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Question 91 of 173

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A 70-year-old man is admitted to the Acute Medicine Unit as he is pyrexial and feeling generally unwell. He has a history of ischaemic heart disease and had a myocardial infarction 5 years ago. An echocardiogram is arranged which shows a small vegetation around the mitral valve. Blood cultures are taken which are reported as follows:
Streptococcus viridans

B C D E

49.1% of users answered this question correctly

What is the most appropriate antibiotic therapy?

May 2012 exam

A. IV benzylpenicillin B. IV benzylpenicillin + ceftriaxone C. IV flucloxacillin + gentamicin D. IV vancomycin + rifampicin + gentamicin E. IV vancomycin + benzylpenicillin

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Infective endocarditis: prognosis and management Poor prognostic factors Staph aureus infection (see below) prosthetic valve (especially 'early', acquired during surgery) culture negative endocarditis low complement levels

Mortality according to organism staphylococci - 30% bowel organisms - 15% streptococci - 5%

Current antibiotic guidelines (source: British National Formulary)

Scenario Initial blind therapy Initial blind therapy if prosthetic valve is present or patient is penicillin allergic Endocarditis caused by staphylococci Native valve endocarditis caused by fullysensitive streptococci (e.g. viridans) Native valve endocarditis caused by less sensitive streptococci OR prosthetic valve Endocarditis caused by streptococci Suggested antibiotic therapy Flucloxacillin + gentamicin (benzylpenicillin + gentamicin if symptoms less severe) Vancomycin + rifampicin + gentamicin Flucloxacillin (add rifampicin if prosthetic valve, vancomycin + rifampicin if penicillin allergic or MRSA) Benzylpenicillin (large vegetation, intracardial abscess or infected emboli then benzylpenicillin + gentamicin, vancomycin if penicillin allergic) Benzylpenicillin + gentamicin (vancomycin + gentamicin if penicillin allergic)

Indications for surgery severe valvular incompetence aortic abscess (often indicated by a lengthening PR interval) infections resistant to antibiotics/fungal infections cardiac failure refractory to standard medical treatment recurrent emboli after antibiotic therapy

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