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Algorithm for Patients with Suspected Infective Endocarditis

Algorithm for Patients with Suspected Infective Endocarditis - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Cardiovascular, Related


Suspected Infective Endocarditis
Draw Blood Cultures
Consult ID
In clinically unstable patients, start empiric antimicrobial therapy.
In clinically stable patients, HOLD antimicrobial therapy until organism identified.
A
Transesophageal echo (TEE) if any of the following:
1. High risk clinical features.
B
2. Suboptimal TTE images.
3. High risk TTE findings.
C
ECHO ATTENDING (OR FELLOW)
reports critical findings to primary team
Additional Evaluation & Management
ξ Repeat blood cultures every 24-48 hours until negative.
ξ Continue antimicrobial therapy as per Infectious Disease.
ξ Repeat TTE/TEE if clinical features suggest development of new cardiac complications.
ξ Cerebrovascular imaging to detect ICMA or CNS bleed in symptomatic patients.
ξ Evaluation for metastatic foci of infection in symptomatic patients.
ξ Dental evaluation for pre-valve surgical patients, and upon discharge of all confirmed IE cases.
Positive
Echo?
Reference: Infective Endocarditis – Adult
– Inpatient Clinical Practice Guideline
Inpatient Management of Adult Patients with
Suspected Infective Endocarditis Algorithm
YES NO
Additional Details
A. In the absence of sepsis or
other defined source of
infection (i.e., UTI, pneumonia)
and high suspicion of IE.
B. High risk clinical features:
Prosthetic heart valves, most
congenital heart diseases,
previous IE, heart failure, or
other stigmata of endocarditis.
C. High risk echo findings:
Large or mobile vegetations,
valvular insufficiency,
suggestion of perivalvular
extension, or secondary
ventricular dysfunction.
D. Cardiology consult service
will assess patient for
appropriateness of transfer to
inpatient cardiology service.
E. Potential surgical indications:
Left sided vegetation > 1 cm,
recurrent embolic events, heart
failure, perivalvular extension
or abscess, prosthetic heart
valve, persistently positive
cultures.
ξ Look for alternate sources of infection
ξ Repeat TEE in 3-5 days if suspicion remains high
IE CONSULT PANEL INITIATED
¨ ID (if not already consulted)
¨ Cardiology
D
(if potential surgical indication
E
)
¨ CT Surgery (if potential surgical indication
E
)
¨ EP if patient has cardiac implanted device
Discharge and Follow Up
Notes regarding IE Consult Panel:
ξ The echo staff will communicate the critical echo
findings to the primary team.
ξ The echo attending will prompt the primary team to use
the IE Consult order.
ξ The consult orders will be placed by the primary team.
ξ On a case by case basis, the echo staff/fellow will
directly communicate the critical echo findings to the
consulting service(s).
Transthoracic echo (TTE)
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Empiric Anti micro bial The rapy for Infe c tive Endocard itis

Fo r use in the absenc e of sepsis or othe r defined so u rce of infec ti o n (i. e. UTI, pneumonia ) and high suspi cion
of IE:
- In clini cally uns table patients, start empiric an timi cr o bial therapy as outline d below. (UW Health Class I; Level of
Evidence B)
- In clini cally stable patient s, withhold antibioti cs until an organis m is identif ie d. (UW Health Class I; Level of
Evidence C)
-Dose adjustments may be warranted per collateral guidelines: Vancomycin Use, Renal Dosing, and
Pharmacokinetic/Pharmacodynamic Dose Optimization.
Native Valve Endocardi tis (acute clinical presentation )
Comment: Most common organisms include Staphylococcus aureus ,
β - hemolytic Streptococc i, and aerobic Gram –neg ative bacilli 1
(ACC/AHA Class IIa, Level of Evidence C)
- Vancomycin 20mg/kg I V x1, then 15mg /kg
IV every 12 hours
- Cefepime 2g IV every 8 ho urs pro longe d
infusio n
Native Valve Endocardi tis (suba cute pre sentation )
Comment: Most common organisms include Staphylococcus aureus ,
nutritionally variant Streptococc i, HACE K organisms, and Enterococci
sp .
1
(ACC/AHA Class IIa, Level of Evidence C)
- Vancomycin 20mg/kg IV x1, then 15mg /kg
IV every 12 hours
- Ampi cillin/s ulbacta m 3g IV every 6 hou rs
Pro sthetic Va lve Endocar di tis
(< 1 year fro m valve replacement surge ry)
Comment: Most common organism s include Staphylococcus aureus ,
nutritionally variant Streptococc i, HACE K organisms, Enterococci sp . ,
and pseudomonas
1
(ACC/AHA Class IIa, Level of Evidence C)
- Vancomycin 20mg/kg IV x1, then 15mg /kg
IV every 12 hours
- Cefepime 2g IV every 8 ho urs pro longe d
infusio n
- Tobra mycin 5mg/kg IV x1 OR Ci pro flo xacin
400 mg IV eve ry 8 hours
Pro sthetic Va lve Endocar di tis
(> 1 year fro m valve replacement surge ry)
Comment: Most common organisms include Staphylococcus (MRSE ,
MRSA, and MSSA ), nutritionally variant Streptoc occ i, and Enterococci
sp.
1
(ACC/AHA Class IIa, Level of Evidence C)
- Vancomycin 20mg/kg IV x1, then 15mg /kg
IV every 12 hours
- Ceftria xone 2g IV every 24 hours


Dis charge & Follow - Up

- Iden tify and schedul e initi al visit with the health care tea m respo nsible for ad ministration and moni toring
OPAT per Cli nical Monitor ing of Outpa t ient Paren ter al Antimicrob ial Therapy (OPAT) – Adul t . Initial visit is
typically 5 da ys to 2 wee ks post - disc harge, dependi n g on antimi cr o bial agents used.
- Schedule TTE at the time of completio n of anti micr o bial therapy , usually 6 - 8 weeks pos t - d ischarge (TEE
usua lly not warr anted)
- Schedule Cardiolo gy follo w up for pati ents with sig nificant valve lesio n (sched ule after or in conju n c tion with
TTE)
- Arra nge for dental evalua tion if not complet ed whil e IP. Dane County dental reso urces
Dental reso ur ces in surr o u nding cou nties
- Pa tient edu c ation: Sig ns & symptoms of IE, daily dent al hygiene, dental vis its every 6 mon ths , and antibio t ic
prophylaxis prio r to specifi c dental and inva siv e pro cedures as outli ned in the 200 8 AHA/AC C Guideline
Updat e on Valvula r Heart Disea se: Focu sed Upda te on IE .
1. Baddour LM, Wilso n WR, Bayer AS, et al. Infective End o carditis in Adults: Diag nos is, Antimi crobial
Therapy, an d Manage men t of Co mplica t ions : A Scien t ifi c State men t for Heal thca re Pro fess iona ls Fro m the
American Hea rt Asso ciatio n. Circulation. 201 5;13 2(1 5):1435 -1486.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org