Altered mental status, vomiting and diarrhea
History of Present Illness
Patient was brought into the emergency department by family after becoming altered and lethargic. The patient was found to be septic with suspected source of urinary tract or intra-abdominal infection and subsequent microbiology and echocardiography revealed Enterococcus faecalis mitral valve endocarditis.
Drug Therapy Problems
Care Plan (by Problem)
What are the risk factors for this patient having enterococci as the causative organism?
Hint: See Table 78-2 and Etiology in PPP
What signs/symptoms are consistent with enterococcal endocarditis in this patient? How are each classified per Duke criteria?
Hint: See Table 78-3, Table 78-4, and Clinical Presentation and Diagnosis in PPP. See reference #1 and #2 below
Why was daptomycin initiated upon microbiology reporting presumptive enterococcus? Was the daptomycin dose appropriate for the indication?
Hint: See Treatment and Table 78-7 in PPP
Is vancomycin the antibiotic that should be used for the remainder of therapy or is another regimen preferred?
Hint: See Table 78-7 and Treatment in PPP. See reference #3 below
Based on microbiology susceptibilities, is there an appropriate oral regimen that the patient can be discharged to complete therapy? Is there a specific physician(s) that should determine this?
Hint: See Treatment in PPP and reference #4-#6 below
Follow up – Is the end date of therapy known? Explain rationale for how this is determined and/or monitored.
Infective Endocarditis (IE) can often be overlooked in the emergency department given variability in patient presentation. Prompt diagnosis and management is needed to minimize the potential numerous complications and high mortality rates. Enterococcal endocarditis continues to evolve in increasing importance. Treatment can be complex based on identified species, resistance, surgical requirements, drug efficacy and toxicity. Management typically requires multiple medical specialties to optimize the patient’s outcome.
NE. Sign of the Times: Updating Infective Endocarditis Diagnostic Criteria to Recognize Enterococcus faecalis as a Typical Endocarditis Bacterium. Clin Infect Dis. 2022 Mar 9:ciac181. doi: 10.1093/cid/ciac181. Epub ahead of print.
SA. Impact of Brain MRI on the Diagnosis of Infective Endocarditis and Treatment Decisions: Systematic Review and Meta-Analysis. AJR Am J Roentgenol. 2022 Jun;218(6):958–968. doi: 10.2214/AJR.21.26896. Epub 2022 Jan 19.