Infective Endocarditis: September 2020

Volume 22, Number 9

Identification and Authors

Anthony J. Hackett, DO, FAAEM, FACEP

Management in the Clinical Assistant Professor of Medicine, Texas A&M University

College of Medicine; Emergency Medicine Physician, CHI St. Joseph
Regional Hospital, Bryan, TX

Emergency Department Jonathan Stuart, DO, MS

Assistant Professor of Emergency Medicine, Uniformed Services
University of the Health Sciences. Emergency Medicine Physician,
Madigan Army Medical Center, Joint Base Lewis-McChord, WA
Abstract Peer Reviewers

Recognition of infective endocarditis in the emergency depart- Katrina Harper-Kirksey, MD

Assistant Professor, Department of Anesthesia Critical Care,
ment continues to be a challenge, as its signs and symptoms Department of Emergency Medicine, NYU Langone Hospitals, New
can be subtle, laboratory results are limited, and it can involve York, NY

or lead to many other serious conditions. With the increase
in use of medical access devices, implantable cardiac devices,
and the rise of intravenous drug use, the epidemiology of
infective endocarditis is changing. Diagnostic imaging has
evolved, and the use of point-of-care ultrasound and trans-
thoracic echocardiography are critical in making an early
diagnosis. This review provides a best-evidence approach to
diagnostic strategies, antibiotic recommendations, and surgi-
cal treatment recommendations for infective endocarditis.
Evan Leibner, MD, PhD
Assistant Professor, Department of Emergency Medicine, Institute for
Critical Care Medicine, Icahn School of Medicine at Mount Sinai, The
Mount Sinai Hospital, New York, NY
Prior to beginning this activity, see “CME Information”
on the back page.
This issue is eligible for 2 Infectious Disease CME credits.

Editor-In-Chief
Andy Jagoda, MD, FACEP
Professor and Chair Emeritus,
Department of Emergency Medicine;
Director, Center for Emergency
Medicine Education and Research,
Icahn School of Medicine at Mount
Sinai, New York, NY
Associate Editor-In-Chief
Kaushal Shah, MD, FACEP
Associate Professor, Vice Chair
for Education, Department of
Emergency Medicine, Weill Cornell
School of Medicine, New York, NY
Editorial Board
Saadia Akhtar, MD, FACEP
Associate Professor, Department of
Emergency Medicine, Associate Dean
for Graduate Medical Education,
Program Director, Emergency
Medicine Residency, Mount Sinai
Beth Israel, New York, NY
William J. Brady, MD
Professor of Emergency Medicine
and Medicine; Medical Director,
Emergency Management, UVA
Medical Center; Operational Medical
Director, Albemarle County Fire
Rescue, Charlottesville, VA
Calvin A. Brown III, MD
Director of Physician Compliance,
Credentialing and Urgent Care
Services, Department of Emergency
Medicine, Brigham and Women's
Hospital, Boston, MA
Peter DeBlieux, MD Medicine, NYU/Langone and
Professor of Clinical Medicine,
Louisiana State University School of NY; CEO, MD Aware LLC
Medicine; Chief Experience Officer,
University Medical Center, New
Orleans, LA
Deborah Diercks, MD, MS, FACEP,
FACC
Professor and Chair, Department of
Emergency Medicine, University of
Texas Southwestern Medical Center,
Dallas, TX
Daniel J. Egan, MD
Associate Professor, Vice Chair of
Education, Department of Emergency Associate Professor, Department
Medicine, Columbia University
Vagelos College of Physicians and
Surgeons, New York, NY
Marie-Carmelle Elie, MD
Associate Professor, Department
of Emergency Medicine & Critical
Care Medicine, University of Florida
College of Medicine, Gainesville, FL NY
Nicholas Genes, MD, PhD
Associate Professor, Department of
Emergency Medicine, Icahn School
of Medicine at Mount Sinai, New
York, NY
Michael A. Gibbs, MD, FACEP
Professor and Chair, Department
of Emergency Medicine, Carolinas
Medical Center, University of North
Carolina School of Medicine, Chapel
Hill, NC
Steven A. Godwin, MD, FACEP
Professor and Chair, Department
of Emergency Medicine, Assistant
Dean, Simulation Education,
University of Florida COM-
Jacksonville, Jacksonville, FL
Joseph Habboushe, MD MBA
Assistant Professor of Emergency
Bellevue Medical Centers, New York,
Eric Legome, MD
Chair, Emergency Medicine, Mount
Sinai West & Mount Sinai St. Luke's;
Vice Chair, Academic Affairs for
Emergency Medicine, Mount Sinai
Health System, Icahn School of
Medicine at Mount Sinai, New York, NY
Keith A. Marill, MD, MS
of Emergency Medicine, Harvard
Medical School, Massachusetts
General Hospital, Boston, MA
Angela M. Mills, MD, FACEP
Professor and Chair, Department
of Emergency Medicine, Columbia
University Vagelos College of
Physicians & Surgeons, New York,
Charles V. Pollack Jr., MA, MD,
FACEP, FAAEM, FAHA, FACC,
FESC
Clinician-Scientist, Department of
Emergency Medicine, University
of Mississippi School of Medicine,
Jackson MS
Ali S. Raja, MD, MBA, MPH
Executive Vice Chair, Emergency
Medicine, Massachusetts General
Hospital; Associate Professor of
Emergency Medicine and Radiology,
Harvard Medical School, Boston, MA Scott D. Weingart, MD, FCCM
Robert L. Rogers, MD, FACEP,
FAAEM, FACP
Assistant Professor of Emergency
Medicine, The University of
Maryland School of Medicine,
Baltimore, MD
Alfred Sacchetti, MD, FACEP
Assistant Clinical Professor,
Department of Emergency Medicine,
Thomas Jefferson University,
Philadelphia, PA
Robert Schiller, MD International Editors
Chair, Department of Family Medicine,
Peter Cameron, MD
Beth Israel Medical Center; Senior
Academic Director, The Alfred
Faculty, Family Medicine and
Emergency and Trauma Centre,
Community Health, Icahn School of
Monash University, Melbourne,
Medicine at Mount Sinai, New York, NY
Australia
Scott Silvers, MD, FACEP
Associate Professor of Emergency Andrea Duca, MD
Attending Emergency Physician,
Medicine, Chair of Facilities and
Planning, Mayo Clinic, Jacksonville, FL Ospedale Papa Giovanni XXIII,
Bergamo, Italy
Corey M. Slovis, MD, FACP, FACEP
Suzanne Y.G. Peeters, MD
Professor and Chair, Department
Attending Emergency Physician,
of Emergency Medicine, Vanderbilt
Flevo Teaching Hospital, Almere,
University Medical Center, Nashville, TN
The Netherlands
Ron M. Walls, MD
Edgardo Menendez, MD, FIFEM
Professor and COO, Department of
Professor in Medicine and Emergency
Emergency Medicine, Brigham and
Medicine; Director of EM, Churruca
Women's Hospital, Harvard Medical
Hospital of Buenos Aires University,
School, Boston, MA
Buenos Aires, Argentina
Critical Care Editors Dhanadol Rojanasarntikul, MD
Attending Physician, Emergency
William A. Knight IV, MD, FACEP, Medicine, King Chulalongkorn
FNCS Memorial Hospital; Faculty of
Associate Professor of Emergency
Medicine, Chulalongkorn University,
Medicine and Neurosurgery, Medical Thailand
Director, EM Advanced Practice
Provider Program; Associate Medical Stephen H. Thomas, MD, MPH
Director, Neuroscience ICU, University Professor & Chair, Emergency
of Cincinnati, Cincinnati, OH Medicine, Hamad Medical Corp.,
Weill Cornell Medical College, Qatar;
Emergency Physician-in-Chief,
Professor of Emergency Medicine;
Chief, EM Critical Care, Stony Brook Hamad General Hospital,
Doha, Qatar
Medicine, Stony Brook, NY
Edin Zelihic, MD
Research Editors Head, Department of Emergency
Aimee Mishler, PharmD, BCPS Medicine, Leopoldina Hospital,
Emergency Medicine Pharmacist, Schweinfurt, Germany
Program Director, PGY2 EM
Pharmacy Residency, Valleywise
Health, Phoenix, AZ
Joseph D. Toscano, MD
Chief, Department of Emergency
Medicine, San Ramon Regional
Medical Center, San Ramon, CA
Case Presentations
A 25-year-old man presents to the ED with general
malaise and fever for the preceding 3 weeks. He was seen
recently at an outpatient clinic, diagnosed with pneumo-
nia, and treated with azithromycin; however, he contin-
ues to have fevers. His history is remarkable for heroin
addiction with recurrent treatment in rehabilitation over
the past 3 years. He is ill-appearing, with a temperature
of 39°C (102.2°F); heart rate, 120 beats/min; blood pres-
sure, 100/60 mm Hg; respiratory rate, 26 breaths/min;
and oxygen saturation of 90% on room air. He has diffuse
crackles bilaterally; you do not auscultate any heart
murmurs. Chest x-ray reveals the presence of multifocal
infiltrates. Broad-spectrum antibiotics are administered,
and the patient is admitted to the hospital with a diag-
nosis of multifocal pneumonia and sepsis. The more you
contemplate the case, though, you wonder whether there is
a diagnostic test that could have been done...
On a morning shift, a 55-year-old woman arrives
in severe distress. Her husband informs you that she has
had a decrease in energy over the past month and that
her past medical history is notable for poorly controlled
lupus and mitral valve prolapse. She was evaluated the
week prior and discharged with a diagnosis of influenza.
Her heart rate is 122 beats/min; blood pressure, 80/60
mm Hg; temperature, 38.0° (100.4°F); respiratory rate,
28 breaths/min; and oxygen saturation, 88% on room air.
You auscultate crackles bilaterally and a loud holosys-
tolic murmur most prominent at the cardiac apex. Chest
x-ray reveals bilateral infiltrates. The patient improves
initially with fluid resuscitation but rapidly decompen-
sates, requiring intubation and vasopressor support. You
administer 2 g of ceftriaxone IV and 1 g of vancomycin
IV and admit her to the ICU for sepsis secondary to post–
influenza pneumonia, but knowing that sepsis outcome
is linked to administration of the correct antibiotic, you
wonder whether there is a diagnostic test that would help
in identifying the etiology...
A 62-year-old man presents to your ED complaining
of oral pain. He has poor dentition and several past dental
abscesses as well as a prosthetic aortic valve. Today, he
presents with what appears to be a simple, superficial den-
tal abscess that is amenable to drainage. Just as you are
ready to incise and drain, you wonder whether you should
give prophylactic antibiotics and, if so, which one...
Introduction
Infective endocarditis (IE) can be difficult to diag-
nose in the emergency department (ED) because its
signs and symptoms can represent many different
and comorbid conditions. Although diagnostic and
treatment therapies have advanced over the de-
cades, the mortality rate has changed very little. The
epidemiology of IE has changed greatly, however,
due to evolving cultural, social, and technologi-
cal factors, and it is essential to be aware of these
Copyright © 2020 EB Medicine. All rights reserved.
factors in order to prevent, recognize, and treat this
disease.1 Not only are there diagnostic difficulties
associated with identification of patients with IE,
but there is debate over the best courses of treatment
and when to advance to more aggressive therapies.
In addition, treatment presents a variety of social
challenges, as the burden of injection drug use in-
creases in the United States.
There have been recent guideline changes and
technical advances in identification and manage-
ment of IE. Epidemiologic studies of the effects of
recently implemented recommendations have been
carried out, and the results are presented here. Key
presentations and risk factors for IE are discussed,
to help in the clinical decision-making needed to
maximize outcomes for patients with IE. This issue
of Emergency Medicine Practice reviews the best avail-
able evidence regarding the diagnosis and treatment
of patients with IE, and provides evidence-based
recommendations for treatment.
Critical Appraisal of the Literature
PubMed and MEDLINE®, Google Scholar, and the
Cochrane Database of Systematic Reviews were
searched for literature published from 2009 to 2020,
using specific search terms: infective endocarditis,
infectious endocarditis, culture negative endocardi-
tis, bacterial endocarditis, valvular infection, infective
endocarditis in injection drug users, and cardiac device
infections. Because the disease carries a high risk of
morbidity and mortality and affects a broad demo-
graphic, there is abundant literature available, as
well as many articles discussing the controversies
associated with management strategies. Extrapola-
tion of data was limited to meta-analyses, systematic
reviews, well-designed clinical trials, large obser-
vational studies, and clinical guidelines. Case series
and case reports were included only when trends
were seen across the literature for specific organisms
or populations.
In all, 94 articles were identified, including mul-
tiple medical, surgical, and several combined society
guidelines. Challenges in the search and assimilation
of data included the broad scope of literature, with
many publications geared toward inpatient manage-
ment of already-diagnosed disease and not specifi-
cally toward acute management and diagnosis.
Etiology and Pathophysiology
First described in 1646 by Lazar Riviere, IE remains
an elusive and deadly disease. Although IE has clas-
sically been associated with malformed or damaged
heart valves that have been seeded by bacteria (most
commonly, streptococci), the increasing burden
of intravenous (IV) drug use as well as the use of
implantable cardiac devices and medical venous ac-
2 Reprints: www.ebmedicine.net/empissues
cess devices have changed the disease’s etiology and to be at the highest risk for contracting enterococ-
epidemiology. Historically, specific entities of acute cal IE.9 (See Table 1, page 4.) S aureus bacteremia
and subacute bacterial endocarditis were defined, alone is likely an independent risk factor for IE
but it has been recognized that the site of infection development. In a 2014 systematic review of 3513
(right vs left) and type of bacteria involved are more patients with S aureus bacteremia, transesophageal
important factors in classification and management. echocardiography (TEE) demonstrated that between
More than 70% of IE cases occur in native valves 14% and 28% of those with bacteremia actually had
that are either damaged or possess altered flow IE; however, this review may be biased, in that it
dynamics that predispose the patient to platelet ag- included only prospective observational studies, and
gregation. In native valves, mitral valve prolapse is it is likely that clinician suspicion for IE influenced
the most common risk factor for IE, and it raises the referral for TEE.10 More-recent reviews reinforce that
risk of IE by 8-fold. In the subpopulation of patients TEE is useful in undifferentiated or complicated S
with IV drug use, impurities in an injectable drug aureus bacteremia; however, there is a low-risk group
contribute to valvular damage through micro-trau- of patients who are less likely to benefit from TEE.11
ma that serves as a nidus for infection. Regardless of This group includes patients without indwelling
the initiating factor, platelets provide a surface for
bacterial adherence and synergistically act to shelter
anchored bacteria from immune mechanisms.2 Figure 1. Changes in Infective Endocarditis
While often considered a rare disease, with a Epidemiology
global incidence of between 1.5 and 11.6 cases per
100,000 people, bias toward the developed world in 1960s
the literature likely underestimates the worldwide
disease burden and mortality.3 The association of IE S aureus, 18% Other organisms, 26%
with rheumatic heart disease is no longer the case in
developed countries, where most cases are related to
either valvular degeneration, IV drug use, or nosoco-
mial infection.4 Due to the increased use of invasive CoNS, 3%
intravenous access medical devices, today the mean
age of an IE patient is older than 50 years, whereas a
Enterococci,
century ago, the mean age was under 30 years.5 Cur- 8%
rently, hospitalization or recent hospital exposure is
associated with 25% of cases of IE.5
In a 2013 systematic review of global trends in
IE epidemiology over the last 50 years, the percent-
age of staphylococcal endocarditis had increased
significantly, with this organism outpacing viridans Culture-negative,
group streptococci as the leading cause of endocar- S viridans, 27% 18%
ditis in the United States. Cases of enterococcal and
coagulase-negative staphylococcal (CoNS) endo-
2000s
carditis have also increased over time, and are fast
approaching that of viridans group streptococci IE.6 Other organisms, 18%
(See Figure 1.) S aureus, 29%
These trends are most evident in North America,
where the opioid abuse epidemic has led to an
increase in native valve endocarditis caused by
Staphylococcus aureus. Currently, 75% of cases of IE
are native valve endocarditis, with 80% of all cases Culture-
involving either the mitral or aortic valves.7 In cases negative,
14%
of IE in IV drug users, most lesions are located on
the tricuspid valve, leading to few systemic mani-
festations. Cases of native valve endocarditis due
to CoNS approximate 8% to 10%, and about half of
these cases are healthcare related. Despite differenc- CoNS, 10%
es in virulence, large studies show similar mortality
S viridans, 18%
in IE patients infected with S aureus and CoNS.8
Enterococci, 11%
In addition to risk factors already discussed for
IE in general, patients who are immunocompro- Abbreviations: CoNS, coagulase-negative staphylococcus; S aureus,
mised, elderly, have had abdominal or genitourinary Staphylococcus aureus; S viridans, Staphylococcus viridans.
instrumentation, or prosthetic heart valves seem www.ebmedicine.net

