February 12, 2020

REBEL Core Cast 27.0 – Endocarditis

Take-Home Points

  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

REBEL Core Cast 27.0 – Endocarditis

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Endocarditis

  • 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

Incidence

  • 40,000 to 50,000 new cases of endocarditis in the US each year.
  • In-hospital mortality 14-22%
  • 1-year mortality of 20-40%

Risk Factors

  • 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

Clinical Presentation

  • 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

Extracardiac Manifestations 

  • 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

Complications from Emboli

  • Cerebral emboli
    • Acute CVA presentations
    • Meningitis
  • Pulmonary emboli
    • More common in IVDU, tricuspid almost always involved
  • Splenic Emboli
    • Can present with flank pain or diaphragmatic irritation
  • Renal Emboli
    • Present with flank pain, pyuria and hematuria

Work Up

  • CBC
  • UA 
    • Hematuria could indicate renal emboli
  • ESR/CRP 
    • Elevated in >90% of cases
  • Blood Cultures
    • 3 sets from different sites

Imaging

  • Get imaging based on symptoms
  • Respiratory symptoms
    • CXR
    • Chest CT 
  • AMS / Headache
    • Noncontrast head CT 
  • Abdominal symptoms
    • Abdominal CT

Diagnosis

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

Treatment

  • 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

References

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

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

Cite this article as: Anand Swaminathan, "REBEL Core Cast 27.0 – Endocarditis", REBEL EM blog, February 12, 2020. Available at: https://rebelem.com/rebel-core-cast-27-0-endocarditis/.
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Anand Swaminathan

Clinical Assistant Professor of Emergency Medicine at St. Joe's Regional Medical Center (Paterson, NJ)
REBEL EM Associate Editor and Author
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