Endocarditis
Approach to the Intravenous Drug User with a Fever
-Hx: IVDU.
Ask patient about needle sharing and/or licking. Ask them to show you where they inject.
-Dx: Inspect skin
carefully for signs of abscess formation or cellulitis. Auscultate for new murmurs. 3 sets of blood
cultures, ideally 1 hour apart, BEFORE abx. R/o other causes of infection with
urine culture, CXR, & exam. Order TTE +/- TEE
-Tx: Start empiric abx if no other cause of fever found. If patient does not look very toxic, or has
no h/o MRSA and hasn’t been hospitalized often start with:
-Oxacillin 2g IV Q4hrs & Gent 1mg/kg IV Q8hrs until culture speciation
returns(Vanc if pt has a PCN allergy).
If
appears toxic, has h/o of MRSA and/or frequent hospitalization, start with:
-Vancomycin 1g IV Q12hrs & Gent 1mg/kg IV Q8
Duke criteria = [2 Major] or [1 Major + 3 Minor]
or [5 minor];
Major (microbiologic): 1. typical orgs x 2 blood cx (S. viridans, S. bovis,
HACEK, S. aureus, Enterococcus w/o primary); OR 2. persistent bactermia
(>=12h); OR 3. 3/3 or ¾ pos. bld cx
Major (Valve): 1. Vegetation seen on echo; OR 2. new valve regurgitant murmur
Minor: 1. Predisposing heart cond. or IVDU; 2. Fever >=38C (100.4F); 3.
Vascular phenomenon (arterial embolism, mycotic aneurysm, intracerebral bleed,
conjunctival hemorrhage); 4. Immune phenomenon (glomerulonephritis, Osler node,
Roth spot, rheumatoid factor, Janeway lesions); 5. Pos. bld cx not meeting
above criteria; 6. Echo abnl but not diagnostic
-
Tests: Viral Load; CD4 count; PPD;
serologies for HAV, HBV, HCV, toxoplasmosis, and CMV; RPR, G6PD (African
Americans), and lipid panel (if starting HAART). Resistance testing for failure to respond to HAART (best to test
while on HAART or within 2 wks of stopping)
-
Other evaluation: ophthalmology, PAP smear
-
Prophylaxis:
PCP
if CD4 < 200: bactrim SS qd or bactrim DS 3x/wk or dapsone 100mg qd.
Toxoplasmosis
if CD4 < 100 & toxo IgG+: bactrim DS qd.
MAI
if CD4 < 50: azithromycin 1200mg qwk
Tb
if PPD > 5mm or known exposure: INH 300 mg qd & pyridoxine 25mg qd.
-
Vaccinations: pneumovax (q 1yr if CD4
<200), HAV, HBV, Td (q 10yrs), influenza (q yr)