Infective EndocarditisInfective Endocarditis

Shehla P.Islam, M.D.Shehla P.Islam, M.D.

Division of Infectious Diseases Division of Infectious Diseases University of Florida University of Florida

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EpidemiologyEpidemiology Pathogenesis & Antibiotic prophylaxisPathogenesis & Antibiotic prophylaxis Clinical ManifestationsClinical Manifestations Diagnosis (TEE & Modified Duke Criteria)Diagnosis (TEE & Modified Duke Criteria) ComplicationsComplications Treatment (emphasis on early surgery)Treatment (emphasis on early surgery)

CaseCase At midnight on July 2, your first night on call as an intern, At midnight on July 2, your first night on call as an intern,

you’ve just admitted 5 patients and are cross-covering for you’ve just admitted 5 patients and are cross-covering for your co-intern. You got a call from the micro lab. One of your co-intern. You got a call from the micro lab. One of the patients your colleague admitted earlier that day, one the patients your colleague admitted earlier that day, one set of the blood cultures is positive, growing gram positive set of the blood cultures is positive, growing gram positive cocci.cocci.

The patient is a 40 y.o. female with a history of asthma. The patient is a 40 y.o. female with a history of asthma. One day PTA, she was seen in the ER with several days of One day PTA, she was seen in the ER with several days of low grade fevers, and the initial work up was unrevealing. low grade fevers, and the initial work up was unrevealing. Blood cultures were drawn and she was sent home. She Blood cultures were drawn and she was sent home. She came back with persistent low grade fevers, and now has came back with persistent low grade fevers, and now has pleuritic chest pain and some shortness of breath.pleuritic chest pain and some shortness of breath.

Her admission WBC was 10.2 with a left shift, CXR showed Her admission WBC was 10.2 with a left shift, CXR showed small left pleural effusionsmall left pleural effusion

What would you do at this time?What would you do at this time?1. This is bacterial endocarditis; I’d start her on 1. This is bacterial endocarditis; I’d start her on

vancomycin STATvancomycin STAT

2. draw one more set of blood cultures to be sure, and 2. draw one more set of blood cultures to be sure, and start her on vancomycinstart her on vancomycin

3. draw 2 more sets of blood cultures, and start her on 3. draw 2 more sets of blood cultures, and start her on vancomycinvancomycin

4. could be a contaminant; I’d draw 2 more sets of blood 4. could be a contaminant; I’d draw 2 more sets of blood cultures and hold off on abxcultures and hold off on abx

5. it’s probably a contaminant (coag negative staph); 5. it’s probably a contaminant (coag negative staph); hold off on abx, order tylenol STAT, and go back to hold off on abx, order tylenol STAT, and go back to bed bed

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EpidemiologyEpidemiology Pathogenesis & Antibiotic prophylaxisPathogenesis & Antibiotic prophylaxis Clinical ManifestationsClinical Manifestations Diagnosis (TEE & Modified Duke Criteria)Diagnosis (TEE & Modified Duke Criteria) ComplicationsComplications Treatment (emphasis on early surgery)Treatment (emphasis on early surgery)

EpidemiologyEpidemiology

>50% of case over age 50>50% of case over age 50 male:female 1.7:1male:female 1.7:1 Aortic valve and Mitral valve most commonAortic valve and Mitral valve most common

(age dependent) (age dependent) Tricuspid rarer (iv drug abusers) Tricuspid rarer (iv drug abusers) Pulmonary valve exceedingly rare Pulmonary valve exceedingly rare

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EpidemiologyEpidemiology PathogenesisPathogenesis Clinical ManifestationsClinical Manifestations Diagnosis (TEE & Modified Duke Criteria)Diagnosis (TEE & Modified Duke Criteria) ComplicationsComplications Treatment (emphasis on early surgery)Treatment (emphasis on early surgery)

PathogenesisPathogenesis Host factorsHost factors

– Nonbacterial thrombotic endocarditis Nonbacterial thrombotic endocarditis (NBTE)(NBTE)