September 2020 • www.ebmedicine.net 3 Copyright © 2020 EB Medicine. All rights reserved.

lines, patients without cardiac devices or valvular
disease, and those with brief bacteremic episodes
(< 48 hours duration). If bacteremia persists for more
than 3 days, it would be appropriate to consider
TEE. If the TEE is negative, it is prudent to repeat the
TEE in 2 days if the patient is still febrile and without
a source, given that TEE does have a small (but not
insignificant) false-negative rate.
One notable type of CoNS leading to IE is
Staphylococcus lugdunensis (SLuG). SLuG behaves
much like methicillin-resistant Staphylococcus aureus
(MRSA), with an aggressive course and a propensity
to cause perivalvular abscess. Detection of SLuG in
a single blood culture indicates IE in approximately
16% of patients, and in 25% of patients with 2 posi-
tive cultures. Thus, SLuG should be considered as a
cause of IE, especially in a patient with CoNS in pe-
ripheral blood cultures and fever without a source.
Despite its MRSA-like behavior, SLuG is sensitive to
beta-lactam antibiotics.12
Other risk factors for IE include subaortic val-
vular stenosis, ventricular septal defects, pulmonic
stenosis, tetralogy of Fallot, and other congenital
heart lesions. The risk of IE in adults with congenital
heart disease is approximately 1% and is lesion-de-
pendent, with patients having patent ductus arterio-
sus having the lowest risk.13 In children, however,
approximately half of all IE cases are related to
congenital heart disease.14
Historical mortality in cases of IE approximates
30%, according to several different analyses. Recent
meta-analysis data indicate that although diagnos-
tics and therapeutics have changed, mortality has
not been significantly impacted. In a meta-analysis
of worldwide outcomes including 22,382 patients,
short-term 30-day all-cause mortality for IE was
20%, while long-term post discharge mortality rates
approached 37%.15 In the United States, 90-day mor-
tality rates are approximately 24%.15,16 Global and
regional mortality differences are multifactorial and
stem from a combination of healthcare disparities,
differences in patient risk factors, valvular involve-
ment, and bacterial virulence.
Table 1. Risk Factors for Infective
Endocarditis
• Intravenous drug use
• Staphylococcus aureus bacteremia
• Valvular heart disease
• Implantable cardiac devices
• Hemodialysis
• Indwelling lines
• Repeated vascular access
• Unrepaired congenital cardiac anomalies
• Immunocompromise
• Immunomodulator use
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Differential Diagnosis
Many of the differential diagnoses for IE may pres-
ent with IE and lead to IE’s reputation as the “great
imitator.” Differential diagnoses include pneumonia,
sepsis, acute heart failure, acute ischemic stroke,
intracranial hemorrhage, meningitis, acute kidney
injury, and dysrhythmias, among others. IE may in-
volve or lead to any of these conditions, and the key
is for the emergency clinician to consider IE when
caring for critically ill patients with multisystem
involvement.
Prehospital Care
Prehospital care in the setting of suspected IE is
supportive, as when other systemic infections are
suspected. Critical elements of the history that raise
suspicion for IE may be gained from emergency
medical services (EMS) providers, the patient, and
bystanders. EMS or bystander history of IV drug
use or observation of paraphernalia at scene may
prove invaluable in early recognition of IE in altered
patients or those hesitant to reveal substance abuse
to emergency clinicians. Similar to recent studies of
prehospital antibiotics for sepsis, there is no role or
clinical benefit for administration of antibiotics in
the prehospital setting when IE is suspected.
Emergency Department Evaluation
History
High clinical suspicion is the most important fac-
tor in the diagnosis of IE. IE should be considered
in any patient with a fever of more than a week in
duration or with repeated evaluations for persistent
fever. Fever is the most common symptom, regard-
less of duration, and is present in up 80% of cases.7
Inquiring about a history of heart murmur is critical,
as the majority of patients with left-sided IE have a
pre-existing structural valve abnormality. Several
risk factors that increase a patient’s risk for left-sided
native valve endocarditis may be identified from his-
tory, and include known bicuspid aortic valve (pres-
ent in 8.8% of cases), prior congenital heart disease,
mitral valve prolapse (present in 8.5% of cases), or a
prior history of IE (8.3% of cases).17 Aortic stenosis
(20% of cases) and aortic/mitral valve insufficiency
(10% of cases) are also risk factors for IE.17
A history of prosthetic valve replacement and
the timing of such is also helpful to identify IE. Left-
sided prosthetic valve endocarditis is classified as
“early” if it occurs within 6 to 12 months of place-
ment, and it is most likely due to MRSA. After one
year, presentations and organisms in left-sided pros-
thetic valve endocarditis are similar to native valve
endocarditis.18 (Of note, society guidelines differ on
whether a 6- to 12-month-old valve is considered
4 Reprints: www.ebmedicine.net/empissues
“early;” in our work, for safety considerations, we teria in septic emboli that present as nontender, pain-
choose the 12-month mark.) less erythematous macules on the palms and soles in
Patients with a history of IV drug use, implant- 5% of patients with IE.21 (See Figure 3.) Pulmonary,
able pacemakers, defibrillators, and central venous renal, splenic, and brain infarcts or hemorrhages also
catheters are at increased risk of IE and should be occur from a similar embolic mechanism, damaging
identified. In those with central venous catheters, and/or occluding vessels.
IE often occurs without underlying valve disease.
Healthcare-associated IE risk factors include im-
munosuppression (medications or disease states), Figure 2. Splinter Hemorrhages
history of malignancy, and hemodialysis.19 A history
of recent surgeries or dental procedures within 6
weeks increases the risk of bacteremia and IE.20 IE
described as “chronic” occurs less commonly and
from unique modes of transmission and bacteria,
such as Coxiella burnetii, in specific patient popula-
tions (eg, livestock handlers).21 The American Heart
Association (AHA) and European Society of Car-
diology base their treatment recommendations on
a composite of factors such as mode of acquisition,
underlying cardiac conditions, location, and pres-
ence of intracardiac devices, reinforcing the need for
a comprehensive history identifying pertinent risk
factors.21

Physical Examination
The emergency clinician must consider findings on
examination that may occur due to both cardiac and
noncardiac sequelae of IE. The clinical presentation
of IE is influenced by the valve involved and wheth-
er it is native or prosthetic. A new murmur should
raise suspicion for IE, but is present infrequently.
By Splarka - Own work, Public Domain. Available at:
(See Table 2 for signs suggestive of IE.) Examina-
https://commons.wikimedia.org/w/index.php?curid=11254973
tion findings consistent with the acute onset of heart
failure (suggested by tachycardia, hypotension, poor
peripheral perfusion, and delayed capillary refill)
Figure 3. Janeway Lesions
accompanied by vascular and immunologic phe-
nomena should raise suspicion for IE, especially in a
young patient.
Vascular phenomena occur in IE as a result of
septic emboli damaging or occluding vessels and
activating an inflammatory response. These include
splinter hemorrhages, which are 1- to 2-mm brown, sub-
ungual streaks caused by microemboli in capillaries,
occurring in up to 8% of cases of IE. (See Figure 2.)
Janeway lesions are microabscesses caused by the bac-

Table 2. History and Physical Elements

Suggestive of Infective Endocarditis*

• New-onset acute heart failure in a young patient

• More than 1 week of fever
• Ischemic stroke or transient ischemic attack in a young patient
• Embolic phenomenon (renal or pulmonary infarcts)
• Development of a new heart block plus fever
Republished with permission of McGraw-Hill Education from Fitzpat-
*Classical findings of infective endocarditis, though observed in <10% rick's Color Atlas and Synopsis of Clinical Dermatology. Klaus Wolff,
of cases. Richard Allen Johnson, Arturo P. Saavedra, Ellen K. Roh. 8th ed. 2017.
www.ebmedicine.net Permission conveyed through Copyright Clearance Center, Inc.

September 2020 • www.ebmedicine.net 5 Copyright © 2020 EB Medicine. All rights reserved.

 Immunologic phenomena occur in IE as a result Diagnostic Studies
of the effects of immune system activation or direct-
ly from immune complex deposits damaging vessels A definitive diagnosis of IE is rarely made in the ED,
and tissues. Notably, these include Osler nodes, as classic history and physical findings are limited
which are painful red or brown lesions on the palms or absent, and many components of established
and soles thought to be from circulating immune diagnostic criteria are not available until admission.
complexes. (See Figure 4.) They are often preceded Pathologic and clinical diagnoses are separate de-
by several days of pain. Roth spots are retinal hemor- terminations, with pathologic signs being unhelpful
rhages with white centers, seen in 5% of cases.21 during the emergency evaluation. Pathologic criteria
See Table 3 for a summary of vascular and im- are met by the demonstration of micro-organisms by
munologic phenomena seen in IE. culture or histological examination of in situ veg-
Many of the vascular embolic phenomena in etations, embolized vegetations, or an intracardiac
IE (more likely seen in left-sided IE) will present abscess specimen.23
with central nervous system findings in up to half A clinical diagnosis is more useful in the ED,
of patients, with 20% to 30% of patients initially based on historical, clinical, radiological, echocardio-
presenting with a cerebrovascular accident or stroke graphic, and, in rare cases, microbiological findings.
syndrome.22 Patients may also present with en- Diagnostic studies to consider include a complete
cephalopathy, due to effects of multifocal embolic blood cell (CBC) count for leukocytosis or anemia,
cerebral infarcts, meningitis, or intracranial hemor- chemistry panel for renal function (which may be
rhage from ruptured mycotic aneurysms. Tachypnea compromised by a shock state or renal infarction
and hypoxemia, along with crackles on auscultation, from septic emboli), troponin to identify myocardial
may occur in right-sided IE from septic pulmonary injury, and brain natriuretic peptide for signs of
infiltrates. heart failure.
The classic physical findings for IE are encoun- When IE is suspected, an electrocardiogram
tered in subacute, left-sided IE and are actually rare (ECG) should be obtained. The presence of a new
overall, occurring only in 5% to 8% of patients.21 The heart block or conduction abnormality on an ECG in
evolving epidemiology of this disease process likely
means that the presence of many of these vascular
phenomena may continue to decline with time, as Table 3. Vascular and Immunologic
right-sided IE becomes more prevalent (in Western Phenomena in Infective Endocarditis
society) with increasing IV drug use. Circumstances
Type Phenomenon Comments
remain, however, where identification of classic
physical findings may provide the diagnostic key. Vascular Septic emboli • Lead to cerebrovascular
accident, digit gangrene,
conjunctival hemorrhage,
pulmonary infiltrates,
splenic and renal
infarctions
Janeway lesions • Painless lesions
• Palms and soles
Figure 4. Osler Nodes • Microabscesses and
necrosis of dermis caused
by bacteria deposited via
septic emboli

