Podcast 166 – Endocarditis with David Carr

• Keep Endocarditis on the radar for all febrile patients without a source
• Examine your febrile-listen for murmur and look at teeth
• Ask about teeth cleaning in past 2 weeks
• Even though we were taught about Janeway lesions and Osler’s nodes in medical school, the reality is that these peripheral manifestations of endocarditis occur in only about 10% of patients.  Listening for heart murmurs which are present in about 90% of patients with endocarditis is one of the most important physical exam maneuvers in patients who present with fever
• Various Ways to Categorize
  • Native Valve | Prosthetic Valve | IV Drug User
  • Right vs. Left-sided
  • Acute vs. Subacute
• Acute Endocarditis may present so acutely that a murmur has not yet developed despite the patient being quite ill
• Oh so fastidious, the HACEK organisms are Haemophilus species, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae
• Endocarditis should be on your radar for any patient with valvular heart disease who presents to the ED whether they are febrile or not, especially if they are vaguely unwell
• Ideal cultures: 3 sets at 3 sites with an hour between first and last, each with a bunch of blood
• Coag-Negative Staph Aureus positive blood culture in a patient with valvular disease is endocarditis until proven otherwise, even though the majority of Coag Negative Staph Aureus positive blood cultures are contaminants. A blood culture positive for a particular type of Coag-Negative Staph Aureus called SLUG (Staphylococus lugdunensis) should raise the possibility of endocarditis even in patients without valvular heart disease
• Get nervous when the bacteria doesn’t fit the crime
• No ED/ICU procedure requires prophylaxis
• 2/3 of L-sided emboli will be CNS. Brain emboli will be in the MCA territory
• Be scared of new-onset of CHF and CHF in young patients
• Look at the ECG for new heart blocks in patients with fever (Even 1st Degree HB) – Consider Valvular Abscess
• Antibiotic coverage-your empiric sepsis antibiotics + sepsis-dose Vanco will cover everything you need to worry about. Vanco alone will get the job done in almost every case

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