– Venturi effectVenturi effect Bacterial factorsBacterial factors

– Bacterial adherenceBacterial adherence– Transient bacteremiaTransient bacteremia

““Vegetation”Vegetation”

Nonbacterial Thrombotic Endocarditis Nonbacterial Thrombotic Endocarditis (NBTE)(NBTE)

Damage to the endocardium results in the Damage to the endocardium results in the deposition of platelets, and fibrindeposition of platelets, and fibrin

Causes of endocardial damage include:Causes of endocardial damage include:1. Rheumatic heart disease (age 10-35)1. Rheumatic heart disease (age 10-35)2. Bicuspid Valve (age 50-60) 2. Bicuspid Valve (age 50-60) (Most common)(Most common)

3. Calcific Aortic Stenosis (age 60-70)3. Calcific Aortic Stenosis (age 60-70)4. Mitral Valve Prolapse (murmur present)4. Mitral Valve Prolapse (murmur present)5. Marfan’s Syndrome5. Marfan’s Syndrome

No risk factor in 38% No risk factor in 38% (J.Infect. 38:87-93, 1999)(J.Infect. 38:87-93, 1999)

PathogenesisPathogenesisVenturi effectVenturi effect

Pressure gradient required producing a high-Pressure gradient required producing a high-velocity jet stream. velocity jet stream.

The high flow results in a Venturi effect (a low The high flow results in a Venturi effect (a low pressure area adjacent to the area of high pressure area adjacent to the area of high flow) flow)

Bacteria to settle in this area of low pressure.Bacteria to settle in this area of low pressure. In mitral regurgitation on atrial side, in aortic regurgitation on In mitral regurgitation on atrial side, in aortic regurgitation on

aortic side aortic side

VenturiVenturi

Bacterial AdherenceBacterial Adherence

Accounts for the preponderance of certain Accounts for the preponderance of certain organismsorganisms

Adherence of oral streptococci to NBTE may Adherence of oral streptococci to NBTE may depend on the production of a complex depend on the production of a complex extracellular polysaccharide, dextran.extracellular polysaccharide, dextran.

S. aureus: ability to destroy normal valvesS. aureus: ability to destroy normal valves

Transient BacteremiaTransient Bacteremia

Procedure or actionProcedure or action DentalDental

Dental extraction Dental extraction Periodontal surgery Periodontal surgery Chewing gum Chewing gum Tooth brushing Tooth brushing Oral irrigation device Oral irrigation device

Upper airwayUpper airway Bronchoscopy Bronchoscopy Intubation Intubation

% + Blood Cultures% + Blood Cultures

18-8518-8532-8832-8815-5115-510-260-2627-5027-50

15151616

Transient Bacteremia (cont)Transient Bacteremia (cont) GastrointestinalGastrointestinal

Upper GI endosc. Upper GI endosc. Sigmoidoscopy Sigmoidoscopy Barium Enema Barium Enema Liver Bx percutan. Liver Bx percutan.

UrologicUrologic Urethral dilatation Urethral dilatation Urethral Catheter Urethral Catheter Cystoscopy Cystoscopy Transurethral Transurethral prostatectomy prostatectomy

8-128-120-9.50-9.511113-133-13

18-3318-33880-170-1712-4612-46

The VegetationThe Vegetation

Platelet fibrin complex provides a protective Platelet fibrin complex provides a protective environment. Phagocytes incapable of environment. Phagocytes incapable of entering, eliminating an important host entering, eliminating an important host defensedefense

Pathogenic bacteria often induce platelet Pathogenic bacteria often induce platelet aggregationaggregation

Colony counts in vegetations 10 Colony counts in vegetations 10 99-10 -10 1111 bacteria/g of tissuebacteria/g of tissue

Is Prophylaxis Useful?Is Prophylaxis Useful? Efficacy of prophylaxis has never been provenEfficacy of prophylaxis has never been proven

Risk of one dental procedure causing endocarditis = 1/400

To prove efficacy would need a huge study. Who would agree to be in the placebo group?

