Infective Endocarditis (IE): Management

00:01 What’s new and an important approach to the management of infective endocarditis is an endocarditis team.

00:11 That team should consist of a cardiologist. We’re finding an increasing numbers of women who are cardiologists.

00:21 We used to consider the cardiologists as kind of the jet pilots of internal medicine. But there are women jet pilots now. A cardiac surgeon and some of these are women as well, the ID physician, a microbiologist, and an intensivist. A lot of these patients are going to be in the intensive care unit.

00:46 So this should be the endocarditis team. This should be the team that’s involved in every patient that you diagnose with endocarditis. Now, why? We’re going to discuss each patient weekly by the entire team. We’re going to make a decision about whether they need surgery or not and when.

01:13 It’s actually, in my view, malpractice to call in a cardiac surgeon after you’ve been treating somebody for endocarditis in the hospital for two weeks. A cardiac surgeon should know about a patient who’s in the hospital who’s got endocarditis because things can go bad in a hurry. You don’t want to have a surprise for the cardiac surgeon. Oh, by the way, Mr. Jones has gone into heart failure because his treatment for endocarditis wasn’t good. So anyway, they make these decisions about the surgical priorities and especially for follow up. After their discharge, they would be followed by a cardiologist and ID doc ideally on the same day at one, three, six, and twelve months. When this strategy of the endocarditis team was employed, a study showed that the one year mortality went from 18.5% all the way down to 8.2%.

02:26 So, we can’t argue with those kinds of data. Every hospital should have at the ready an endocarditis team.

02:39 Now, what about starting antibiotics? Well, there are some patients that we want to start antibiotics immediately after we get our cultures cooking. We can then adjust the antibiotics based on the microscopy, culture and sensitivity of the organism. So, who are the high-risk patients? Well, certainly somebody who is in congestive heart failure, who has a stroke, recurrent embolus, septic shock. They’ve had fever for seven to ten days, or they’ve got a large, friable or enlarging vegetation, or if there’s obvious evidence that they’ve got more than just the valve involved, they’ve got part of their valve annulus, that the infection is extending. They’ve got, for example an annular abscess, or somebody who has endocarditis that’s got heart block. That is a relative emergency. Somebody who’s got very severe left-sided regurgitation and that would include aortic regurgitation or mitral regurgitation because one of the most important killers of infective endocarditis is congestive heart failure.

04:04 If their prosthetic valve is just terribly malfunctioning, we know it’s got to come out.

04:10 We know we’ve got to get treatment started fast. They have a low left ventricular ejection fraction or, and this is important, pathogens other than viridans strep especially Staph aureus which can destroy valves quickly; fungi, having fungal endocarditis is almost an immediate indication for removal of the valve because it’s so hard to treat medically; ditto gram-negative bacilli or enterococcal endocarditis; and those who come in in acute renal failure. So those are the high-risk patients that we need to act on fast.