Endocarditis checklist o Initial evaluation o Peripheral blood cultures (three sets at three different sites) o Additional culture of any indwelling line in place >48 hours o Echocardiography (TTE +/ - TEE) o Chest CT scan, if suspect right - sided endocarditis w/ septic pulmonary embolization o Evaluate for metastatic infection, if suspected (e.g., spine, joints, spleen, brain) o Empiric therapy o Acute bacterial endocarditis: May consider vancomycin * plus cefazolin o Subacute bacterial endocarditis: May consider vancomycin * plus ampicillin/sulbactam o Prosthetic valve, acute - onset, <1 yr after surgery: May consider vancomycin * , gentamycin, and cefepime o Prosthetic valve, acute - onset, >1 yr after surgery: May consider vancomycin * , gentamycin, and cefazolin o Prosthetic valve, subacute onset: May consider vancomycin * , gentamycin, ampicillin/sulbactam o *Dose vancomycin like you mean it – obtain levels early & consider pharmacokinetic modeling o Indications for surgical consultation o Valve regurgitation or fistula causing heart failure o Myocardial abscess o Vegetation enlargement despite ABX o Persistent fever, positive cultures o Large vegetation with multiple embolic phenomen a o Follow course o Adjust antibiotics depending on speciation & sensitivities o Obtain single blood culture daily (until blood sterilizes) o Monitor on telemetry for heart block (+/ - daily EKG) o Consider repeat echo (to r/o vegetation growth or worsening valve function) o Aggressive management of any metastatic foci of infection (e.g. septic arthritis, splenic abscess ) o Address opioid use disorder if present o Untreated opioid use disorder is likely to persist and lead to recurrent endocarditis & death. o Consider initiation of buprenorphine and close follow - up care. The Internet Book of Critical Care, by @PulmCrit