No relationship between bleeding during dental No relationship between bleeding during dental procedure and bacteremiaprocedure and bacteremia

Amoxacillin po 1 hr. before the procedure only for high Amoxacillin po 1 hr. before the procedure only for high risk patients risk patients – prosthetic materialprosthetic material– prior endocarditisprior endocarditis– congenital heart diseasecongenital heart disease

Use bacteriocidal abtibiotics – time it so that peak serum Use bacteriocidal abtibiotics – time it so that peak serum level is at the time of the procedurelevel is at the time of the procedure

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EpidemiologyEpidemiology Pathogenesis & Antibiotic prophylaxisPathogenesis & Antibiotic prophylaxis Clinical ManifestationsClinical Manifestations Diagnosis (TEE & Modified Duke Criteria)Diagnosis (TEE & Modified Duke Criteria) ComplicationsComplications Treatment (emphasis on early surgery)Treatment (emphasis on early surgery)

Case (back to the patient)Case (back to the patient) 40 yo female with low grade fevers and GPC

in blood You decided that you want to get more hx She tells you that 2 week prior to admission,

she had removed a splinter from her foot. Over the past week, she has low grade fevers, malaise, and generalized weakness, but no pulmonary/GI/GU Sx

Clinical ManifestationsClinical Manifestations

Incubation period usually < 2 wksIncubation period usually < 2 wks Time of onset of symptoms until Rx 4-5 wksTime of onset of symptoms until Rx 4-5 wks Hx: Fever 80%Hx: Fever 80% Fatigue Fatigue

History in Infective EndocarditisHistory in Infective Endocarditis

FeverFeverChillsChillsWeaknessWeaknessSweatsSweatsAnorexiaAnorexiaWeight lossWeight lossMalaiseMalaiseCoughCoughArthralgia/MyalgiaArthralgia/MyalgiaBack painBack pain

80%80%40%40%40%40%25%25%25%25%25%25%25%25%25%25%15%15%10%10%

Physical Findings in IEPhysical Findings in IE

FeverFeverHeart murmurHeart murmurEmbolic phenomenonEmbolic phenomenonSkin manifestationsSkin manifestations Oslers nodes Oslers nodes Splinters Splinters Petechiae Petechiae Janeway lesion Janeway lesionSplenomegallySplenomegallyClubbingClubbingRetinal lesionRetinal lesion

90%90% 85% 85%>50%>50% 18-50% 18-50% 10-23% 10-23% 15% 15% 20-40% 20-40% <10% <10% 20-57% 20-57% 12-52% 12-52% 2-10% 2-10%

CaseCase You decided to review her admission lab You decided to review her admission lab

valuesvalues– WBC 9.0WBC 9.0– Hct 30 (MCV 90)Hct 30 (MCV 90)– Cr 1.2Cr 1.2– ESR 95ESR 95

Q: WBC count is normal, this can’t be Q: WBC count is normal, this can’t be endocarditisendocarditis– 1. True1. True– 2. False2. False

Laboratory Findings in IELaboratory Findings in IE

Normochromic, Normocytic anemia (90%)Normochromic, Normocytic anemia (90%) WBC usually normal, can be increasedWBC usually normal, can be increased High ESR (90-100%)High ESR (90-100%) Positive Rheumatoid factor (50%)Positive Rheumatoid factor (50%) Hypergammaglobulinemia (20-30%)Hypergammaglobulinemia (20-30%)

(false positive lyme or VDRL serology)(false positive lyme or VDRL serology) Proteinuria (50-65%), hematuria (30-50%)Proteinuria (50-65%), hematuria (30-50%)

CaseCase The next day right before rounds, you got The next day right before rounds, you got

another call from the micro lab. Both sets of another call from the micro lab. Both sets of initial BCx turned out to be S. aureus, and the initial BCx turned out to be S. aureus, and the BCx you drew overnight (12 hours later from BCx you drew overnight (12 hours later from the initial BCx) are also postive, and is the initial BCx) are also postive, and is growing gram positive coccigrowing gram positive cocci

You presented the case to your medical You presented the case to your medical attending, and you’re asked:attending, and you’re asked:

What do you think the patient has? What do you think the patient has? (i.e. what is your diagnosis?)(i.e. what is your diagnosis?)