Splinter hemorrhage • Visible emboli in

Immunologic Glomerulonephritis
Osler nodes
Roth spots
By Roberto J. Galindo - Own work. Licensed under the Creative
Commons Attribution Share-Alike 4.0 License. Available at: https://
commons.wikimedia.org/w/index.php?curid=11398310
capillaries of nail bed
• Reactive immune complex
deposits and complement
activation, damaging
glomeruli
• Painful lesions
• Immune complex
deposition, causing
inflammatory response
and pain at site
• Immune complex
deposition, damaging
retinal capillaries
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a febrile patient should raise suspicion for IE as well
as perivalvular extension of a cardiac abscess affect-
ing the conduction pathway and, much like acute
heart failure, this portends a worse prognosis.
Diagnostic Criteria
Many diagnostic results are nonspecific but have
been incorporated into well-studied criteria to aid in
the diagnosis of IE.23 The most universally accepted
tool is the Duke criteria, proposed by Durack and
colleagues, which stratifies patients with suspected
IE into 3 categories: (1) definite, (2) possible, and
(3) rejected, based on combinations of pathological
criteria, major criteria, and minor criteria. The criteria
have a specificity of 74% to 80% and sensitivity of
72% to 80%.21,24 Utility in the ED for suspected IE is
limited, however, as full application of the criteria is
not readily available. The criteria can still serve as a
guide during ED evaluations. (See Table 4.)
Imaging
Though not diagnostic, all patients with suspected
IE should have a chest x-ray performed, which may
demonstrate pulmonary infiltrates in right-sided IE.
Echocardiography is central to the diagnosis and
management of patients with IE. The role of ED
point-of-care ultrasound (POCUS) in diagnosing
IE is limited, and although no prospective studies
exist, case reports document emergency physicians
successfully identifying valvular vegetations with
POCUS. (See Figure 5, page 8.) Suggestive findings
on POCUS include the presence of an echogenic
mass tethered to, but moving independently of a
valve, and the presence of valvular regurgitation in
the setting of high clinical suspicion.26,27 Further, use
of ED POCUS offers important additional informa-
tion when evaluating a patient in undifferentiated
shock and can help exclude other etiologies.

Table 4. Duke Criteria for Infective Endocarditis, With Definitions23,25

Definite Infective Endocarditis
• 2 major clinical criteria
• 1 major + any 3 minor criteria
• 5 minor clinical criteria
• Histologic findings
• Positive Gram stain or cultures from surgery or
autopsy
Possible Infective Endocarditis
• 1 major criterion + 1 minor criterion
• 3 minor criteria
Rejected Infective Endocarditis
• Firmly established alternate diagnosis
• Resolution of the symptoms suggesting IE with
antibiotic therapy for ≤ 4 days
• No pathological evidence of IE at surgery or
autopsy (with antibiotic therapy for ≤ 4 days)
• Does not meet criteria for possible IE
An online/mobile calculator for the Duke criteria
is available at: www.mdcalc.com/duke-criteria-
infective-endocarditis
Major Criteria
1. Blood cultures positive for IE
• Micro-organisms typically associated with IE from 2 separate blood cultures: viridans
streptococci, Streptococcus gallolyticus (Streptococcus bovis), HACEK group,
Staphylococcus aureus; or community-acquired enterococci, in the absence of a
primary focus
• Micro-organisms consistent with IE from persistently positive blood cultures: at least 2
positive cultures of blood samples drawn > 12 hours apart; or positive results of all of 3
or a majority of ≥ 4 separate blood cultures (with first and last samples drawn at least 1
hour apart)
• A single positive blood culture for Coxiella burnetii or phase I IgG antibody titer > 1:800
2. New valvular regurgitation (worsening or changing of pre-existing murmur is not sufficient
criterion)
3. Imaging findings highly suggestive of IE
• Echocardiogram positive for IE: vegetation, abscess, pseudoaneurysm, intracardiac
fistula, pendulum-like intracardiac mass on valve or supporting structure, valvular
perforation or aneurysm; acute partial dehiscence of prosthetic valve.
• Abnormal activity around the site of prosthetic valve implantation detected by 18F-FDG
PET/CT (only if the prosthesis has been implanted for > 3 months) or radiolabeled
leukocytes SPECT/CT
• Definite paravalvular lesions by cardiac CT
Minor Criteria
1. Predisposition, eg, predisposing heart condition or injection drug use
2. Fever, with temperature > 38°C
3. Vascular phenomena (including those detected by imaging only): major arterial emboli,
septic pulmonary infarcts, infectious (mycotic) aneurysm, intracranial hemorrhage,
conjunctival hemorrhage, and Janeway lesions
4. Immunological phenomena: glomerulonephritis, Osler nodes, Roth spots, and
rheumatoid factor
5. Microbiological evidence: positive blood culture, but does not meet a major criterion or
serological evidence of active infection with organism consistent with IE
Histologic Findings
Micro-organisms demonstrated by culture or histological examination of a vegetation, a
vegetation that has embolized, or an intracardiac abscess specimen; or vegetation or
intracardiac abscess by histological examination showing active endocarditis

Abbreviations: 18F-FDG, fluorodeoxyglucose; CT, computed tomography; HACEK, Haemophilus, Aggregatibacter, Cardiobacterium hominis, Eikenella
corrodens, Kingella; IE, infective endocarditis; IgG, immunoglobulin G; PET, positron-emission tomography; SPECT, single-photon emission computed
tomography.

September 2020 • www.ebmedicine.net 7 Copyright © 2020 EB Medicine. All rights reserved.

 To view a video recording of POCUS diagnosis
of left-sided endocarditis, go to: https://www.
ncbi.nlm.nih.gov/pmc/articles/PMC4899075/bin/
wjem-17-383-s001.mp4
To view the video, scan QR code with enabled
smartphone or tablet.
Figure 5. Aortic Valve Vegetation and
Pseudoaneurysm as Seen on Ultrasound
In View A, an aortic valve vegetation is visible during end diastole,
moving independently of valve; In View B, pseudoaneurysm identified
on POCUS and formal transthoracic echocardiography.
View A from video link in Western Journal of Emergency Medicine,
DOI: https://doi.org/10.5811/westjem.2016.2.29921 Reproduced in
accordance with https://creativecommons.org/licenses/by/4.0/
View B reproduced from Journal of American College of Cardiology.
Challenges in infective endocarditis. Thomas Cahill, Larry Baddour,
Gilbert Habib, et al. Volume 69, Issue 3. © 2017 with permission of
Elsevier. DOI: https://doi.org/10.1016/j.jacc.2016.10.066
Copyright © 2020 EB Medicine. All rights reserved.
Transthoracic Echocardiography and
Transesophageal Echocardiography
Both transthoracic echocardiography (TTE) and
transesophageal echocardiography (TEE) may be
performed in the initial evaluation of IE and, together,
they offer complementary information. Combined
TTE and TEE show vegetations in 90% of cases, valve
regurgitation in 60%, and paravalvular abscess in
20%.7 Seven echocardiographic findings comprise
major criteria in the diagnosis of IE: vegetation, ab-
scess, pseudoaneurysm, fistulae, new dehiscence of a
prosthetic valve, perforation, and valve aneurysm.28
Ideally, echocardiography should be performed
within 12 hours of initial evaluation, making TTE
the initial approach for many cases. In comparison
to TEE, TTE may offer enhanced visualization of
tricuspid vegetations and right ventricular outflow
tract abnormalities and can help quantify hemody-
namic dysfunction better than TEE.23 For left-sided
IE (even with a positive TTE), due to enhanced vi-
sualization of the left ventricular outflow tract, TEE
should still be performed. High-quality TTE images
alone may suffice in cases of isolated right-sided
IE.29 In these cases, if TTE demonstrates vegetations
but the likelihood of complications is low, TEE is
unlikely to alter management further. However, TTE
alone is not sufficient to rule out IE or potential com-
plications in high-risk patients and may be further
limited by patient comorbidities (chronic obstructive
pulmonary disease, prior cardiothoracic surgery,
presence of prosthetic valve, obesity). Sensitivity
of TTE for diagnosis of abscess is 50% compared to
90% for TEE. When used together, specificity greater
than 90% has been reported.7
If clinical suspicion for IE or the risk for com-
plications is high, we recommend obtaining an
urgent TEE. If TEE is unavailable, TTE should be
performed, followed by TEE in cases where clinical
suspicion is high, initial TTE is negative, IE involves
left-sided structures, or when initial TTE is positive
but risk of complications (such as abscess) is high. A
goal of the emergency clinician should be to obtain
an echocardiogram as soon as possible, based on
available resources.
False-negative echocardiography results typi-
cally occur early in the disease course if vegetations
are small or have embolized. False-positives may
occur if noninfectious valvular lesions are visualized
(eg, from scarring).23
Features indicating risk for a complicated course
or need for surgery are:
• Large vegetations (> 10 mm), which carry a
higher risk for embolization
• Abscess or pseudoaneurysm
• Severe valvular insufficiency
• Valvular perforation
• Decompensated heart failure
8 Reprints: www.ebmedicine.net/empissues
 These findings should prompt the emergency
clinician for early consultation of a cardiothoracic
surgeon. If there is still a high suspicion for IE
despite an initial negative TEE, repeat TEE is rec-
ommended in 3 to 5 days, or sooner if the patient is
unstable.23
Technological advancements of 3-D echocardio-
graphic imaging have allowed for enhanced recon-
struction of images that primarily affect surgical
planning and intervention but not diagnosis.28 3-D
TEE has limited emergent use, as it actually has a
lower diagnostic sensitivity than 2-D echocardiog-
raphy, which remains the mainstay of diagnostic
imaging in the setting of IE.30
metastatic infectious events (57.4% diagnosis rate vs
18% when not utilized).32,33 Molecular imaging mo-
dalities appear to be most beneficial in the diagnosis
of suspected IE in patients with prosthetic valves or
implantable devices who fall into the Duke criteria
“possible” IE category.18,34 PET/CT is more likely to
have false-positives in the setting of native valve en-
docarditis post cardiac surgery, but shows promise
in monitoring response to microbial treatment.18,35
The improved diagnostic performance in prosthetic
valve endocarditis, when used in combination with
the Duke criteria, has led to PET/CT inclusion in
recent updates of diagnostic algorithms in society
guidelines.36

Computed Tomography
Currently, cardiac multislice computed tomography Figure 6. Cardiac Multislice Computed
(MSCT) is the key adjunctive imaging modality Tomographic Imaging of Infective
when echocardiography does not delineate anatomy Endocarditis
clearly.29 MSCT can be utilized to detect and charac-
terize abscess or pseudoaneurysm, and it provides
additional structural information for surgical plan-
ning.18 Recent evidence suggests that MSCT may
be superior when evaluating for prosthetic valve
dysfunction.18 MSCT is not the only type of CT that
should be considered in the full evaluation of IE,
as CT angiography (CTA) of cerebral vessels may
reveal mycotic aneurysms that may require endovas-
cular or neurosurgical intervention.31 (See Figure 6.)

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) has an impor-
tant role in detecting the cerebral consequences of
IE, given its higher sensitivity than CT. Multiple
studies have reported detection of cerebral lesions
in the setting of IE in up to 80% of cases.18 Cerebral
lesion detection without neurologic symptoms is a
Duke minor criterion, and discovery may result in
upgrade from “possible” to “definite” IE. MRI imag-
ing of the spleen, kidneys, and liver may also reveal
lesions in up to one-third of patients with IE.31 Thus,
we recommend considering CT/CTA of the head
and neck in the ED in patients for whom there is a
high suspicion of IE and cerebrovascular accident/
transient ischemic attack symptoms to evaluate for
mycotic aneurysms. In patients with minor or tran-
sient neurologic symptoms, MRI is indicated in the
inpatient setting.

Nuclear Molecular Imaging

Nuclear molecular imaging techniques such as
positron-emission CT (PET/CT) are evolving as
important supplemental diagnostic modalities for
the subgroup of patients with implantable cardio-
verter-defibrillator/implantable cardiac leads. PET/
CT utilizes CT imaging in combination with radio-
labeled glucose uptake to detect hypermetabolism
associated with peripheral embolic and whole-body
In View A, aortic valve vegetation is identified in left ventricular outflow
tract (arrow) on cardiac computed tomography (CT) image. In View B,
anterior pseudoaneurysm (arrow) is identified on short axis cardiac
CT image.
Reproduced from Journal of American College of Cardiology.
Challenges in infective endocarditis. Thomas Cahill, Larry Baddour,
Gilbert Habib, et al. Volume 69, Issue 3. © 2017 with permission of
Elsevier. DOI: https://doi.org/10.1016/j.jacc.2016.10.066

September 2020 • www.ebmedicine.net 9 Copyright © 2020 EB Medicine. All rights reserved.

