Your approach to fever + murmur in a pt w/ IVDA hx

[pinipig523]

What's your approach for your presumptive endocarditis patient?

Do you subscribe to:

1. If febrile but stable, draw cultures x3 over a certain period of time, admit for echo, hold antibiotics?

Or

2. Give antibiotics (and what are your choices) and admit for culture and echo?

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[Rendar5]

4 cultures, and start the antibx. endocarditis has complications and I'd hate to look like I let one happen by not giving antibx while awaiting culture ID. I'd rather let it look like an unfortunate consequence despite my doing everything I could.

 

[WilcoWorld]

1st I look to see if this murmur has been previously documented.

If the patient has had this same murmur in the past, and I dont' see other signs of endocarditis (yes, I look at the palms and fingernails) I'll hold on the ABX.

If it's new, if I see evidence of septic emboli (brian/lungs/extremities) or if the patient looks sick - I'll pull out the big guns immediately after the cultures.

 

[Hamhock]

Do you folks even use the murmur?

I don't trust my physical exam or the documentation of others enough to know if there is a new murmur or if the current murmur is different than a previously documented murmur.

 

[Hamhock]

Also:

Do you guys admit all of these folks? That seems to be the culture at my current shop, but I don't see why in a reliable person who is otherwise well-appearing that the cultures can't be drawn, IV abx drawn and the patient sent home. The ECHO can be obtained in the morning.

Anyone do it this way?

HH

 

[WilcoWorld]

Do you folks even use the murmur?

I don't trust my physical exam or the documentation of others enough to know if there is a new murmur or if the current murmur is different than a previously documented murmur.

I trust my exam when the circumstances are good, and I'll trust documentation if it's clear.

So, if a Cardiology chart reads "3/6 mid systolic murmur loudest at the R upper sternal border with radiation to the neck" (or better yet, there's an old echo) then I'll believe it. But if Ortho's chart reads "NCAT, CTAB, no W/R/R, RRR, no M/R/G, S/NT/ND w/ NABS" then no, I'm not going to conclude that the murmur MUST be new. Also, if a chart reads "faint murmur" without other description then I'm also not going to conclude that this is indeed the same murmur.

 

[Flopotomist]

Also:

Do you guys admit all of these folks? That seems to be the culture at my current shop, but I don't see why in a reliable person who is otherwise well-appearing that the cultures can't be drawn, IV abx drawn and the patient sent home. The ECHO can be obtained in the morning.

Anyone do it this way?

HH

Don't you think that an IV drug user is difficult to define as "reliable" enough to return and obtain an echo? If they have a fever, are an IVDU, and have a murmur... I can't imagine NOT admitting that person. Seems super risky to me.

 

[pinipig523]

I think they need to be admitted as r/o endocarditis.

I trust my exam enough to hear a murmur.

You guys are right about if they have signs of instability or signs of complications then starting big guns is good. But I think I read that the new guidelines is if there are no signs of complications (sepsis, emboli, etc), then no antibiotics and to have your antibiotic choice be guided by cultures.

No one does this?

 

[VienneseWaltz]

At my hospital, shooter with a fever = endocarditis until proven otherwise, so they get Cx x 3, IV abx, and admission. Our patients aren't reliable enough to provide a valid address and working telephone number, much less return for an echo the following day. Of course, half of them sign out AMA before the cultures come back...

 

[EctopicFetus]

At my hospital, shooter with a fever = endocarditis until proven otherwise, so they get Cx x 3, IV abx, and admission. Our patients aren't reliable enough to provide a valid address and working telephone number, much less return for an echo the following day. Of course, half of them sign out AMA before the cultures come back...

My practice as well. Not a common problem where I am at. As stated above IVDU imo means not reliable.

 

[blackavar]

Where I work, generally the approach is shooter with a fever gets admitted as r/o endocarditis even if they have no other signs or symptoms unless you have a VERY clear alternative source. This is because generally speaking, out patient population is very unreliable.

Then about six months ago, I saw this young guy, 23, came in with a fever, 101...It all looked and sounded very viral syndrome, labs and cxr looked fine. Then it came to light that he had a hx of IVDU, had shot up a total of twice about six months ago, but didn't shoot up anymore . No murmur, no other signs of endocarditis....Talked it over with the attending, and at the end of the day, we drew blood cultures x 3, no abx, and sent him home (after his fever resolved w some tylenol) making sure we had a reliable phone number. At the end of the day, we weren't quite sure how long the shooter history carries over, but we made a call.

It made me very nervous to send him home and I was waiting to get an M&M call, but every time I've looked him up, he hasn't come back to our place yet...

 

[deleted65604]

http://journals.lww.com/em-news/Fulltext/2002/05000/Admit_All_Febrile_IV_Drug_Users.20.aspx

I think I heard about the above article (discussion about other articles) from EMRAP.

Febrile IV drug abusers have over a 40% incidence of bacteremia...

Over 40%!

That is higher than a neutropenic patient.

Febrile IV drug abusers should be a slam-dunk admission, no questions asked.

 

[EctopicFetus]

Where I work, generally the approach is shooter with a fever gets admitted as r/o endocarditis even if they have no other signs or symptoms unless you have a VERY clear alternative source. This is because generally speaking, out patient population is very unreliable.

Then about six months ago, I saw this young guy, 23, came in with a fever, 101...It all looked and sounded very viral syndrome, labs and cxr looked fine. Then it came to light that he had a hx of IVDU, had shot up a total of twice about six months ago, but didn't shoot up anymore . No murmur, no other signs of endocarditis....Talked it over with the attending, and at the end of the day, we drew blood cultures x 3, no abx, and sent him home (after his fever resolved w some tylenol) making sure we had a reliable phone number. At the end of the day, we weren't quite sure how long the shooter history carries over, but we made a call.

It made me very nervous to send him home and I was waiting to get an M&M call, but every time I've looked him up, he hasn't come back to our place yet...

After they go to the morgue they typically dont have any more ED visits.. im kidding of ccourse.. things like this make our jobs hard..helping those who dont want help.