MEDizzy - A 54-year-old man was admitted to the hospital with fever

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BACTERIAL CELL WALL SYNTHESIS INHIBITORS

A 54-year-old man was admitted to the hospital with fever (100.6°F, 38.1°C), night sweats, arthralgias, and 15 lb (6.8 kg) of unintentional weight loss. Past history was significant for rheumatic fever at the age of 9 and for dental surgery 1 month ago. The symptoms started about 2 weeks after the dental procedure. Physical examination was significant for mitral regurgitation, subungual splinter hemorrhages, and hemorrhagic plaques on the soles of both feet. Three blood cultures were ordered, and an empiric therapy was started. Which of the following should be an appropriate treatment for the patient at this time?

ExplanationThe correct answer is D. The patient’s history and clinical presentation suggest that the man is suffering from infective endocarditis. He appears chronically ill and represents the typical patient with subacute disease. He has mitral valve prolapse, which is the predominant defect in infective endocarditis, and he also exhibits several peripheral manifestation of infective endocarditis, including hemorrhages in the hands and feet. The gram-positive bacteria most commonly involved in infective endocarditis are streptococci and staphylococci. Streptococci of the viridans group are the principal cause of endocarditis in an abnormal heart valve (which is present in this case), and they reach the bloodstream typically after dental trauma. The temporal relationship between the dental procedure and the onset of symptoms makes it the most obvious cause of the disease. Most viridans streptococci are sensitive to penicillins and cephalosporins. Single-drug regimens include high-dose penicillin G or ceftriaxone for 2 to 4 weeks. When empirical therapy is needed, the guidelines suggest high-dose penicillin G plus an aminoglycoside, as in this case. This is a synergistic combination that can achieve bactericidal activity against resistant streptococcal species. A, B These are combinations of a bactericidal plus a bacteriostatic antibiotic. In general, these combinations should be avoided (with few exceptions), as an antagonistic interaction can occur in many cases. C These antibiotics are mainly effective against gram-negative bacteria.