February 12, 2020

REBEL Core Cast 27.0 – Endocarditis

1. 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
2. Patients may present with fever, sepsis of unclear source or may have manifestations of emboli to the skin, eyes, brain, lungs, spleen or kidney.
3. Diagnosis is based on the modified Duke Criteria and workup should include THREE good sets of blood cultures. 
4. 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