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Continue IV vancomycin and gentamicin
14%
5/37
Switch to oral penicillin V
41%
15/37
Switch to oral amoxicillin/clavulanate
Stop vancomycin and continue IV gentamicin
3%
1/37
Switch to IV ceftriaxone
24%
9/37
Select Answer to see Preferred Response
Patients with subacute bacterial endocarditis (SBE) with Streptococcus viridans highly susceptible to penicillin should be treated with IV penicillin G or IV ceftriaxone, based on American Heart Association recommendations. Transient bacteremia from dental work can cause seeding of a pre-existing abnormal valve. Abnormal valves cause turbulent flow, which erodes the endocardium, thereby predisposing the valve to bacterial colonization and endocarditis. Patients with SBE present with prolonged intermittent low-grade fever and progressive fatigue. Streptococcus viridans is the most common microbe involved in native valvular infections and should be treated with intravenous penicillin or ceftriaxone for four weeks when susceptible. Pierce et al. review the treatment of infective endocarditis. Antibiotic treatment of infectious endocarditis depends on whether the involved valve is native or prosthetic, the causative microorganism, and its antibiotic susceptibilities. Common blood culture isolates include Staphylococcus aureus, Streptococcus viridans, enterococci, and coagulase-negative staphylococci. Hoen and Duval also discuss the treatment of infective endocarditis. Antibiotic treatment should be started immediately after drawing two to three blood cultures. An aminopenicillin with beta-lactam inhibitor should be given empirically in combination with gentamicin. Patients with cerebral embolic events and large, mobile valve vegetations should undergo urgent valve surgery. The antibiotic regimen should be narrowed after blood and tissue cultures identify the microorganism. Figure A shows an echocardiogram of a mitral valve with subacute bacterial endocarditis. Incorrect Answers: Answer 1: The antibiotic coverage should be narrowed once the results of cultures and sensitivities are known. Answers 2 and 3: Oral antibiotics are not used to treat endocarditis. Answer 4: IV aminoglycosides are not used as monotherapy for endocarditis.
4.9
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