Board Review Question

You are caring for a 33-year-old man in the intensive care unit with hypoxemic respiratory failure. You are suspecting “Pneumocystis jiroveci” pneumonia. You are considering a diagnostic bronchoscopy that includes bronchoalveolar lavage, brushing, and standard cultures. The CT scan of the chest was significant for basilar ground glass opacities and reticular infiltrates but no masses.
He has a history of HIV, dyslipidemia, and aortic stenosis associated with a bicuspic aortic valve and mitral valve prolapse with regurgitation.
He has not been taking any of his prescribed medications, and he is allergic to penicillin.
Currently he is receiving levofloxacin and enoxaparin.

Which of the following describes the most appropriate endocarditis prophylaxis strategy?

 

A. Single dose of vancomycin 1 gram IV

B. Add pipercillin/tazobactam to his regimen

C. Single dose of cephalexin 2 grams orally

D. Single dose of azithromycin 500 mg orally or IV

E. No prophylaxis is necessary.

 

+ Answer and Discussion - Answer and Discussion

Correct answer: E – No prophylaxis is necessary.


Key Point: Only patients at the highest risk undergoing high risk procedures need prophylaxis for infection endocarditis (IE).


Discussion: Prophylaxis for infectious endocarditis is limited to patients with the highest risk for adverse outcomes from the infection. This includes:

  1. Those with prosthetic heart valves or other prosthetic material
  2. Prior IE
  3. Unrepaired cyanotic congenital heart disease
  4. Repaired congenital heart disease with residual defects
  5. Any repaired congenital heart disease within the first 6 months
  6. Cardiac transplant with valve dysfunction

Compared to the previous recommendations patients no longer requiring prophylaxis include native valve aortic or mitral stenosis/regurgitation, including bicuspid valves.
Additionally, these patients only require prophylaxis prior to specific procedures that are thought to be most likely to result in transient bacteremia – theoretically putting the patient at a higher risk for developing IE. For procedures involving the respiratory tract, antibiotic prophylaxis is recommended only if incision or biopsy of the mucosa is involved. This includes bronchoscopy with biopsy. The patient in the case stem is only undergoing diagnostic bronchoscopy for suspected respiratory infection and does not need any change in his antibiotic regimen.

 

Reference:

Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group.