 See Table 5 for a summary of imaging modali-
ties in IE.
Blood Tests and Blood Cultures
Laboratory studies such as CBC, inflammatory
markers (C-reactive protein, erythrocyte sedimenta-
tion rate), and urinalysis (for microscopic hematuria)
may allude to secondary complications, severity of
sepsis, and further support the diagnosis of IE, but
none of them definitively support a diagnosis of IE.
Blood cultures remain a mainstay in diagnosing
IE. If possible, 3 sets of blood samples from periph-
eral veins should be obtained in the ED prior to
antibiotic administration.7,18 Cultures are typically
repeated inpatient at 48 to 72 hours after initial cul-
tures are positive for a microorganism. Nonetheless,
blood cultures rarely provide useful information in
the ED setting, because even the most aggressive
presentations of IE do not mount positive cultures
until an average of 14 hours; a shorter time to posi-
tivity is an independent predictor of mortality.37 In
patients recently discharged and re-presenting to the
ED, an understanding of recent culture results may
prove valuable in suspecting IE. The presence of
MRSA, CoNS, viridans group streptococci, Strepto-
coccus gallolyticus, enterococci, HACEK (Haemophi-
lus species, Aggregatibacter species, Cardiobacterium
hominis, Eikenella corrodens, and Kingella species), and
Coxiella burnetii increase the risk of IE in the correct
clinical presentation.31
Blood-culture-negative IE accounts for one-third
of cases and is likely the result of fastidious bacteria
or fungi, which has led to the development and fur-
ther study of clinical prediction rules using biomark-
Table 5. Imaging Modalities Useful in
Diagnosing Infective Endocarditis
Imaging Modality Indications/Benefits
Transthoracic Identifies right-sided infective endocardi-
echocardiography tis and assesses cardiac function
Transesophageal Preferred echocardiographic modality;
echocardiography identifies left-sided infective
endocarditis
Cardiac multislice Identifies abscess or pseudoaneurysm;
computed tomography determines prosthetic valve function;
delineates anatomy if poorly visualized
with echocardiography
Cerebral computed Identifies mycotic aneurysm and
tomography cerebral embolic lesions
Cerebral magnetic Identifies cerebral embolic lesions
resonance imaging
3-D echocardiography Enhanced image reconstruction for
surgical planning
Positron-emission Identifies peripheral embolic and whole-
computed tomography body metastatic infectious events
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Copyright © 2020 EB Medicine. All rights reserved.
ers. These rules are promising, but require further
validation before incorporation into decision-making
algorithms.38,39 It is outside the scope of initial ED
evaluation, but guidelines now recommend serologi-
cal testing followed by polymerase chain reaction
in suspected blood-culture-negative IE.40 Molecular
methods often offer higher sensitivity over conven-
tional methods, but they remain limited in scope,
with some valuable only when samples are taken
during cardiac surgery.41
Treatment
Treatment decisions for IE are challenging for the
emergency clinician, since most guidelines provide
recommendations for therapy in the setting of a
confirmed diagnosis/organism, which is rarely
available in the ED. The goals of emergency therapy
are to stabilize the patient and begin the process of
sterilizing the valve vegetation.
Antimicrobial Treatment
Microbiologic factors, such as resistance patterns,
impact the effectiveness of therapy. For these rea-
sons, early infectious disease consultation is recom-
mended, but we recognize this may not be available
in every ED. Thus, we provide a framework for
empiric antibiotic therapy and invasive intervention
that is applicable for the majority of IE patients. (See
Tables 6 and 7, page 11.) This framework is based
on patient risk factors, history, immunocompetence,
and clinical presentation, and is meant to cover the
pathogens common in IE.
Once definitive diagnosis is made and blood
cultures grow out a specific organism, susceptibil-
ity testing can be conducted and antibiotic regimens
adjusted accordingly. Because these data are un-
available in the ED, generalizations are made about
empiric therapy and medication dosing regimens
based on several society guidelines. Addition of
specific antibiotics should be considered based on
factors such as recent hospitalizations, prosthetic
versus native valve, and the timeline of the symp-
toms. We recommend using doses that cover the
most common and resistant organisms, which can
be adjusted later, as indicated. We recommend this
approach because initial penetration of the bacterial
biofilm covering an infected valve is often inad-
equate with lower doses of bactericidal antibiotics.
Further, bacteria gathered en masse have heightened
resistance to the effects of bactericidal drugs such as
beta-lactams, a phenomenon known as the inoculum
effect. Beta-lactams are time-dependent antibiotics,
and the addition of an antibiotic with a different
mechanism adds a synergistic effect. This is the rea-
soning behind the addition of medications (such as
gentamicin) in some cases.
Because approximately 60% of IE cases are
10 Reprints: www.ebmedicine.net/empissues
caused by either Staphylococcus or Streptococcus, this
discussion on antibiotic therapy focuses primarily
on these organisms. We will also briefly discuss en-
terococci, hospital-acquired organisms, and unique
pathogens, as these are often associated with specific
risk factors. Regardless of the cause, recognition of
the disease and risk factors for unique complications
are paramount.
The majority of cases of IE caused by strep-
tococci are caused by viridans group streptococci
(including Streptococcus anginosus, Streptococcus
mutans and others) that are part of normal oral flora.
Non–viridans group streptococci, such as beta he-
molytic streptococci (group A or C), group B, group
D (Streptococcus bovis), and Streptococcus pneumoniae
lead to IE only in rare situations (eg, gastrointestinal
malignancy-associated S bovis). Therefore, suspicion
for non–viridans group streptococci does not change
the treatment but may be useful in eliciting the ori-
gins of the bacteria leading to IE. Traditionally, most
authorities recommend aqueous penicillin G (12-24
million units IV per day) or ceftriaxone (2 g IV once
daily) plus gentamicin (3 mg/kg IV daily) to cover
presumed penicillin-resistant strains. For patients
who cannot receive penicillin or cephalosporins, a
reasonable choice is vancomycin alone.
Recent literature, however, suggests avoiding
gentamicin, as even a single dose may cause kidney
injury, with a rate of 22% for IE patients receiving
gentamicin versus 8% in those who received an
alternative.42 The effect is likely compounded by the
addition of vancomycin. Based on the evidence, at
this time, we recommend initial treatment with cef-
triaxone plus vancomycin in presumed streptococcal
or staphylococcal (methicillin-sensitive Staphylococ-
cus aureus [MSSA]/MRSA), and reserving gentami-
cin for the critically ill.
Specific circumstances warrant addition of an
aminoglycoside to empiric antibiotic regimens.
In most cases of acute native valve endocarditis,
coverage for Staphylococcus, Streptococcus, and to a
lesser extent, gram-negatives, is sufficient. Prosthetic
valves in place less than a year, however, are more
susceptible to hospital-acquired organisms, and thus
the AHA recommends that these patients receive
vancomycin, rifampin, and gentamicin initially. We
suggest infectious disease consultation to help coor-
dinate the management strategy. Valves in situ for

Table 6. Empiric Antimicrobial Therapies for Infective Endocarditis23

Valve History
Native valve or prosthetic valve
≥ 12 months post placement
Prosthetic valve < 12 months post
placement
Antibiotic Comments
Ceftriaxone 2 g IV once daily Gentamicin 3 mg/kg IV daily may be indicated in specific
PLUS situations (see Table 7)
Vancomycin 15-20 mg/kg IV q8-12h
OR
Vancomycin alone 15-20 mg/kg IV q8-12h May be as effective as ceftriaxone plus vancomycin
Vancomycin 15-20 mg/kg IV q8-12h Early rifampin use has risks and minimal impact on final
PLUS outcome; use only with infectious disease consultation
Gentamicin 1 mg/kg IV q8h
PLUS
Rifampin 300 mg IV q8h

Abbreviations, IV, intravenous; q, every.

Table 7. Indications for Specific Antimicrobial Therapies for Infective Endocarditis23

Antibiotic Comments

Gentamicin 1 mg/kg IV q8h
Rifampin 300 mg IV q8h
Cefepime 2 g IV q8h
Daptomycin 8-10 mg/kg IV daily
Fosfomycin 6-8 g IV q8h
• For large vegetations, resistant Streptococcus, enterococci, PVE < 12 months
• Increases risk for acute kidney injury when used alone or in combination with vancomycin
• Infectious disease consultation recommended
• Third agent in early PVE infection
• Minimal benefit from early use
• Early use may contribute to antimicrobial resistance
• Infectious disease consultation recommended
• Use in place of ceftriaxone if Pseudomonas suspected (< 5% of IE)
• Use for vancomycin intolerance
• Equivalent efficacy to vancomycin
• Equivalent efficacy in MRSA IE
• Available only in Europe

Abbreviations: IE, infective endocarditis; IV, intravenous; q, every; MRSA, methicillin-resistant Staphylococcus aureus; PVE, prosthetic valve endocarditis.

September 2020 • www.ebmedicine.net 11 Copyright © 2020 EB Medicine. All rights reserved.

more than 1 year usually have similar microbiology
to native valves and can receive similar treatment to
native valves (ie, ceftriaxone plus vancomycin). This
regimen also covers HACEK endocarditis, which is
highly susceptible to ceftriaxone and must be con-
sidered in native valve IE when subacute presenta-
tion occurs.23,43,44
Alternative Antibiotics
For patients who cannot tolerate common empiric
antibiotics, there are alternatives. Given the high
proportion of staphylococcal endocarditis, vancomy-
cin intolerance presents a problem. There are several
promising studies demonstrating the efficacy of dap-
tomycin compared to vancomycin. A recent propen-
sity-matched trial of vancomycin versus daptomycin
for S aureus bacteremia demonstrated a reduction in
clinical failure rates and mortality in the daptomycin
cohort.45 In a randomized controlled trial of stan-
dard therapy for IE versus daptomycin, daptomycin
was also found to be noninferior in IE treatment,
with a lower incidence of renal dysfunction.46
Over the past several years, data from outside
the United States are emerging that fosfomycin may
play a role in treatment of IE. Fosfomycin prevents
peptidoglycan synthesis in a step prior to that inter-
vened on by beta-lactams, and consequently has a
broad spectrum of activity to include MRSA, Pseudo-
monas, and resistant enterobacteria. It also possesses
excellent synergistic ability with other antibiotics
and can penetrate biofilms, underscoring its poten-
tial role in IE. In 2 small multicenter clinical trials in
Europe, IV fosfomycin in combination with imipe-
nem showed promise for resistant MRSA bacteremia
as well as for cases of MRSA IE, resulting in a 7%
higher cure rate than vancomycin alone.47,48 In the
United States, fosfomycin is available in oral formu-
lation only, and further studies of IV formulations
are needed, given its potential therapy for difficult
cases and the prevalence of bacterial resistance.49
Antibiotic Treatment Duration
Treatment duration ranges from 2 to 6 weeks, and
depends on the location of the IE and the resistance
patterns of the organism. Patients with native valve
endocarditis often receive 4 weeks of treatment,
while those with prosthetic valve endocarditis are
treated for at least 6 weeks. Duration of antibiotic
therapy also depends on whether surgical interven-
tion occurred and the results of follow-up echocar-
diogram. Because of the kinetics of bacterial killing,
some recommend continuous infusions, but as of
yet, this has not been shown to be beneficial.
Surgical Treatment
Surgical therapy has specific indications in the initial
care of IE patients. The goals of emergent and urgent
surgical intervention are to decrease embolization
Copyright © 2020 EB Medicine. All rights reserved.
risk and mortality. Emergent surgery is typically
defined as within 24 hours of diagnosis, and urgent
surgery is within the first 2 days, though it may en-
compass a protracted period of up to several weeks,
depending on the clinical situation. Because it is
estimated that approximately 50% of IE patients will
require surgical intervention, surgical teams should
be engaged early, since embolization risk is highest
in the first 2 weeks of antibiotic therapy.50
The strongest indications for surgical interven-
tion include IE with acute heart failure, severe val-
vular dysfunction, or fistulas into a cardiac chamber.
(See Table 8.) Acute congestive heart failure treat-
ment should be initiated as well, with special atten-
tion paid to the effects of altering preload and after-
load in valvular insufficiency. Signs of perivalvular
abscess, such as heart block, aortic insufficiency, or
destructive-appearing lesions on echocardiogram
are indications for surgery as well, but the urgency
depends on multidisciplinary discussion and input.
The American Association for Thoracic Surgery
(AATS) indicates that all patients with prosthetic
valve endocarditis should eventually be treated
surgically, due to a high risk of recurrence otherwise.
Although not often recognized in the ED, fungal
IE or IE caused by certain organisms (Staphylococcus
lugdunensis, Brucella, Coxiella burnetii, and Pseudomo-
nas) is an independent indicator for surgical inter-
vention due to the difficulty in eradication and the
aggressive nature of these organisms.23,51 The AATS
advocates for an early approach for patients at risk
for embolization (ie, large vegetations), more so in
those with left-sided endocarditis or any patient
developing severe valvular insufficiency or recurrent
pulmonary embolism in right-sided endocarditis.50
The presence of neurologic symptoms such as TIA or
cerebrovascular accident also warrant urgent surgi-
cal therapy as long as there is no associated intracra-
nial bleed, in which case delay of up to 4 weeks is
advised.52
For IV drug users, the AHA recommends avoid-
ance of surgery, if possible, given the risks for recur-
rence due to social factors. Subgroups with severely
compromised valves and right heart failure may be
Table 8. Indications for Surgical
Consultation for Infective Endocarditis
• Acute congestive heart failure
• Severe valvular dysfunction
• Abscess detected on imaging
• Intracardiac fistulas
• Destructive vegetations or those with high likelihood of embolism
• New heart blocks
• Cerebrovascular accident or transient ischemic attack without
bleeding
www.ebmedicine.net
12 Reprints: www.ebmedicine.net/empissues
the exception in this population. There is also a role
for minimally invasive therapies in this subgroup
(see the “Controversies and Cutting Edge” section
on page 15) as well as paired drug rehabilitation and
IE treatment programs.51
Special Circumstances and Populations
Antibiotic Prophylaxis
Antibiotic prophylaxis guidelines for prevention of
IE have undergone several revisions, most recently
in 2007. Guidelines propose limiting prophylaxis to
high-risk patients (see Table 9) undergoing the high-
est-risk procedures (see Table 10).53 This resulted
from data suggesting that few IE cases were pre-
vented by antibiotics, as IE is now more likely due to
frequent exposure to bacteremia from daily activi-
ties (teeth brushing, etc) than from medical proce-
dures.18,54 Debate still continues over current guide-
lines that also promote specific prevention measures
(oral and skin hygiene) over antibiotics.55,56 To date,
2 of 8 large studies completed since the guideline
change have demonstrated an increased incidence
of IE, which were attributed to the guideline change.
However, they did not establish a causal relation-
ship, and these cases may represent an increased
incidence of identification, changes in epidemiology,
or improvements in imaging and diagnosis.20,57-59
Several smaller studies have shown both increased
and decreased IE incidence, but only limited ob-
servational data are available and the majority of
studies are underpowered. Confounding variables,
such as increasing prevalence of IV drug use and
variability of outcomes contribute to the lack of clear
consensus among studies since the most recent AHA
revision. Given the available literature, we recom-
mend following the more conservative AHA guide-
lines over European guidelines (which recommend
prophylaxis only during dental procedures) and
United Kingdom National Health Service guidelines
(which no longer recommend prophylaxis for any
patient).53 According to current AHA guidelines,
prophylaxis is no longer recommended for bron-
choscopy alone, for gastrointestinal/genitourinary
procedures, or for sterile procedures in patients
with implanted cardiac devices (pacers/automatic
implantable cardioverter defibrillators). See Tables
9 and 10 for current indications for prophylaxis and
antibiotic choices.18,60
Infective Endocarditis-Related Neurologic
Complications
Neurologic complications from septic thrombo-
embolism are common in IE, with acute ischemic
stroke having an incidence of 30% in IE patients.18,61
Many IE patients with acute ischemic stroke have
large-vessel occlusion, and up to 25% have middle
cerebral artery syndrome. More than half will have
cerebral embolism below the threshold for CT imag-
ing and clinically silent embolism or additional