1. this is obviously S. aureus endocarditis1. this is obviously S. aureus endocarditis 2. she has S. aureus bacteremia, and 2. she has S. aureus bacteremia, and

possibly has endocarditispossibly has endocarditis 3. she has S. aureus bacteremia, but no 3. she has S. aureus bacteremia, but no

evidence of endocarditisevidence of endocarditis 4. hmmm, let me look up the Duke criteria, 4. hmmm, let me look up the Duke criteria,

and get back to you in an hourand get back to you in an hour 5. I’ll call ID consult and they’ll tell us the 5. I’ll call ID consult and they’ll tell us the

diagnosisdiagnosis

Quantitation of Bacteremia in IEQuantitation of Bacteremia in IE

Abscess

Endocarditis

Time (hrs)

Blood Cultures in IEBlood Cultures in IE Blood Cultures (15 min intervals)Blood Cultures (15 min intervals)

Yield 85-95% on 1st BC Yield 85-95% on 1st BC 95-100% on the 2nd 95-100% on the 2nd

Recommend 3 BC in the 1st 24 hrs. Recommend 3 BC in the 1st 24 hrs. Low level bacteremia, 100 bacteria/mlLow level bacteremia, 100 bacteria/ml

Draw at least 10 ml/BCDraw at least 10 ml/BC If HACEK group suspected hold 4 wks.If HACEK group suspected hold 4 wks. Prior antibiotics within 2 wks Prior antibiotics within 2 wks

lower sensitivitylower sensitivity

“Why are blood cultures so often false-negative, making it necessary that three be drawn?”

Only falsely negative if the patient has received antibiotics before blood cultures

What is your next step to confirm What is your next step to confirm the diagnosis of endocarditis?the diagnosis of endocarditis?

1. order EKG1. order EKG 2. draw more blood cultures2. draw more blood cultures 3. order TTE (transthoracic echo)3. order TTE (transthoracic echo) 4. order TEE (transesophageal echo)4. order TEE (transesophageal echo) 5. order both TTE and TEE5. order both TTE and TEE 6. call infectious disease consult6. call infectious disease consult 7. call cardiology consult7. call cardiology consult

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EpidemiologyEpidemiology Pathogenesis & Antibiotic prophylaxisPathogenesis & Antibiotic prophylaxis Clinical ManifestationsClinical Manifestations Diagnosis (TEE & Modified Duke Criteria)Diagnosis (TEE & Modified Duke Criteria) ComplicationsComplications Treatment (emphasis on early surgery)Treatment (emphasis on early surgery)

Cardiac Echo in IECardiac Echo in IE Transthoracic(TTE): sensitivity 65%Transthoracic(TTE): sensitivity 65%

If negative order a transesophageal echoIf negative order a transesophageal echo Transesophageal(TEE): sensitivity 95-100%Transesophageal(TEE): sensitivity 95-100%

Can detect vegetations < 10 mmCan detect vegetations < 10 mmHelpful in assessing the need for surgeryHelpful in assessing the need for surgeryDetects perivalvular extensionDetects perivalvular extensionUse in the initial evaluation for suspected IEUse in the initial evaluation for suspected IE(if prior probability 4-60%) (useful in S. aureus (if prior probability 4-60%) (useful in S. aureus line sepsis 2 vs 4 wk abx)line sepsis 2 vs 4 wk abx)

Modified Duke Criteria for Modified Duke Criteria for Diagnosis of IE Diagnosis of IE

(Clin. Inf. Dis. 30:633, 2000)(Clin. Inf. Dis. 30:633, 2000)

