Fever, new murmur, emboli, splinters; IVDU / prosthetic valve
ABCDE
Resuscitate if septic; 3 cultures then empirical antibiotics; assess for heart failure/emboli.
First: 3 blood cultures (move clock) → start antibiotics after the 3rd (don't wait on echo/culture results)
Empiric: Vancomycin + Gentamicin
Native valve, sensitive Staph → oxacillin/nafcillin (or cefazolin) ×4 wk; + echo/TEE for vegetations
Prophylaxis (amoxicillin before dental) ONLY for: prosthetic valve / prior IE / certain congenital heart disease
Order set
- 3 sets blood cultures
- Echo (TTE→TEE)
- FBC, CRP, U&E
- ECG (conduction)
Criteria
AdmitAll
ICUHeart failure, emboli, conduction abnormality
DischargeAfebrile, cultures cleared, IV course defined, surgical decision made
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- Heart failure
- Embolic events
- New AV block (abscess)
Differentials
- Sepsis other source
- Atrial myxoma
- Marantic endocarditis
Common mistakes
- Single culture set
- Delaying antibiotics after cultures
- Wrong prophylaxis indication
- Gentamicin NOT used for staphylococcal native-valve IE (nephrotoxicity; synergy gent reserved for selected enterococcal/streptococcal cases — ESC 2023)
Disposition & follow-up
Empirical then targeted IV antibiotics; surgery for complications.
Discharge package
MedicationsComplete IV antibiotic course
Follow-upCardiology/ID; repeat echo; dental review
Vaccination—
LifestyleDental hygiene; prophylaxis only for high-risk
Warning symptomsFever, breathlessness, embolic symptoms
💊 Treatment detail — doses & preparation
Vancomycin IVglycopeptide
DoseLoad 25–30 mg/kg (critically ill), then 15–20 mg/kg q8–12h by levels (AUC 400–600)
PreparationDilute to ≤5 mg/mL in NS/D5W; infuse ≥60 min per 500 mg (red-man if fast)
MonitorTrough/AUC before 3rd–4th dose, creatinine, ototoxicity
Gentamicinaminoglycoside
DoseEndocarditis synergy: 1 mg/kg IV q8–12h per protocol; gram-neg sepsis 5–7 mg/kg OD
PreparationDilute in 50–100 mL NS over 30 min
MonitorPeak/trough levels, creatinine, hearing/balance
Ceftriaxone3rd-gen cephalosporin
Dose2 g IV OD (meningitis 2 g q12h); gonorrhoea 500 mg–1 g IM once
PreparationIV: 2 g in 50–100 mL NS over 30 min; IM: reconstitute with lidocaine 1%
MonitorBiliary sludging; avoid with calcium-containing IV fluids in same line
Surgery triggersdefinitive
DoseValve surgery for: heart failure, uncontrolled infection, large vegetations with emboli
PreparationCardiothoracic review early
MonitorEcho response, inflammatory markers
📖 ESC 2023 / AHA 2021 Infective Endocarditis (Duke-ISCVID 2023 criteria)Reviewed July 2026