Table 9. High-Risk Conditions Mandating Antibiotic Prophylaxis60

Condition Notes Antibiotic Prophylaxis and Timing
All prosthetic valves • Includes transcatheter and homograft valves • Antibiotic selection for patients with these
Prosthetic implants • Annuloplasty rings and prosthetic chords high-risk features is based on type of
procedure and is described in Table 10
Repaired CHD in the following • CHD repairs with prosthetics < 6 months from surgery • Antibiotics should be administered 30-60
instances • CHD with lifelong shunt minutes prior to procedure
• CHD with residual defect at repair site
• CHD with valvular regurgitation
Unrepaired CHD Prophylaxis indicated for unrepaired CHD of any type

Abbreviation: CHD, congenital heart disease.

Table 10. Procedures Requiring Antibiotic Prophylaxis for Infective Endocarditis in High-Risk
Patients60
Condition Notes Dose of Antibiotic Timing of Dose
Dental Involving gingiva or periapical tissue One of the following: • Single dose administered 30-60
procedures manipulation • Amoxicillin 2 g PO minutes prior to procedure
Respiratory Only for manipulation of infected tissue • Clindamycin 600 mg PO • Vancomycin is administered 2 hours
procedures • Cephalexin 2 g PO prior to procedure
When incision and drainage is performed
• Ceftriaxone 1 g IV
Soft-tissue When infected skin, soft tissue, or muscle • Same as with dental/respiratory
procedures is incised procedures
• Vancomycin 1 g IV if severe

Abbreviations: IV, intravenous; PO, by mouth.

September 2020 • www.ebmedicine.net 13 Copyright © 2020 EB Medicine. All rights reserved.

microhemorrhages detected on MRI.18,61
In IE, administration of thrombolytics carries
increased risk of hemorrhagic conversion. This in-
creased propensity for hemorrhage occurs due to the
presence of micro-organisms and inflammatory cells
in septic emboli, leading to endothelial damage and
alterations in the endothelium-platelet interactions. At
the time of this writing, all major endovascular trials
demonstrating benefit to patients with acute ischemic
stroke either excluded or had no IE patients. There
are case reports, case series, and small retrospective
studies detailing the use of systemic thrombolytic
and endovascular therapies in IE, and both thera-
pies remain the subject of controversy.62-64 In these
studies, hemorrhagic conversion occurred in 20% to
42% of stroke treated with systemic thrombolysis (vs
6%-6.5% in non-IE patients receiving alteplase) and
hemorrhagic conversion occurred in 12% of patients
undergoing endovascular therapy in IE (vs 4.4% in
non-IE patients).61,63 Mortality was similar between
the groups, but endovascular therapy seems to lead
to improved neurological outcomes, based on the
limited data available.
On the current FDA label for Activase® (al-
teplase), subacute bacterial endocarditis is noted
under “Warnings and Precautions.”65 Endocarditis
was not an exclusion in the original National Insti-
tute of Neurological Disorders and Stroke (NINDS)
trial but is a contraindication for alteplase, per the
2018 AHA guideline for acute ischemic stroke (Class
III: Harm).66,67 Even with neurologic complications,
early diagnosis, antibiotics, and surgery (in high-risk
patients) are the mainstays of embolism prevention,
and treatments for one may involve an opportunity
cost for another.18,67,68 Systemic thrombolysis is
discouraged and, if possible, early consultation with
neurology, interventional radiology, and cardiotho-
racic surgery is recommended.
Transcatheter Valve Repair-Associated
Infective Endocarditis
The risk of prosthetic valve IE with transcatheter
valve replacement versus traditional surgical valve
replacement is being debated. Transcatheter valve
replacement was initially thought to be a lower
risk procedure, given the less-invasive nature of
the intervention, but it is now generally considered
to have a risk of IE equivalent to other prosthetic-
valve-associated IE.69 Transcatheter valve replace-
ment-associated IE requires special consideration,
given the increased use of transcatheter interven-
tions and the fact that IE is most likely to occur
within 6 months of replacement.69,70 Young males,
patients with diabetes mellitus, and elderly patients
are at the highest risk in this cohort, and are more
likely to present with nonspecific symptoms such as
weight loss and fatigue.71 Transcatheter aortic valve
replacement is associated with an increased risk of
Copyright © 2020 EB Medicine. All rights reserved.
enterococci (34% of cases) and transcatheter pulmon-
ic valve replacement is associated with an increased
risk of infection with S aureus (29% of cases).70
Infective Endocarditis and Implantable Devices
IE in the setting of implanted cardiac devices is asso-
ciated with high mortality, and it is one of the most
difficult forms of IE to diagnose because it frequent-
ly presents with nonspecific respiratory symptoms
and signs of limited, local infection at the device site.
Apparent device-site infections (device-pocket infec-
tions) have been associated with intravascular lead
segment infection in up to 70% of patients.18 IE in
this setting is most often due to coagulase-negative
staphylococci (60%-80% of the time), with increasing
rates of MRSA as well. Higher rates of infection are
present in more complex devices such as implanted
cardioverter defibrillators and cardiac resynchroni-
zation therapy devices.72 The majority of patients
require prolonged antibiotic therapy and device
removal.73 TEE has superior sensitivity and specific-
ity for implant lead-related IE, and adjuncts such as
PET/CT will likely be indicated when suspicion is
high and echocardiography is negative.18 A paucity
of literature exists for IE in the setting of implanted
cardiac devices in patients with left ventricular assist
devices (LVADs), but an LVAD infection confers a
greater risk of concomitant IE than a cardiac device-
site infection (pocket infection alone). In this cohort,
the development of IE is more likely to occur later, at
16 to 18 months post LVAD placement.74
An increased risk of IE exists in patients with
intravascular devices such as indwelling lines, and
device removal is often required for definitive treat-
ment. Several other subgroups of patients have an
increased risk of IE as well, specifically the elderly
and patients on dialysis.75,76 Notably, neutropenic
patients do not demonstrate a higher than average
risk of IE.77 At this time, no guidelines recommend
adapting treatment strategies to a patient’s function-
al status or comorbidities.78
Infective Endocarditis in Children
IE is less common in pediatric patients than in
adults, but it occurs more frequently in children with
congenital heart disease with prior repair. At par-
ticularly high risk are patients with palliative shunt
procedures and intracardiac repair with prosthetic
material who are within 6 months of repair.79 An
increased frequency of device-related IE is occurring
in children, particularly in the setting of transcathe-
ter pulmonary valve replacement.80 IE in children, in
the absence of congenital heart disease (10% of cas-
es), occurs more frequently in children with indwell-
ing central venous catheters or NICU/PICU stays.81
Surprisingly, children with congenital or acquired
immunodeficiencies do not appear to be at higher
risk for developing IE. Much like adults, S aureus
14 Reprints: www.ebmedicine.net/empissues
is the predominant pathogen in children. Limited
studies exist for use of the modified Duke criteria in
children, but they appear to validate the criteria in
this age group. Due to more favorable anatomy and
visualization, TTE is likely adequate for diagnosis
in children (versus TEE in adults), but in higher-risk
children, TEE remains superior to rule out IE. The
principles of antimicrobial treatment of pediatric IE
are similar to those for treatment of adult IE.81
Controversies and Cutting Edge
Outpatient Therapy for Infective Endocarditis
Advances in therapy delivery, healthcare costs, and
the changing landscape of IE epidemiology have
ushered in advances in therapy. Outpatient paren-
teral antibiotic treatment (OPAT) regimens have
been investigated over the past 10 years as alterna-
tives to inpatient IV therapy, and they hold prom-
ise. Most of these studies have focused on viridans
group Streptococcus infections as well as S bovis and
S aureus infections in patients with prosthetic valve
endocarditis or native valve endocarditis who are
not IV drug users. Similar outcomes have been re-
ported among groups. In one study, 1466 total days
of hospital stay were avoided by introduction of an
OPAT program. Patients on OPAT with glycopeptide
antibiotics, however, had a higher rate of readmis-
sion (odds ratio, 4.5), underscoring the difficulty of
treating staphylococcal infections in this manner and
a need for closer follow-up for this subset of patients
on OPAT.82 A United States trial of standard therapy
(vancomycin or penicillin plus gentamicin) versus
daptomycin therapy for both Staphylococcus bacte-
remia and IE patients examined the effects of OPAT
or partial OPAT on clinical success and therapy
completion. The rates of clinical success and therapy
completion were higher in the OPAT group versus
the full-inpatient group. Additionally, no differences
were found between the traditional therapy and
daptomycin groups.
Due to social factors, many studies have ex-
cluded IV drug users and are weighted toward those
with left-sided IE.83 Nonetheless, a recent pilot study
of OPAT plus buprenorphine for IV drug use-related
infections shows promise, with similar rates of clini-
cal and drug use outcomes to those who received
inpatient versus outpatient parenteral antibiotic
treatment for the same disorders, as well as a 24-day
reduction in hospital stay.83
Partial Oral Therapy for Infective Endocarditis
Partial oral therapy for IE has been investigated in
a trial published in 2019 on patients with left-sided
IE. The patients studied had a broad variety of
causative bacteria, including Streptococcus, MRSA,
enterococci, and coagulase-negative staphylococci,
and approximately 30% had prosthetic valve endo-
September 2020 • www.ebmedicine.net
carditis. All patients received at least 10 days of IV
antibiotic therapy and were then randomized to con-
tinue IV therapy or change to oral therapy (in cases
not complicated by abscess development). Most
patients assigned to oral therapy were discharged
within 3 days of transitioning from IV to oral
therapy. Noninferiority was demonstrated, and no
difference in mortality or worsening echocardiogram
findings were observed at a 6-month interval evalua-
tion. Inpatient stay duration was reduced by 17 days
in the oral therapy group as well.84 This trial, again,
excluded IV drug users and right-sided IE, but oral
therapy regimens appear to hold promise as future
treatment options in select patient populations.
Catheter-Assisted Vegectomy
As the cases of IE in IV drug users continue to rise
in North America, effective alternatives are being
developed to intervene. Given the high rate of recur-
rence and patients’ failure to follow up, alternatives
to open surgical intervention or prolonged inpa-
tient antibiotics may prove beneficial. In the case of
right-sided IE, where systemic embolization risk is
minimal and recurrence is high, catheter-assisted
vacuum removal of vegetation has been attempted
and shows promise, especially in the subgroup of IE
patients who are IV drug users.85-87
Infective Endocarditis Teams
In response to the complexity of IE and the frequent
multisystem involvement, the formation of multidis-
ciplinary IE teams has been studied in Europe and
has shown to improve care and reduce mortality.
The teams are comprised of several subspecialties
including cardiology, infectious disease, and surgery,
and incorporate benchmarks for imaging, emergent
and urgent surgical intervention, and multidisci-
plinary inpatient care.
European studies have demonstrated a mortal-
ity reduction of 10% to 18%, with the decrease noted
both in hospital and overall mortality.88,89 A United
Kingdom-based study had a 25% reduction in mor-
tality after IE team implementation. The additional
reduction compared to prior studies was attributed
to process improvement in proper selection and early
implementation of antibiotic therapies.90 In the future,
IE teams at tertiary referral centers may show out-
come benefits similar to advancements in stroke and
myocardial infarction care that arose from evidence-
based streamlining of care over the last 20 years.
Risk Scores
There have been several tools derived for evalu-
ation of mortality risk in IE, and the most recent
and robust is the IE mortality risk score (ICE-PLUS
score), which was prospectively developed and
externally validated in 2016. This score determines
mortality rates based on features existing at the time
15 Copyright © 2020 EB Medicine. All rights reserved.
of diagnosis and utilizes factors such as age, vegeta-
tion location, presence of heart failure, and stroke to
predict 6-month mortality risk. There are other well-
designed scores with similar test characteristics that
can help predict mortality in IE patients, but they are
either valve-specific (RISK-E score), only for patients
undergoing cardiac surgery (STS short-term risk cal-
culator, EUROSCORE II, AEPEI score), or were not
conducted on a large scale. Given the scale, perfor-
mance, and generalizability of the ICE-PLUS study
score, this score is the most useful for the emergency
care of these patients.92-94
An online/mobile calculator for the IE Mortality Risk
score is available at:
www.mdcalc.com/infective-endocarditis-ie-mortality-
risk-score
Disposition
Patients with suspected IE require admission, even
with the advent of OPAT. If a patient is clinically
unstable or presenting with embolic phenomena,
surgical intervention should be considered as well.
For patients who are IV drug users, early case man-
agement and social work involvement for rehabilita-
tion and treatment are also warranted.
Summary
Even in the modern era of advanced diagnostics, IE
continues to be enigmatic. This is due to the subtle
nature of the disease’s presentation and the lack of
definitive testing available in the acute care setting.
The critical role of the emergency clinician is to
suspect the disease, recognize the risk factors for its
development, and provide stabilization and treat-
ment. Although POCUS can assist with ruling in the
diagnosis (not ruling out the diagnosis), if patient
risk for IE is high, TEE is recommended and, if nega-
tive, should be repeated in cases where suspicion
remains high. Other modalities, such as MSCT and
PET-CT are emerging for specific subsets of difficult-
to-diagnose and device-related IE. Emergency clini-
cians must remember the classically taught features
of IE are present in less than 10% of cases, and that
presentation can be as subtle as intermittent fever
and malaise. IE should also be considered whenever
a young patient first presents with stroke, heart fail-
ure, or a new heart block or when persistent bactere-
mia or multiorgan embolic phenomena are detected.
Given the propensity for septic embolism formation,
30% of IE cases are associated with cerebrovascular
accident, and thus we recommend CT/CTA imag-
ing for suspected IE with neurological features. This
subset of cerebrovascular accident carries a 5-fold-
higher bleeding risk if lytics are used and a 3-fold-
Copyright © 2020 EB Medicine. All rights reserved.
higher bleeding risk if endovascular therapy is used.
Thus, discretion is advised in light of current data
and AHA warnings regarding alteplase in cerebro-
vascular accident related to IE. We encourage multi-
specialty consultation for endovascular therapies, if
indicated, and avoidance of lytics if possible.
Most IE cases are due to MRSA, coagulase-
negative staphylococci, or viridans group strepto-
cocci; to a lesser extent Enterobacteria, and, rarely,
the HACEK organisms. Thus, empiric antibiotic
therapy can be guided by risk factors, whether a
valve is native or prosthetic, and can be generalized
into several antimicrobial combinations. For na-
tive valves, a third-generation cephalosporin plus
vancomycin or vancomycin alone will cover most
cases. Treatment of prosthetic valve endocarditis is
similar unless the valve is less than 6 months old, in
which case the addition of gentamicin and rifampin
should occur in consultation with infectious disease
consultation, given the known adverse effects of
these drugs. Indications for surgical consultation
include suspicion for valvular abscess, unstable IE
patients, heart blocks, and prosthetic valve endocar-
ditis. Prophylaxis guidelines vary, but currently it is
recommended only for invasive dental, respiratory,
or dermal procedures involving manipulation of
infected tissue in high-risk patients.
Case Conclusions
The 25-year-old patient was admitted for sepsis and
multifocal pneumonia. Blood cultures grew out MRSA in
2 of 2 bottles. Empiric antibiotics were begun in the ED
and cardiac echo demonstrated a large tricuspid vegetation.
Case management consultation occurred early, given the
patient’s past visits for IV drug use-related complications.
Following his hospitalization, he was released to a drug
rehabilitation program as part of the terms of his treatment.
The 55-year-old woman with cardiogenic shock was
rapidly evaluated at the bedside with POCUS, which dem-
onstrated regurgitant jets and pulmonary edema. A TTE
was conducted, which revealed mitral valve vegetations.
Cardiothoracic surgery was consulted emergently, and the
patient was taken to the OR, where a perivalvular abscess
was found. She received a prosthetic valve followed by a
prolonged antibiotic course, with improvement.
For the patient with the dental abscess, before incis-
ing, you discussed the use of prophylaxis based on AHA
guidelines and administered amoxicillin/clavulanate 2 g,
30 minutes prior to the procedure.
Disclaimer
The views expressed are those of the authors and do
not reflect the official policy of the Department of the
Army, the United States Department of Defense, or
the United States Government.
16 Reprints: www.ebmedicine.net/empissues
Time- and Cost-Effective Strategies
• Gather a good surgical, drug, and device history
on all patients with fever of unknown origin or
prolonged duration.
• Consider POCUS as a “rule-in” initial screening
examination to evaluate for valvular regurgita-
tion and large vegetations.
• A negative TTE does not rule out IE, and re-
quires a TEE for further visualization. In cases
of high suspicion, a negative TEE should be
Risk Management Pitfalls for Infective Endocarditis
in the Emergency Department
1. “I figured the persistent fever was just viral;
she looked so well.”
Failing to consider IE in a patient with fever
without a source, even if the patient appears
well, can lead to missed diagnoses. Often,
suspicion of IE is the most difficult part of
the workup, and can add significantly to the
diagnostic momentum if it is suspected.
2. “My 32-year-old patient had developed acute
heart failure, but I assumed it was because he
has diabetes and is on hemodialysis.”
Consider IE in any young patient with new-
onset acute heart failure, which suggests
perivalvular abscess. Other clinical syndromes
in young patients that can indicate IE are stroke
or multifocal pneumonia, both of which are
suggestive of embolic phenomena.
3. “I diagnosed endocarditis, treated the heart
failure, and admitted him to the ICU.”
Always obtain emergent surgical consultation
for a patient with IE with cardiogenic shock or
heart failure. These presentations often indicate
a dehiscence of a perivalvular abscess, and
emergent surgical therapy can be life-saving.
4. “I noticed the new second-degree block in my
septic patient, but it never occurred to me to
consider IE.”
In certain settings, a new heart block can be an
indicator of perivalvular abscess.
5. “I noticed my IE patient had resolving left-
sided weakness, but since it was transient, I
obtained only a CT. Since it was negative, I
didn’t think there was a need for further ED
imaging studies.”
CT/CTA imaging should be conducted in
IE patients with permanent and transient
neurologic symptoms to rule out mycotic
aneurysm that may be throwing small emboli.
September 2020 • www.ebmedicine.net
repeated in 3 to 5 days, given its sensitivity.
• If IE is suspected, order 3 sets of blood cultures,
separated by time.
• With limited IV access, if suspicion for IE is high,
administer vancomycin first, in addition to other
antibiotics, as it covers the most common and
most deadly organisms.
• In cases of acute decompensated heart failure
related to IE, emergent surgical consultation is
warranted, as this presentation often indicates
complications related to valvular abscess.
6. “A TTE was negative in the ED, so I assumed
that the patient didn’t have IE.”
Imaging modalities such as TTE and POCUS
are most useful as rule-in, not rule-out tests.
Even if a TEE is negative, in the presence of high
suspicion, it should be repeated within a short
interval, as it is only 90% sensitive and can miss
small lesions, especially right-sided lesions.
7. “The patient presented with fever and conges-
tive heart failure; I didn’t think to use POCUS
to evaluate her.”
POCUS is a useful initial evaluation for
regurgitation or vegetations but should not be
used to rule out IE.
8. “I always include gentamicin when I suspect
IE.”
Gentamicin is likely more harmful than helpful,
and should be reserved for prosthetic valves less
than 6 months from placement and in patients
with resistant Streptococcus infection.
9. “The patient returned to the ED with persis-
tent fevers, and I reviewed the culture from
prior visits, noting skin-contaminant coagulase
negative staph in 2 bottles.”
Do not fail to recognize that organisms such as
coagulase-negative Staphylococcus (specifically
S lugdunensis) may result in IE. In some
populations, this can result in morbidity and
delays in diagnosis.
10. “It was a minor dental abscess incision and
drainage; I didn’t think the patient with a pros-
thetic valve needed prophylaxis for IE.”
Although many of the current prophylaxis
guidelines have become more conservative,
patients with prosthetic valves still require
prophylaxis for invasive dental procedures.
17 Copyright © 2020 EB Medicine. All rights reserved.
 Clinical Pathway for Emergency Department Management
of Patients With Infective Endocarditis