DefiniteDefinite Infective Endocarditis Infective Endocarditis- 2 major- 2 major- 1 major & 3 minor- 1 major & 3 minor- 5 minor- 5 minor

PossiblePossible Infective Endocarditis Infective Endocarditis- 1 major & 1 minor - 1 major & 1 minor - 3 minor- 3 minor

Major CriteriaMajor Criteria + Blood cultures for endocarditis+ Blood cultures for endocarditis

- 2 separate + B.C. with typical organisms - 2 separate + B.C. with typical organisms including S. aureus associated with line sepsis including S. aureus associated with line sepsis (OR)(OR)- Persistent (2 + 12 h apart or 3 + over 1 h)- Persistent (2 + 12 h apart or 3 + over 1 h)

Evidence of endocardial involvementEvidence of endocardial involvement+ echo (patients with Possible IE a TEE is + echo (patients with Possible IE a TEE is recommended) (OR)recommended) (OR)- new regurgitant murmur- new regurgitant murmur

Positive Q fever serology or single +BCx for Positive Q fever serology or single +BCx for Coxiella burnetii Coxiella burnetii

Minor CriteriaMinor Criteria

Predisposing heart condition or IVDUPredisposing heart condition or IVDU Fever Fever >> 38°C 38°C Vascular phenomenonVascular phenomenon Immunologic phenomenon Immunologic phenomenon Single positive BC with typical organismSingle positive BC with typical organism

Etiologic Agent in IEEtiologic Agent in IE

Etiologic Agent in IEEtiologic Agent in IE StreptococciStreptococci 60-80% 60-80%

Viridans Streptococci Viridans Streptococci30-40% 30-40% Enterococci Enterococci 5-18% 5-18% Other Streptococci Other Streptococci 15-25%15-25%

StaphylococciStaphylococci 20-35%20-35% Coagulase + Coagulase + 10-27%10-27% Coagulase - Coagulase - 1-3% 1-3%

Gram Negative aeorobicGram Negative aeorobic 1.5-13% 1.5-13% FungiFungi 2- 4% 2- 4% Culture NegativeCulture Negative <5-24%<5-24%

HACEKHACEK Fastidious organisms, slow growingFastidious organisms, slow growing

Hold blood cultures x 4 wks, Hold blood cultures x 4 wks, Subculture on chocolate agar, 5%CO2 Subculture on chocolate agar, 5%CO2 Haemophilus aphrophilusHaemophilus aphrophilus Actinobaccillus actinomycetemcomitansActinobaccillus actinomycetemcomitans Cardiobacterium hominusCardiobacterium hominus EikenellaEikenella KingellaKingella

An Additional cause of Culture NegAn Additional cause of Culture Neg Tropheryma whippelii Tropheryma whippelii

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EpidemiologyEpidemiology Pathogenesis & Antibiotic prophylaxisPathogenesis & Antibiotic prophylaxis Clinical ManifestationsClinical Manifestations Diagnosis (TEE & Modified Duke Criteria)Diagnosis (TEE & Modified Duke Criteria) ComplicationsComplications Treatment (emphasis on early surgery)Treatment (emphasis on early surgery)

Cardiac Complications of IECardiac Complications of IE

Congestive Heart Failure Congestive Heart Failure Myocardial abscess/pericarditisMyocardial abscess/pericarditis Conduction defects can progress to complete Conduction defects can progress to complete

heart block (which valve most commonly is heart block (which valve most commonly is associated with this complication?) associated with this complication?)

