Publication Date: September 2020 (Volume 22, Number 9)
CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-A or 2-B CME credits. CME expires 9/01/2023.
Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 2 Infectious Disease CME credits, subject to your state and institutional approval.
Recognition of infective endocarditis in the emergency department continues to be a challenge, as its signs and symptoms can be subtle, laboratory results are limited, and it can involve or lead to many other serious conditions. With the increase in use of medical access devices, implantable cardiac devices, and the rise of intravenous drug use, the epidemiology of infective endocarditis is changing. Diagnostic imaging has evolved, and the use of point-of-care ultrasound and transthoracic echocardiography are critical in making an early diagnosis. This review provides a best-evidence approach to diagnostic strategies, antibiotic recommendations, and surgical treatment recommendations for infective endocarditis.
Excerpt From This Issue
A 25-year-old man presents to the ED with general malaise and fever for the preceding 3 weeks. He was seen recently at an outpatient clinic, diagnosed with pneumonia, and treated with azithromycin; however, he continues to have fevers. His history is remarkable for heroin addiction with recurrent treatment in rehabilitation over the past 3 years. He is ill-appearing, with a temperature of 39°C (102.2°F); heart rate, 120 beats/min; blood pressure, 100/60 mm Hg; respiratory rate, 26 breaths/min; and oxygen saturation of 90% on room air. He has diffuse crackles bilaterally; you do not auscultate any heart murmurs. Chest x-ray reveals the presence of multifocal infiltrates. Broad-spectrum antibiotics are administered, and the patient is admitted to the hospital with a diagnosis of multifocal pneumonia and sepsis. The more you contemplate the case, though, you wonder whether there is a diagnostic test that could have been done...
On a morning shift, a 55-year-old woman arrives in severe distress. Her husband informs you that she has had a decrease in energy over the past month and that her past medical history is notable for poorly controlled lupus and mitral valve prolapse. She was evaluated the week prior and discharged with a diagnosis of influenza. Her heart rate is 122 beats/min; blood pressure, 80/60 mm Hg; temperature, 38.0° (100.4°F); respiratory rate, 28 breaths/min; and oxygen saturation, 88% on room air. You auscultate crackles bilaterally and a loud holosystolic murmur most prominent at the cardiac apex. Chest x-ray reveals bilateral infiltrates. The patient improves initially with fluid resuscitation but rapidly decompensates, requiring intubation and vasopressor support. You administer 2 g of ceftriaxone IV and 1 g of vancomycin IV and admit her to the ICU for sepsis secondary to post–influenza pneumonia, but knowing that sepsis outcome is linked to administration of the correct antibiotic, you wonder whether there is a diagnostic test that would help in identifying the etiology...