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PATIENT PRESENTATION

Chief Complaint

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.

Student Work-Up

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Missing Information?

Evaluate:

Patient Database

Drug Therapy Problems

Care Plan (by Problem)

TARGETED QUESTIONS

  1. What are the risk factors for this patient having enterococci as the causative organism?

    Hint: See Table 78-2 and Etiology in PPP

  2. 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

  3. 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

  4. 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

  5. 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

Follow up – Is the end date of therapy known? Explain rationale for how this is determined and/or monitored.

Hint: See Outcome Evaluation in PPP

CASE SUMMARY

Global Perspective

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.

Key References

1. +
Dahl  A, Fowler  VG, Miro  JM, Bruun  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.
2. +
Ahn  Y, Joo  L, Suh  CH, Kim  S, Shim  WH, Kim  SJ, Lee  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. 
3. +
Marino  A, Munafo  A, Zagami  A, ...

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