Patient presents with features

suggestive of IE: Patient stable? NO Stabilize
• Fever > 1 week
• Risk factors for IE* YES
• Prosthetic valves
• Classical findings
• Obtain blood cultures x3
• Obtain CBC, CMP, UA, UDS
• Consider Duke criteria (Class I)

• Perform noncontrast head CT

Urgent TTE available? NO Neurologic findings? YES • Perform head/neck CTA
(Class I)
NO YES

Perform TTE (Class I); positive?

Perform POCUS (Class III); positive? Bleed present?
NO YES
NO YES
NO YES
Perform TEE • Administer
(Class I); empiric • Administer
• Administer • Administer • Administer
positive? antibiotics empiric
empiric empiric empiric
antibiotics antibiotics • Obtain surgical antibiotics antibiotics
NO YES
• Perform TEE • Perform TTE consultation if • Perform TTE (Class I)
• Rule out other • Obtain surgical vegetation > 10 • Obtain surgical • Perform TTE
causes consultation mm or abscess consultation (or POCUS, if
• Obtain ICU • Obtain ID (Class I) • Obtain ID unavailable)
consultation consultation consultation (Class III)
• Obtain ID (Class I) • Administer empiric antibiotics (Class I) (Class I) • Follow ICP/ICH
consultation • Interval repeat TEE (Class I) precautions
(Class I) • Perform PET-CT or MSCT (Class II) (Class I)
• Obtain ID consultation (Class I)

*Risk factors: IV drug use, Staphylococcus aureus bacteremia, valvular heart disease, implantable cardiac devices, hemodialysis, indwelling lines,
repeated vascular access, unrepaired congenital cardiac anomalies, immunocompromise, immunomodulator use.

Abbreviations: CBC, complete blood cell (count); CMP, comprehensive metabolic panel; CT, computed tomography; CTA, computed tomographic
angiography; ID, infectious disease; ICH, intracranial hemorrhage; ICP, intracranial pressure; ICU, intensive care unit; IE, infective endocarditis;
MSCT, multislice computed tomography; PET, positron emission computed tomography; POCUS, point-of-care ultrasound; TEE, transesophageal
echocardiography; TTE, transthoracic echocardiography; UA, urinalysis; UDS, urine drug screen.

Class of Evidence Definitions

Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.
Class I
• Always acceptable, safe
• Definitely useful
• Proven in both efficacy and effectiveness
Level of Evidence:
• One or more large prospective studies
are present (with rare exceptions)
• High-quality meta-analyses
• Study results consistently positive and
compelling
Class II Class III Indeterminate
• Safe, acceptable • May be acceptable • Continuing area of research
• Probably useful • Possibly useful • No recommendations until further
• Considered optional or alternative treat- research
Level of Evidence: ments
• Generally higher levels of evidence Level of Evidence:
• Nonrandomized or retrospective studies: Level of Evidence: • Evidence not available
historic, cohort, or case control studies • Generally lower or intermediate levels of • Higher studies in progress
• Less robust randomized controlled trials evidence • Results inconsistent, contradictory
• Results consistently positive • Case series, animal studies, • Results not compelling
consensus panels
• Occasionally positive results

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2020 EB Medicine. www.ebmedicine.net. No part of this publication may be reproduced in any format without written consent of EB Medicine.

