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
More Information
- Dave Carr on Anton Helman's Show
- The AHA Guidelines (but highly recommend placing toothpicks under your eyelids before reading)
Now on to the Podcast….
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Scott Weingart
An ED Intensivist from NY. No conflicts of interest (coi).
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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 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 would do remembering that standard of care is a legal term and this jury has decided that the standard of care is that the patient and the primary care provider will be notified for positive blood cultures and the patient only has a minimal responsibility to respond to direct ED calls.
https://bangordailynews.com/2016/01/26/news/bangor/millinocket-couple-awarded-1-785-million-in-malpractice-trial/
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
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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.
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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
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