returned was that a 13 minute conversation with the patient telling him exactly what was going and how critically important coming back to the hospital was. Think long and hard about what you… Read more »
This talk was a mind changer for me.last night I had a 50 year old female with a mechanical valve and A.Fib and NEW CHF,hemoptysis and fever.everyone thought of just pneumonia.but she is admitted to CCU as invective endocarditis.
Dr Hamza,ED Doc
Qatar
Great to hear all of your comments The RN I mentioned on the podcast was cultured x 2. The diagnosis of IE was a fluke of sorts. Was not on anyone’s radar. The key is to a gram positive culture result seriously especially if it is a pathognomonic IE bug
Scott and David, Thanks for the show on IE. I am looking at adjusting our blood culture basic orders in the ED and want to make a case for pulling the cultures at 15 or 30 min intervals but don’t see studies that emphasize the timing except in relation to fever. The opinion of Up To Date is that spacing of the samples does not change yield nor does timing around fever. They site Weinstein from a 96 article in Clinics of Infectious Disease http://www.uptodate.com/contents/blood-cultures-for-the-detection-of-bacteremia/abstract/4?utdPopup=true. Any suggestions? Thanks Paul.
What are your thoughts on adding gentamicin to an empiric IE regimen, plus or minus a penicillin/beta-lactamase inhibitor for the sickest IE patients?
Thanks,
Sarah
EM Resident