Copyright © 2020 EB Medicine. All rights reserved. 18 Reprints: www.ebmedicine.net/empissues

 References
Evidence-based medicine requires a critical ap-
praisal of the literature based upon study methodol-
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equally robust. The findings of a large, prospective,
randomized, and blinded trial should carry more
weight than a case report.
To help the reader judge the strength of each
reference, pertinent information about the study, such
as the type of study and the number of patients in the
study is included in bold type following the references,
where available. The most informative references cited
in this paper, as determined by the authors, are noted
by an asterisk (*) next to the number of the reference.
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(Case review)
28. Afonso L, Kottam A, Reddy V, et al. Echocardiography
in infective endocarditis: state of the art. Curr Cardiol Rep.
2017;19:127. (Review)
29. Vilacosta I, Olmos C, de Agustín A, et al. The diagnostic
ability of echocardiography for infective endocarditis and
its associated complications. Expert Rev Anti Cardiovasc Ther.
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30. Pfister R, Betton Y, Freyhaus Ht, et al. Three-dimensional
compared to two-dimensional transesophageal echocar-
diography for diagnosis of infective endocarditis. Infection.
2016;44(6):725-731. (Prospective cohort study; 144 patients)
31. Cahill TJ, Baddour LM, Habib G, et al. Challenges in infec-
tive endocarditis. J Am Coll Cardiol. 2017;69(3):325-344.
(Review)
32. Kestler M, Munoz P, Rodriguez-Creixems M, et al. Role of
18F-FDG PET in patients with infectious endocarditis. J Nucl
Med. 2014;55(7):1093-1098. (Retrospective; 303 cases)
33. Mikail N, Benali K, Mahida B, et al. 18F-FDG PET/CT
imaging to diagnose septic emboli and mycotic aneurysms
in patients with endocarditis and cardiac device infections.
19 Copyright © 2020 EB Medicine. All rights reserved.
 Curr Cardiol Rep. 2018;20(3):14. (Review)
34. Jiménez-Ballvé A, Pérez-Castejón MJ, Delgado-Bolton RC,
et al. Assessment of the diagnostic accuracy of 18F-FDG
PET/CT in prosthetic infective endocarditis and cardiac
implantable electronic device infection: comparison of dif-
ferent interpretation criteria. Eur J Nucl Med Mol Imaging.
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35. Granados U, Fuster D, Pericas JM, et al. Diagnostic accuracy
of 18F-FDG PET/CT in infective endocarditis and implant-
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study. J Nucl Med. 2016;57(11):1726-1732. (Prospective study;
80 patients)
36. Roque A, Pizzi MN, Cuéllar-Calàbria H, et al. 18F-FDG PET/
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37. Siméon S, Le Moing V, Tubiana S, et al. Time to blood culture
positivity: an independent predictor of infective endocarditis
and mortality in patients with Staphylococcus aureus bacter-
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38. Bai AD, Agarwal A, Steinberg M, et al. Clinical predictors
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39. Subedi S, Jennings Z, Chen SCA. Laboratory approach to the
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40. Liesman RM, Pritt BS, Maleszewski JJ, et al. Labora-
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41. Faraji R, Behjati-Ardakani M, Moshtaghioun SM, et al. The
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42. Cosgrove Sara E, Vigliani Gloria A, Campion M, et al.
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43. Coburn B, Toye B, Rawte P, et al. Antimicrobial susceptibili-
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Agents Chemother. 2013;57(4):1989-1991. (Review)
44. Revest M, Egmann G, Cattoir V, et al. HACEK endocarditis:
state-of-the-art. Expert Rev Anti Infect Ther. 2016;14(5):523-
530. (Review)
45. Claeys KC, Zasowski EJ, Casapao AM, et al. Daptomycin
improves outcomes regardless of vancomycin MIC in a
propensity-matched analysis of methicillin-resistant Staphy-
lococcus aureus bloodstream infections. Antimicrob Agents
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cohort; 262 patients)
46. Fowler VG Jr, Boucher HW, Corey GR, et al. Dapto-
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47. Pericàs JM, Moreno A, Almela M, et al. Efficacy and safety of
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48. del Rio A, Gasch O, Moreno A, et al. Efficacy and safety of
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49. Kaye KS, Rice LB, Dane AL, et al. Fosfomycin for injection
(ZTI-01) versus piperacillin-tazobactam for the treatment of
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complicated urinary tract infection including acute pyelone-
phritis: Zeus, a phase 2/3 randomized trial. Clin Infect Dis.
2019. (Randomized controlled trial; 465 patients)
50. Prendergast BD, Tornos P. Surgery for infective endocarditis.
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51.* Pettersson GB, Coselli JS, Pettersson GB, et al. 2016 the
American Association for Thoracic Surgery (AATS)
consensus guidelines: surgical treatment of infective
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2017;153(6):1241-1258.e1229. (Guideline)
DOI: https://doi.org/10.1016/j.jtcvs.2016.09.093
52. Byrne JG, Rezai K, Sanchez JA, et al. Surgical management
of endocarditis: the Society of Thoracic Surgeons clinical
practice guideline. Ann Thorac Surg. 2011;91(6):2012-2019.
(Guideline)
53. Duval X, Hoen B. Prophylaxis for infective endocarditis: let’s
end the debate. Lancet. 2015;385(9974):1164-1165. (Editorial)
54. Albes JM. Current practice in prophylaxis of endocardi-
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2019;56(1):1-6. (Editorial)
55. Calcaterra G, Crisafulli A, Guccione P, et al. Infective endo-
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56. Grattan MJ, Power A, Fruitman DS, et al. The impact of
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57. Cahill TJ, Harrison JL, Jewell P, et al. Antibiotic prophylaxis
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studies)
58. DeSimone DC, Tleyjeh IM, Correa de Sa DD, et al. Incidence
of infective endocarditis due to viridans group streptococci
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59. Garg P, Shariff S, Jenkyn KB, et al. Infective endocarditis hos-
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60. Wilson W, Taubert KA, Gewitz M, et al. Prevention of
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61. Ong E, Mechtouff L, Bernard E, et al. Thrombolysis for
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62. Marquardt RJ, Cho SM, Thatikunta P, et al. Acute ischemic
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63. Asaithambi G, Adil MM, Qureshi AI. Thrombolysis for
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64. Ambrosioni J, Urra X, Hernández-Meneses M, et al. Me-
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65. United States Department of Health and Human Services
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(Drug label)
66. Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 guidelines
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67. Demaerschalk BM, Kleindorfer DO, Adeoye OM, et al.
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68. Brownlee WJ, Anderson NE, Barber PA. Intravenous throm-
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69. Gedela M, Shrestha A, Stys T, et al. Prosthetic aortic valve
endocarditis following transcatheter aortic valve implanta-
tion. S D Med. 2018;71(12):546-549. (Case report/review)
70. Amat-Santos IJ, Ribeiro HB, Urena M, et al. Prosthetic valve
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72. Arnold CJ, Chu VH. Cardiovascular implantable electronic
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73. Sławin’ski G, Lewicka E, Kempa M, et al. Infections of cardiac
implantable electronic devices: epidemiology, classification,
treatment, and prognosis. Adv Clin Exp Med. 2019;28(2):263-
270. (Review)
74. Riaz T, Nienaber JJC, Baddour LM, et al. Cardiovascular im-
plantable electronic device infections in left ventricular assist
device recipients. Pacing Clin Electrophysiol. 2013;37(2):225-
230. (Retrospective review; 247 patients)
75. Bentata Y. Physiopathological approach to infective endocar-
ditis in chronic hemodialysis patients: left heart versus right
heart involvement. Ren Fail. 2017;39(1):432-439. (Review)
76. Ursi MP, Durante Mangoni E, Rajani R, et al. Infective
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35 studies)
78. Forestier E, Fraisse T, Roubaud-Baudron C, et al. Managing
infective endocarditis in the elderly: new issues for an old
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review; 1299 patients)
21 Copyright © 2020 EB Medicine. All rights reserved.
CME Questions 5. Empiric therapies of IE should include:
a. A cephalosporin plus anti-MRSA agent, such
as vancomycin
Take This Test Online!
b. Gentamicin
c. An antipseudomonal agent
Current subscribers receive CME credit absolutely
d. Rifampin plus gentamicin
free by completing the following test. Each issue
includes 4 AMA PRA Category 1 CreditsTM, 4 ACEP
6. Gentamicin is useful in IE:
Category I credits, 4 AAFP Prescribed credits, or
Take This Test Online! a. As standard therapy for IE
4 AOA Category 2-A or 2-B credits. Online testing
b. When Pseudomonas is suspected
is available for current and archived issues. To
c. For coverage of HACEK organisms
receive your free CME credits for this issue, scan
d. As empiric therapy in prosthetic valve
the QR code below with your smartphone or visit
endocarditis < 1 year after valve placement
www.ebmedicine.net/E0920.
7. Treatment recommendations in the United
States for those with MRSA IE and intolerance
to vancomycin include:
a. Gentamicin IV
b. Fosfomycin IV
c. Daptomycin IV
d. Cefepime IV
1. The following organisms identified on blood
8. Indications for emergent thoracic surgical con-
cultures should raise suspicion for IE:
sultation include:
a. Streptococcus pneumoniae
a. Embolic cerebrovascular accident
b. Pseudomonas
b. Subacute presentations of IE in a stable
c. MRSA and Staphylococcus lugdunensis
patient
d. Corynebacterium
c. Any patient with prosthetic valve IE
d. Perivalvular abscess on echocardiography
2. The most common symptom present in the set-
ting of IE is:
9. Prophylaxis for IE should be administered
a. New murmurs
prior to certain procedures in patients with the
b. Embolic phenomenon
following risk factors:
c. Acute congestive heart failure
a. Prosthetic valves
d. Presence of fever
b. Intravenous drug users
c. Heart transplant patients
3. Development of intracardiac or perivalvular
d. All repaired congenital heart disease
abscess may be indicated by:
patients
a. Embolic phenomenon
b. Development of acute heart failure
10. Ischemic stroke in the setting of IE:
c. Presence of HACEK organisms in culture
a. Is a rare complication
d. Presence of prosthetic valves
b. Carries an increased risk of hemorrhagic
conversion when treated with systemic
4. Acceptable choices for initial evaluation of sus-
alteplase or endovascular intervention
pected IE include:
c. Presents with symptoms of large-vessel
a. 3-D echocardiography, as it has been shown
involvement
to outperform 2-D echocardiography
d. Is an indication for emergency surgery
b. POCUS or TTE, if TEE is unavailable,
followed by TEE as soon as possible
c. Bedside POCUS to rule out IE
d. If TTE is positive, it is not necessary to
arrange for a TEE

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Termination date: September 1, 2023.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical
Education (ACCME) to provide continuing medical education for physicians. This activity has been
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anagement ACCME.
Num
Volume 22,

Ventilator M s in the
Author al Center;
Medic
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Ryan Pedig al Student Education, Geffen Schoo

nt Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA
ine, David

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Directo sor of Emerg

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Assistant ProfesUCLA, Los Angeles,

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Emergency
Peer Review P, FNCS y,
MD, FACE ine and Neurosurger
Knight, IV,
William A. of Emergency
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Program;
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options avai al settings Charl es Stewa
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variety of sing optim Emergency Program

Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 2 Infectious Disease
the er Medicine
There are a ions on choo erstanding Master Disast
cian, and decis circumstances. Und patient , see “CME
Information”
gency clini cal can improve ing this activity
on the clini management and ventilation Prior to beginn on the back page.
will depend ventilator
CME credits.
in enat ion
latest litera
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optimal oxyg lung injury.
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outc the potential t appropriate ventilato ent-
and reducing mos patients pres
reviews the ated adult
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ACEP Accreditation: Emergency Medicine Practice is approved by the American College of Emergency
da-
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for a varie department, making vent
emergency ventilated
patient and
ID-19-associ-
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tions on mon nts. An update on man
lator adjustme iratory distress synd
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Internation
al Editors Physicians for 48 hours of ACEP Category I credit per annual subscription.
ated acute r, MD e, on, MD
Robert Schille ent of Family Medicin Peter Camer Alfred
Director, The Centre,
Chair, Departm Senior Academic

AAFP Accreditation: This Enduring Material activity, Emergency Medicine Practice, has been
e, MD Medical Center; and Trauma
Eric Legom e, Mount Beth Israel Emergency ity, Melbou
rne,
MD, MS, FACEP
,
Chair, Emerge
ncy Medicin Luke's; Medicine and Monash Univers
s, & Mount Sinai
St. Faculty, Family School of
Deborah Dierck Sinai West Affairs for Community
Health, Icahn
New York,
NY Australia
Department
of Academic Mount Sinai,
hief FACC Vice Chair, Mount Sinai Medicine at MD
Editor-In-C, MD, FACEP Professor
and Chair,
University
of Medicine, Andrea Duca, Physician,
Emergency of FACEP Emergency

reviewed and is acceptable for credit by the American Academy of Family Physicians. Term of
Medicine, , Icahn School York, NY Scott Silvers, MD, ncy Attending
Andy Jagoda Chair Emeritus, Emergency estern Medical Center, Health System Sinai, New Profess or of Emerge Papa Giovanni XXIII,
and e; Southw Mount te and le
Professor ncy Medicin Texas Medicine at Associa of Facilities FL
Ospeda
Italy
Department
of Emerge ncy Dallas, TX MD, MS Medicine, Chair Clinic, Jacksonville, Bergamo,
for Emerge Keith A. Marill, Department g, Mayo Peeters, MD
Director, Center ion and Research, MD Profess or, Plannin e Y.G. Physician,
Daniel J. Egan, Vice Chair
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Emergency
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approval begins 07/01/2019. Term of approval is for one year from this date. Physicians should
e at Mount Professor, ncy Medicin husetts Slovis, MD, Attending Almere,
Icahn School
of Medicin Associate of Emerge
ncy of Emerge Corey M. Chair, Departm
ent g Hospital,
York, NY Department , Massac
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Sinai, New Education, University ands
Columbia General Hospita of Emergency e, TN The Netherl
hief Medicine, of Physicians
and l Center, Nashvill dez, MD,
FIFEM
Editor-In-C Vagelos College York, NY Mills, MD,
FACEP University Medica Edgardo Menen
ncy
Associate MD, FACEP New Angela M. Department MD Professor
in Medicin
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claim only the credit commensurate with the extent of their participation in the activity. Approved for
Surgeons, Professor
and Chair, Columbia Ron M. Walls, COO, Department
of
of EM, Churrucity,
Kaushal Shah, Vice Chair Medicine, e; Director
Professor, lle Elie, MD Emergency Professor
and
Brigham and l Medicin l of Buenos Aires Univers
Associate ent of
Marie- Carme Departm ent of College of
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for Educat Weill Cornell Associate e & Critical & Surgeons, Hospital,
Medicine, NY ncy Medicin Physicians Women's Buenos Aires,
Emergency e, New York, of Emerge ity of Florida , Boston , MA sarntik ul, MD
Medicin e, Univers Rojana
School of FL NY School Dhanadol Emergency

4 AAFP Prescribed credits.

Care Medicin Gainesville, MA, MD, rs Physician,
Medicine, Pollack Jr., Attending
rial Board College of Charles V. , FAHA, FESC
Critic al Care Edito e, King Chulalo
ngkorn
of
Edito MD, FACEP ent of Genes, MD,
PhD
of FACEP, FAAEM for MD, FACEP
, Medicin
Hospital; FacultyUniversity,
Saadia Akhtar, Nicholas Department & Senior Advisor Knight IV, Memorial
Professor,
Departm Professor, Professor y Research
and William A. Chulalongkorn
Associate Associate
Dean Associate Icahn School ncy Medicine,
Medicine, Medicine, InterdisciplinarDepartment of FNCS of Emerge
Emergency Education, Emergency Sinai, New l Professor Medical Thailand
te Medical e at Mount Clinical Trials, Sidney Kimmen Associate Neurosurgery, MPH
Medicine, Thomas, MD,

AOA Accreditation: Emergency Medicine Practice is eligible for 4 Category 2-A or 2-B credit hours
for Gradua of Medicin Emergency Medicine and
r, Emergency of Thomas
Jefferso
Advanced
Practice Stephen H. Chair, Emergency
Program Directo cy, Mount Sinai York, NY Medical College lphia, PA Director, EM Medical &
FACEP ; Associate Professor l Corp.,
Medicine ResidenYork, NY Gibbs, MD, University,
Philade
Provider Program University Hamad Medica
Michael A. Department cience ICU, Medicine, , Qatar;
Beth Israel,
New and Chair, MPH
Director, Neuros Medical College
Professor e, Carolinas Ali S. Raja,
MD, MBA,
Emergency ati, Cincinn
ati, OH Weill Cornell hief,
Brady, MD ncy Medicin ity of North Vice Chair, of Cincinn Physician-in-C
e of Emerge Executive
l Emergency l Hospital,

per issue by the American Osteopathic Association.

