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CDHB

Bacterial Endocarditis

Fever of unknown origin, especially if in association with cardiac murmur, must be considered suspicious. If in doubt treat after blood cultures have been taken. Urgent cardiology and infectious disease consultation is essential.

Investigations

• Blood cultures. Three venepunctures inoculating 2 bottles each time, or 6 venepunctures (12 bottles) if antibiotics given in last 2 weeks.
• CXR.
• ECG.
• MSU x 2 before therapy for urinary deposit.
• Na, K, Ca, glucose, creatinine, bili, ALT, AST.
• CBC + diff.
• Echocardiogram.

Treatment

• Initial therapy - benzylpenicillin 2.4 g IV q4h and gentamicin 1 mg/kg IV q8h and flucloxacillin 2 g IV q4h-q6h. If penicillin allergy, seek advice.
• If a prosthetic valve is present, the initial therapy should be vancomycin 20-30 mg/kg IV as a loading dose (max 1.5 - 2 g), then 1 g IV q12h with peak and trough levels around the third dose (refer to the vancomycin dosing guidelines in the Pink Book) and gentamicin 1 mg/kg IV q8h (see gentamicin in the Endocarditis guidelines in the Pink Book) and rifampicin 450 mg BD PO.
• Revise therapy in the light of the organism(s) isolated and their potential clinical significance and sensitivities, e.g., urgent valve replacement may be needed if staphylococcal or fungal endocarditis suspected.
• Observe, closely monitoring cardiac function, renal function and antibiotic levels.

Topic Code: 1349