Justice
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A 54-year-old man is evaluated because of fatigue, backache, and intermittent fever of 3 months duration. He has no history of cardiac disease or drug allergies.
On physical examination, there are three splinter hemorrhages under his fingernails but no other abnormalities of his skin. Ophthalmologic examination reveals a right conjunctival hemorrhage. Funduscopic examination is normal. The lungs are clear. Cardiac examination discloses a soft diastolic murmur of aortic insufficiency, which is a new finding. There is no splenomegaly. Neurologic examination is normal. Four sets of blood cultures grow a microorganism of the viridans streptococci group, which is sensitive to penicillin. A transthoracic echocardiogram shows a thickened bicuspid aortic valve with evidence of mild aortic insufficiency. A transesophageal echocardiogram confirms these findings and also shows an oscillating mass on the aortic valve. Which of the following intravenous agents is the most appropriate initial antibiotic therapy for this patient?
A. Vancomycin for 4 weeks
B. Penicillin G for 4 weeks
C. Penicillin G plus gentamicin, both for 4 weeks
D. Penicillin G plus gentamicin, both for 6 weeks
E. Ceftriaxone for 8 weeks
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| arlete
Intern in 2009!!!!!
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D
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| dr.wad
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C
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| peter90036
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picky picky
D ....guess for 6wk ?
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| vibrio
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Hi.
I think answer is
for native valve step viridans:
give pencillin G for 4 wks.adding gentamicin
reduces the course to only 2 wks.
for prosthetic valve,pencillinG6wks and 2wks of gentamicin.
if pt allergic to pencillin give vancomycin.
Here in this scenario,pt has native valve strep.viridans
endocarditis.so he should be given pencillinG for 4wks.
If we were to add gentamicin then only 2wks course.
and i think we dont have that in our options.
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| khiladi
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why do we give gentamicin if the organism is sensitive to pencillin?
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| cool doctor
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B
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| vibrio
Forum Newbie
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hello.
the answer is here is definetely B.
gentamicin is added if the duration of illness is
more than 3 months,pt is seriously ill and
if there are extracardiac manifestations.
It depends on individual case and guide lines
vary with severity.
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| CocaCola
Forum Guru
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d penicillin plus gentamycin for 6 wks
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| Jcala
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B
khiladi is right.
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| Justice
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The correct answer is B, but the logics behind is different from the one made by khiladi
The patient meets both major Duke criteria for definite endocarditis (that is, a typical microorganism grown on two blood cultures and evidence of endocardial involvement met either by echocardiography because of the oscillating intracardiac mass or by physical examination because of the new aortic regurgitant murmur). His history also raises suspicion of endocarditis. Although not necessary to meet the diagnostic criteria in this case, the presence of the bicuspid aortic valve, fever, and conjunctival hemorrhage (but not the splinter hemorrhages) fulfills three of the minor Duke criteria for endocarditis. Endocarditis due to sensitive viridans streptococci on native valves can be treated for 4 weeks with penicillin or ceftriaxone or for 2 weeks when either agent is combined with synergistic low-dose gentamicin. In a patient with uncomplicated endocarditis, the addition of gentamicin decreases the total treatment course from 4 weeks to 2 weeks.
In the absence of penicillin allergy or penicillin resistance, vancomycin is inappropriate. Although adding synergistic doses of gentamicin is appropriate, using this combination regimen for 4 (or 6) weeks is not part of a standard treatment regimen. Similarly, ceftriaxone can be substituted for penicillin in a standard 4-week regimen but would not be used for 8 weeks for a patient with uncomplicated endocarditis.
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