emDocs - January 24, 2022 - By Adrianna Long / Reviewed by: Manpreet Singh and Alex Koyfman
How can we improve?
- Always be consistent and perform a thorough history and physical examination so you don’t miss subtle findings that can clue you into this diagnosis.
- Consider the diagnosis of IE in patients with underlying cardiac disease (rheumatic heart disease, congenital heart disease, prosthetic valve replacement), IVDA, hemodialysis, immunosuppression (HIV, vasculitis, diabetes, malignancy) or those at risk for nosocomial infections (indwelling venous catheters, surgical hardware placement or recent surgery) and patients with poor oral hygiene.
- Have a higher level of concern for IE in patients with risk factors and known positive blood cultures, echocardiogram findings consistent with IE, new murmur (concerning for valvular regurgitation), fever >38°C (particularly of unknown origin). vascular phenomena, major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway’s lesions, or immunologic phenomena (glomerulonephritis, Osler’s nodes, Roth’s spots). Use the Modified Duke Criteria to aide in diagnosis for high-risk patients.
- Obtain an echocardiogram and three sets of blood cultures from different sites (ideally obtained >1 hour apart and bottles filled completely) in patients who are at risk for IE.
- Start the appropriate antibiotics as soon as IE is identified as possible (usually Vancomycin and Cefepime IV). In patients with prosthetic valves or at risk for enterococcus bacteremia consider addition of Gentamycin.
- Consult CT surgery for patients with IE with severe congestive heart failure or cardiogenic shock caused by aortic valvular regurgitation, severe prosthetic dysfunction (dehiscence or obstruction) or fistula into the cardiac chamber or pericardial space.
- Do not anchor or forget that your patient may have more than one critical diagnosis and that IE may be an underlying cause to your primary diagnosis (such as stroke, meningitis, or pulmonary emboli).