Mythbusting

Delayed endocarditis diagnosis? The patient can have as many diseases as they please.

This is exploratory look at patients diagnosed with endocarditis at admission versus those with a delayed diagnosis. Granted, this is not a US study, and over a 9 year period at a single center, but does provide an interesting look at how we manage these patients….

They looked at those with an admitting diagnosis of endocarditis that eventually went on to have this as a final diagnosis as well (54 patients), and compared them to patients with a non-endocarditis initial diagnosis to those who eventually had a final diagnosis of endocarditis (64 patients).

Even in the two slam-dunk groups- the IVDA & those with valve replacements, the diagnosis was delayed in the 38% of the time for those with a history of IVDA. For those with a valve replacement there were also significant delays with native valves delayed 63% of time, vs prosthetics delayed 24% of time…. Are we really bad at diagnosing this? Let’s peel back this onion.

Cases were placed into 3 categories: (1) complications of endocarditis, but not immediately recognized as endocarditis – 70% of cases (2) infectious disease unrelated to endocarditis (14% of cases) – ie, hepatitis (3) inconsistent non-infectious disease (16% of cases).

Of those in the “complications” category, only 10% were unlikely to be dosed with antibiotics – they were admitted for “stroke” or CHF/ pulmonary edema. This is clearly understandable. Do we need STAT echos for the pulmonary edema patient? Or for the stroke? STAT echo’s right away for all of these patients – or perhaps routinely ordering them on all CHF / stroke patients may prove more costly and harmful than its worth.

The author’s make the argument that there is significant mortality involved with an initial missed diagnosis in their cohort- 75% vs 25% (!!!). I’m not certain these represent a complete whiff on the part of the treating clinicians. Rather, I would argue that these patients had their complications recognized and treated appropriately (ie, the pneumonia and UTI’s got antibiotics initially), and that these patients were likely sicker to begin with and that is why they had all the additional complications and higher mortality.

While perhaps a heightened awareness of valve replacement patients, and/or awareness of the disease process may help, but sadly, when you are looking for a needle in the haystack, having a 100% sensitive and specific diagnostic algorithm is unreasonable. When can certainly do better, but how much better without causing harms to the rest of the department remains debatable.

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