What’s new and an important approach to the management of infective endocarditis is an endocarditis team.
That team should consist of a cardiologist. We’re finding an increasing numbers of women who are cardiologists.
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.
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.
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%.
So, we can’t argue with those kinds of data. Every hospital should have at the ready an endocarditis team.
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.
If their prosthetic valve is just terribly malfunctioning, we know it’s got to come out.
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.