William J. ncy Medicin l Center, Univers Chapel husetts Genera rt, MD, FCCM e; Genera
or of Emerge Director, Medica of Medicin
e,
Medicin e, Massac or of Scott D. Weinga Medicin Hamad
Profess
e; Medical Carolina School te Profess gy, Emergency Doha, Qatar
and Medicin UVA Hospital; Associa e and Radiolo Professor of Care, Stony
Brook
Management, Medical Hill, NC ncy Medicin , MA EM Critical
Emergency onal FACEP Emerge l School , Boston Chief, NY
Edin Zelihic,
MD ncy
Operati Godwin, MD, Stony Brook, ent of Emerge l,
Medical Center; rle County Fire Steven A. Department Harvard Medica , Medicine,
Head, Departm
Director, Albematesville, VA Professor
and Chair,
e, Assistant , MD, FACEP rs e, Leopold
ina Hospita
L. Rogers Edito Medicin
Medicin Robert
Research y

Needs Assessment: The need for this educational activity was determined by a survey of medical
Rescue, Charlot of Emerge
ncy ion, German
MD ion Educat FAAEM, FACP or of Emergency r, PharmD,
BCPS Schweinfurt,
Brown III, Dean, SimulatFlorida COM- Assistant
Profess
ity of Aimee MishleMedicine Pharmacist,
Calvin A. Compliance, University
of The Univers
Physician Jacksonville,
FL
Medicine, Medicine, Emergency
Director of Care
School of r, PGY2 EM
and Urgent ncy Jacksonville, Maryland Program Directo cy, Valleywise
Credentialing ent of Emerge ushe, MD
MBA
MD cy Residen
Departm 's Habbo ncy re,

staff, including the editorial board of this publication; review of morbidity and mortality data from the
s, Baltimo Pharma
Service
Brigham and
Women Joseph or of Emerge , AZ
Medicine, Assistant Profess ngone and tti, MD, FACEP Health, Phoenix
, MA NYU/La Alfred Sacche Professor, Toscano,
MD
Hospital, Boston Medicine, New York, e,
l Centers, Assistant Clinical ncy Medicin Joseph D. ent of Emerge
ncy
ux, MD Bellevue Medica LLC Department
of Emerge
Chief, DepartmRamon Regional
Peter DeBlie Clinical Medicine, NY; CEO,
MD Aware n University, San
of of Thomas Jefferso Medicine, San Ramon
, CA

CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Professor ity School PA
State Univers nce Officer, Philadelphia, Medical Center,
Louisiana
Chief Experie New
Medicine;
Medical Center,
University
Orleans, LA

Supraventricular August 2020 Target Audience: This enduring material is designed for emergency medicine physicians, physician
Tachydysrhythmias in the Authors
Volume 22, Number 8
Delbert D. Clark, DO, FAAEM
assistants, nurse practitioners, and residents.
Emergency Department Staff Physician, Emergency
Medicine Department, Naval

Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-
Camp Pendleton, Oceanside, Hospital
CA
Morgan McGuire, MD
Staff Physician, Emergency
Medicine Department, Naval
Abstract Center San Diego, San Diego, Medical

making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most
CA
Mary Jones, MD
Staff Physician, Emergency
Diagnosing and treating supraventri Medicine Department, Naval
Center San Diego, San Diego, Medical
cular tachycardias is rou- CA

critical presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
tine in emergency medicine, Heather Bruner, MD, FAAEM
and new strategies can improve
efficiency and outcomes. This Assistant Clinical Professor
review provides an overview California San Diego, San
of Palliative Medicine, University
of
supraventricular tachycardia of Diego, CA
s, their pathophysiology, differ- David Bruner, MD, FAAEM
ential diagnosis, and electrocardi

Objectives: Upon completion of this article, you should be able to: (1) identify at-risk groups and
ographic features. Clinical Staff Physician, Department
of Emergency Medicine, Scripps
evidence guiding contempora Mercy Hospital, San Diego,
ry practice is determined largely CA
by multiple observational studies, Peer Reviewers
with
controlled trials. Current prehospital few randomized
ment management strategies
and calcium channel blockers
and emergency depart-
beyond the use of adenosine
are addressed. Diagnostic and
James E. Morris, MD, MPH
Program Director, Emergency
ate Professor, Department
Medicine Residency; Clinical
of Surgery, Division of Emergency
Associ-
common presentations of infective endocarditis (IE); (2) order appropriate diagnostic studies to
evaluate for IE; (3) prescribe appropriate medical treatment for IE; and (4) recognize circumstances
cine, Texas Tech University Medi-
therapeutic recommendations Health Sciences Center, Lubbock,
are provided, based on the Jennifer White, MD TX
available evidence. best
Clinical Associate Professor,
Associate Medical Director,
Program Director, Sidney Kimmel Assistant

when surgical management is indicated.

Prior to beginning this activity, College of Medicine at Thomas
see “CME Information” on Jefferson University Hospital,
the back page. Philadelphia, PA
Editor-In-Chi ef Deborah Diercks, MD, MS,
Andy Jagoda, MD, FACEP FACEP, Eric Legome, MD
FACC Robert Schiller, MD
Professor and Chair Emeritus, Chair, Emergency Medicine,
Professor and Chair, Department Mount International Editors

Department of Emergency
Medicine;
Director, Center for Emergency
Medicine Education and Research,
Icahn School of Medicine
at Mount
Sinai, New York, NY
of Sinai West & Mount Sinai St.
Emergency Medicine, University
of Vice Chair, Academic Affairs
Texas Southwestern Medical
Center, Emergency Medicine, Mount
Dallas, TX
Health System, Icahn School
Daniel J. Egan, MD Medicine at Mount Sinai, New
Chair, Department of Family
Luke's;
Beth Israel Medical Center;
for Senior
Faculty, Family Medicine and
Sinai Community Health, Icahn School
of Medicine at Mount Sinai, New
Discussion of Investigational Information: As part of the journal, faculty may be presenting inves-
Medicine,
Peter Cameron, MD
Academic Director, The Alfred
of Emergency and Trauma Centre,
York, NY Monash University, Melbourne,

Associate Editor-In-Chief
Kaushal Shah, MD, FACEP
Associate Professor, Vice
Chair
Associate Professor, Vice
Chair of
Education, Department of
Emergency
Medicine, Columbia University
Vagelos College of Physicians
and
York, NY
Keith A. Marill, MD, MS
Associate Professor, Department
of Emergency Medicine, Harvard
Medical School, Massachusetts
Scott Silvers, MD, FACEP
Associate Professor of Emergency
Medicine, Chair of Facilities
and
Planning, Mayo Clinic, Jacksonville, FL
tigational information about pharmaceutical products that is outside Food and Drug Administration
Australia
Andrea Duca, MD
Attending Emergency Physician,
Ospedale Papa Giovanni XXIII,

approved labeling. Information presented as part of this activity is intended solely as continuing
for Education, Department Surgeons, New York, NY General Hospital, Boston, Bergamo, Italy
of MA Corey M. Slovis, MD, FACP,
Emergency Medicine, Weill FACEP
Cornell Marie-Carmelle Elie, MD Angela M. Mills, MD, FACEP Professor and Chair, Department Suzanne Y.G. Peeters, MD
School of Medicine, New York,
NY Associate Professor, Department Professor and Chair, Department of Emergency Medicine, Vanderbilt Attending Emergency Physician,
Editorial Board of Emergency Medicine & of Emergency Medicine, Columbia University Medical Center, Nashville, Flevo Teaching Hospital, Almere,
Critical TN

Saadia Akhtar, MD, FACEP
Associate Professor, Department
Emergency Medicine, Associate
of
Dean Nicholas Genes, MD, PhD
for Graduate Medical Education,
Program Director, Emergency
Medicine Residency, Mount
medical education and is not intended to promote off-label use of any pharmaceutical product.
Care Medicine, University University Vagelos College The Netherlands
of Florida of Ron M. Walls, MD
College of Medicine, Gainesville, Physicians & Surgeons, New
FL York, Professor and COO, Department Edgardo Menendez, MD,
NY Emergency Medicine, Brigham of FIFEM
Women's Hospital, Harvard
and Professor in Medicine and
Emergency
Associate Professor, Department Charles V. Pollack Jr., MA, Medicine; Director of EM, Churruca
of MD, Medical
Emergency Medicine, Icahn FACEP, FAAEM, FAHA, FACC, School, Boston, MA Hospital of Buenos Aires University,
School

Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance, independence,

Sinai
Beth Israel, New York, NY
William J. Brady, MD
Professor of Emergency Medicine
and Medicine; Medical Director,
of Medicine at Mount Sinai,
York, NY
New
Michael A. Gibbs, MD, FACEP
Professor and Chair, Department
of Emergency Medicine, Carolinas
FESC Buenos Aires, Argentina
Clinician-Scientist, Department Critical Care Editors
of Dhanadol Rojanasarntikul,
Emergency Medicine, University MD
William A. Knight IV, MD, Attending Physician, Emergency
of Mississippi School of Medicine, FACEP,
FNCS Medicine, King Chulalongkorn
Jackson MS Associate Professor of Emergency
Memorial Hospital; Faculty

Emergency Management,
UVA
Medical Center; Operational
Medical
Director, Albemarle County
Fire
Rescue, Charlottesville, VA
Steven A. Godwin, MD, FACEP
Medical Center, University Ali S. Raja, MD, MBA, MPH
of North
Carolina School of Medicine, Executive Vice Chair, Emergency
Chapel Medicine, Massachusetts
Hill, NC
Hospital; Associate Professor
transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating
of
Medicine and Neurosurgery, Medical Medicine, Chulalongkorn University,
Director, EM Advanced Practice
Thailand
Provider Program; Associate
General Medical Stephen H. Thomas,
Director, Neuroscience ICU, MD, MPH
University
of Professor & Chair, Emergency

Calvin A. Brown III, MD
Director of Physician Compliance,
Credentialing and Urgent Care
Services, Department of Emergency
Emergency Medicine and
Professor and Chair, Department Radiology,
Harvard Medical School, Boston,
of Emergency Medicine, Assistant MA Scott D. Weingart, MD, FCCM
Robert L. Rogers, MD, FACEP,
Dean, Simulation Education,
FAAEM, FACP
University of Florida COM-
of Cincinnati, Cincinnati, OH
Professor of Emergency Medicine;
Chief, EM Critical Care, Stony
Brook
Medicine, Stony Brook, NY
in the planning or implementation of a sponsored activity are expected to disclose to the audience
Medicine, Hamad Medical Corp.,
Weill Cornell Medical College,
Qatar;
Emergency Physician-in-Chief
,
Hamad General Hospital,

Medicine, Brigham and Women's
Hospital, Boston, MA
Joseph Habboushe, MD
Peter DeBlieux, MD
Professor of Clinical Medicine,
any relevant financial relationships and to assist in resolving any conflict of interest that may arise from
Jacksonville, Jacksonville, Assistant Professor of Emergency Doha, Qatar
FL Medicine, The University
of
MBA Maryland School of Medicine, Research Editors Edin Zelihic, MD
Assistant Professor of Emergency Baltimore, MD Head, Department of Emergency
Medicine, NYU/Langone and Aimee Mishler, PharmD,
BCPS Medicine, Leopoldina Hospital,
Alfred Sacchetti, MD, FACEP Emergency Medicine Pharmacist,

the relationship. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for
Louisiana State University Bellevue Medical Centers, Schweinfurt, Germany
School of New York, Assistant Program Director, PGY2 EM
Medicine; Chief Experience NY; CEO, MD Aware LLC Clinical Professor,
Officer, Department of Emergency Pharmacy Residency, Valleywise
University Medical Center, Medicine,
New Thomas Jefferson University, Health, Phoenix, AZ
Orleans, LA
Philadelphia, PA Joseph D. Toscano, MD

this CME activity were asked to complete a full disclosure statement. The information received is
Chief, Department of Emergency
Medicine, San Ramon Regional
Medical Center, San Ramon,
CA

as follows: Dr. Hackett, Dr. Stuart, Dr. Harper-Kirksey, Dr. Leibner, Dr. Mishler, Dr. Toscano, Dr.
Jagoda, and their related parties report no relevant financial interest or other relationship with
the manufacturer(s) of any commercial product(s) discussed in this educational presentation.

In upcoming issues of Commercial Support: This issue of Emergency Medicine Practice did not receive any commercial
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