Myocardial InfarctionMyocardial Infarction

Other Complications of IEOther Complications of IE

Emboli - CNS, Splenic, Lung (Rt sided IE)Emboli - CNS, Splenic, Lung (Rt sided IE) Immune-complex glomerulonephritisImmune-complex glomerulonephritis Mycotic aneurysmsMycotic aneurysms

Occur at bifurcations Occur at bifurcations -Middle cerebral artery-Middle cerebral artery

-Adominal aorta-Adominal aorta-Mesenteric arteries-Mesenteric arteries

CaseCase TTE showed a small vegetation on the TTE showed a small vegetation on the

tricuspid valve, there is no abscesstricuspid valve, there is no abscess BCx ultimately grew MSSABCx ultimately grew MSSA She is currently on vancomycin, what would She is currently on vancomycin, what would

you do?you do?1.1. Penicillin 20 million units per day x 6 weeksPenicillin 20 million units per day x 6 weeks

2.2. Oxacillin 10 gms per day x 4 weeksOxacillin 10 gms per day x 4 weeks

3.3. Doxycycline 100 mg iv twice per day x 4 weeksDoxycycline 100 mg iv twice per day x 4 weeks

4.4. Penicillin 20 million units per day combined with gentamicin 80 mg 3 x per day x Penicillin 20 million units per day combined with gentamicin 80 mg 3 x per day x 2 weeks2 weeks

5.5. Chloramphenicol 400 mg four times per day x 4 weeksChloramphenicol 400 mg four times per day x 4 weeks

6.6. Ceftriaxone 1 gm per day x 6 weeksCeftriaxone 1 gm per day x 6 weeks

“I found the antibiotic therapy for infective endocarditis section difficult and slightly overwhelming.”

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EpidemiologyEpidemiology Pathogenesis & Antibiotic prophylaxisPathogenesis & Antibiotic prophylaxis Clinical ManifestationsClinical Manifestations Diagnosis (TEE & Modified Duke Criteria)Diagnosis (TEE & Modified Duke Criteria) ComplicationsComplications Treatment Treatment (emphasis on early surgery)(emphasis on early surgery)

IV antibioticsIV antibiotics consider surgery evaluationconsider surgery evaluation

Antibiotic TreatmentAntibiotic Treatment Prolonged parenteral therapy requiredProlonged parenteral therapy required

Privileged environment of vegetationPrivileged environment of vegetation High number of organisms some dormant High number of organisms some dormant

Avoid Bacteriostatic agentsAvoid Bacteriostatic agents Serum bacteriocidal level of possible valueSerum bacteriocidal level of possible value

(1:64 peak, 1:34 trough = 100% cure)(1:64 peak, 1:34 trough = 100% cure)

Important to follow up blood cultures to Important to follow up blood cultures to document sterilizationdocument sterilization

Antibiotic Treatment (Continued)Antibiotic Treatment (Continued) Penicillin susceptible StreptococciPenicillin susceptible Streptococci

(MBC 0.1-1 ug/ml)(MBC 0.1-1 ug/ml)PCN x 4 wks or PCN + gentamicin x 2 wk PCN x 4 wks or PCN + gentamicin x 2 wk

EnterococciEnterococci(High risk of relapse, MBC to PCN high)(High risk of relapse, MBC to PCN high)PCN (ampicillin) and Gentamicin x 4-6 wksPCN (ampicillin) and Gentamicin x 4-6 wks

Staphylococcus aureus (coagulase +)Staphylococcus aureus (coagulase +)Oxacillin or Nafcillin x 4-6 wksOxacillin or Nafcillin x 4-6 wks

Surgery for IESurgery for IE Threshold has loweredThreshold has lowered

Delay to often results in a fatal outcome due to Delay to often results in a fatal outcome due to irreversible L. ventricular dysfunctionirreversible L. ventricular dysfunction

Indications: Indications:

(1) Refractory CHF, (1) Refractory CHF, (2) more than one systemic embolus, (2) more than one systemic embolus, (3) uncontrolled infection, (3) uncontrolled infection, (4) resistant organisms, (4) resistant organisms, (5) perivalvular/myocardial abscess(5) perivalvular/myocardial abscess

Focal neurological deficit is not a contraindication for Focal neurological deficit is not a contraindication for surgerysurgery

