Emergency Department Care

The first priority in the care of patients with acute infective endocarditis is stabilization of respiratory and cardiac symptoms. For patients with mental status changes and hypoxia or a compromised airway, intubation may be required. Cardiac decompensation is usually due to left-sided valvular incompetence and/or rupture. Acute rupture of the mitral or aortic valve should be stabilized with afterload reducers such as sodium nitroprusside, with insertion of a Swan-Ganz catheter for monitoring therapy as soon as possible. Preparation for emergency surgery should be made for patients suspected of acute valvular rupture. 20 Aortic balloon counterpulsation may be helpful for mitral valve rupture but is contraindicated for wide-open aortic valve rupture.

The second priority is drawing three blood cultures from different sites and then starting empiric antibiotic therapy. 21 For acute infective endocarditis, a penicillinase-resistant penicillin, such as oxicillin 2 g q4h, should be given with an aminoglycoside, such as gentamicin 1 mg/kg up to 80 mg q8h, chosen on the basis of local patterns of susceptibility. In areas where there is a high incidence of methicillin-resistant Staphylococcus or in the case of a patient taking oral antibiotics already, vancomycin 1 g intravenously should be used in addition to an aminoglycoside. Patients with prosthetic valve endocarditis should be treated with antibiotics that cover S. epidermidis, usually vancomycin, 1 g intravenously, in addition to an aminoglycoside and rifampin. Although subacute cases are frequently caused by S. viridans and this bacteria is covered by penicillin G, patients with subacute presentations that require admission should be started on a newer cephalosporin, such as ceftriaxone, 1 g intravenously, in addition to an aminoglycoside until cultures and sensitivities are known. For patients with subacute disease who were taking oral antibiotics for another presumed infection, consideration should be given to collecting at least seven cultures or waiting until culture results turn positive before giving intravenous antibiotics.

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