inpatient / Infectious Disease
Endocarditis and Bacteremia
# Endocardidits
# *** Bacteremia
Checklist
-- Chart Check: prior infections, cultures, hardware
-- HPI Intake: IVDU, prior infections, fevers, localizing symptoms
-- Can't Miss: CNS septic emboli
-- Admission Orders: infectious workup, ESR
-- Initial Treatment to Consider: antibiotics, pain regimen,
Assessment:
-- History: *** IVDU, prior infections, recent dental procedures, immunocompromised, hardware (valves, knee, hip, spine)
-- Clinical: *** fever/chills, HF, AV block, dyspnea or AMS (septic emboli)
-- Exam: *** ill-appearing, dentition, murmur, splinter hemorrhage, Janeway lesions, Osler nodes, focal deficits
-- Data: *** WBC, ESR, BCx, Echo (TTE and TEE)
-- Etiology/DDx: *** SSTI, osteomyelitis, oral flora, pneumonia, UTI, GI source, indwelling line
The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.
Plan:
Workup
-- WBC, ESR, UA
-- TTE --> TEE if negative but high suspicion
-- CXR to eval for septic emboli; renal US if c/f splenic clot or abscess; CT or MRI head if c/f intracranial septic emboli
-- f/u BCx - surveillance BCx daily until sterile for 48 hours
-- Serial EKGs - assess for AV block, TWI, and arrhythmia
Treatment
-- Abx: *** empiric - vanc/cefepime; Strep - amp 2g q4 OR CTX 2g daily for 4 weeks; MSSA - cefazolin 2g q8 for 6 weeks; MRSA - vanc OR dapto for 6 weeks;Enterococci (feacalis, faecium) - amp 2g q4 AND CTX 2g daily for 6 weeks; VRE - dapto AND amp OR linezolid; HACEK - CTX OR amp; Candida - amphotericin B
-- Consult ID and f/u further recs
-- Dental evaluation for confirmed IE for source control
-- Surgical consult if new-onset HF, abscess, AV block, large vegetation >10mm on L, >20mm on R, mechanical valve
-- If IVDU - discuss MOUD and consider psych consult
-- Hold AC for 2 weeks if concern for cranial septic emboli
PDF coming soon!
If You Remember Nothing Else
Send 2-3 peripheral blood cultures before starting empiric abx of vanc/cefepime - narrow treatment with culture data. All staph aureus and fungi bacteremia get TTE (only 75% sensitive for vegetations so if cultures aren't clearing, should consider TEE). Just consult ID for guidance; the literature suggests improved outcomes. For endocarditis, consult CT surgery if there is new heart failure, abscess present, a prosthetic valve, vegetation >10mm on left or >20mm on right. Antibiotic regimens are often via IV route and 4-6 weeks long, but some trials are investigating if these courses can be shorter and utilizing PO antibiotics.
Clinical Pearls
- Duke Criteria - 2 Major OR 1 Major + 3 Minor OR 5 Minor; Major: BCx pos with common org (strep, staph, enterococcus, HACEK), TTE with vegetation, abscess, new regurg; Minor: Bcx pos with uncommon org, Risks (IVDU, valve dx, prosthetic, indwelling line), Fever, septic emboli, immunologic phenomena (GN, Osler node, roth spots)
- TEE should be pusued if TTE negative but you have a high suspicion (90% vs 75% sensitivity for vegetations)
- IVDU more likely to have involvement of the right heart - tricuspid valve
- Staph aureus often damages native valves, most common cause of acute IE (days-weeks, severe symptoms); Viridians Strep (sanguinis, mutans, etc) are oral flora that cause subacute IE (weeks-months), often on pre-damaged valves, usually after dental procedures; Staph Epi commonly grows on indwelling lines and common cause of subacute IE on prosthetic valves or other hardware
- Coxiella and Bartonella species can cause culture negative IE - need to send serologies
- Strep bovis (gallolyticus) bacteremia can be associated with colon cancer
- Fungal endocarditis usually seen in IDVU or immunocompromised (HIV, transplant) or indwelling lines
- Prosthetic valves <12 months more likely to have pathogens like CoNS, GNR, and fungus
- Fevers and chills are seen in ~90% of patients with IE; classic manifestations (splinter hemorrhage, Janeway lesions) are rare (5-10% of patients)
- 38-69% of patients with c/f septic shock have positive blood cultures
- Rigoring has a LR 4.7 for bacteremia, normal PO intake has LR 0.18
- Staph aureus is sticky, requires daily surveillance cultures in bacteremia (not necessary for GNRs) and removal of lines/hardware
- In MSSA bacteremia, beta lactam > vanc; vanc is not that great an antibiotic, it just covers MRSA which is why we use it empiricially
- If growing yeast in blood always treat as a true infection, need TTE and ophtho consult to rule out endophthalmitis, should also remove lines
- Sterile vegetations often remain on the valves after treatment - made of fibrin and scar
- Ppx before dental procedures - 2g amoxicillin 30-60 mins beforehand ONLY if prosthetic valve, congenital heart disease, or previous endocarditis
- Sibman-Sacks Endocarditis - noninfective verrucous vegetations in pts with SLE or APLS - vegetations are immunologic, painful when embolize (Osler nodes)
Trials and Literature
- ID consult leads to improved outcomes for staph aureus and candida bacteremia
- Blood Culture-negative endocarditis (Medicine Baltimore, 2017)
Other Resources