Conclusions:Conclusions:Infective EndocarditisInfective Endocarditis

Usually requires an NBTE except Usually requires an NBTE except S. aureusS. aureus Organisms that cause IE increased adherenceOrganisms that cause IE increased adherence Clinical symptoms usually nonspecific Clinical symptoms usually nonspecific Always look for embolic lesionsAlways look for embolic lesions Duke criterion, importance of timed Blood Duke criterion, importance of timed Blood

Cultures, use of TEECultures, use of TEE Privileged environment of vegetation requires Privileged environment of vegetation requires

prolonged cidal antibioticsprolonged cidal antibiotics Low threshold for surgeryLow threshold for surgery

This 51 yo WF presented with a C.C. of: Fever, myalgias, nausea, vomiting and diarrhea

Mrs S. had a long history of asthma requiring corticosteroids. Otherwise she was healthy until 2 days PTA when she experienced the sudden onset of fever . Fever was associated with nausea, vomiting and watery diarrhea, as well as a generalized HA. 1 day PTA she noted the acute onset of sharp pleuritic chest pain along the lateral aspect of her left chest wall. . She had no weight loss. She noted 1 week prior to admission she had removed a splinter from her foot.

PE: PE: Temp 38.4, HR. 112, BP 127/69, RR 28,

GENERAL: Small female lying in bed, complaining of chest pain.

SKIN: No rashes or evidence of microemboli Fundi: no hemorrhages.

. HEART: Normal S1., S2 No murmurs, rubs or gallops. All pulses intact. LUNGS: Decreased breath sounds at the left base, broncho-vesicular BS, e to a changes

ABDOMEN: Nontender, no organomegally

EXTREMITIES: No edema. NEUROLOGICAL EXAM: No focal deficits

LAB: WBC 17,000 (80% PMN, 10 Bands) Hct 27 ESR 140 CXR: moderate sized left pleural effusion, several “cannon ball-like” iniflitrates

BC pending, cardiac echo pending

Host factors usually involves formation of a predisposing cardiac lesion. Endocardial damage that has occurred previously leads to accumulation of fibrin and platelets, leading to the formation of a NBTE. This lesion now can serve as an ideal site to trap bacteria.

I would have expected that they would infect the right side of the heart---or get "stuck" in the lung capillaries before they made it to the left side of the heart.

American Heart ProphylaxisAmerican Heart Prophylaxis

Penicillin does not reduce the level of Penicillin does not reduce the level of bacteremiabacteremia

Cumulative exposure is often hundreds of Cumulative exposure is often hundreds of times greater than a single proceduretimes greater than a single procedure

“I don't understand why prophylaxis has not been proven... if you provided consistent antibiotic therapy, should it be able to overcome and even prevent the "cumulative exposure”

This 51 yo WF presented with a C.C. of: Fever, myalgias, nausea, vomiting and diarrhea

Mrs S. had a long history of asthma requiring corticosteroids. Otherwise she was healthy until 2 days PTA when she experienced the sudden onset of fever . Fever was associated with nausea, vomiting and watery diarrhea, as well as a generalized HA. 1 day PTA she noted the acute onset of sharp pleuritic chest pain along the lateral aspect of her left chest wall. . She had no weight loss. She noted 1 week prior to admission she had removed a splinter from her foot.

PE: PE: Temp 38.4, HR. 112, BP 127/69, RR 28,

GENERAL: Small female lying in bed, complaining of chest pain.

SKIN: No rashes or evidence of microemboli Fundi: no hemorrhages.

. HEART: Normal S1., S2 No murmurs, rubs or gallops. All pulses intact. LUNGS: Decreased breath sounds at the left base, broncho-vesicular BS, e to a changes

ABDOMEN: Nontender, no organomegally

EXTREMITIES: No edema. NEUROLOGICAL EXAM: No focal deficits

LAB: WBC 17,000 (80% PMN, 10 Bands) Hct 27 ESR 140 CXR: moderate sized left pleural effusion , several “cannon ball-like” infiltrates

BC pending, cardiac echo pending