WBR1064

Author	[[PageAuthor::Mohamed Moubarak, M.D. [1]]]
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Primary Care Office
Sub Category	SubCategory::Cardiovascular
Prompt	[[Prompt::A 35 year-old male comes to your office complaining of fever, along with chills, anorexia, malaise, and chest pain. These symptoms started suddenly over the last 5 days. His past medical history is not significant. He smoke one pack of cigarette per day for the last 10 years, and drinks alcohol occasionally. He is sexually active, and use I.V drugs with the recent use one week ago. On examination, his temperature is 102.9°F (39.4° C), blood pressure 140/90 mmgH, heart rate 100/min, and respiratory rate of 21/min. There is a painful, red, raised lesion on the finger pulps. His chest x-ray shows patchy infiltrations, and his echocardiography shows tricuspid valve vegetation. Blood culture results shows viridans group streptococci that is highly penicillin-resistant. What is the best antibiotic choice for this patient?]]
Answer A	AnswerA::Intravenous penicillin G sodium
Answer A Explanation	[[AnswerAExp::Incorrect According to AHA recommendations, a compination of gram positive and gram negative antibiotics (intravenous penicillin G sodium+ gentamicin sulfate), should be used in resistant viridans group streptococci.]]
Answer B	AnswerB::Intravenous penicillin G sodium+ gentamicin sulfate
Answer B Explanation	[[AnswerBExp::Correct According to AHA recommendations, intravenous penicillin G sodium + gentamicin is the recommended regimen for resistant viridans group streptococci.]]
Answer C	AnswerC::Intravenous penicillin G sodium + ceftriaxone sodium
Answer C Explanation	[[AnswerCExp::Incorrect According to AHA recommendations, a combination of gram positive and gram negative antibiotics (intravenous penicillin G sodium+ gentamicin sulfate), should be used in resistant viridans group streptococci. Ceftriaxone does not provide the gram negative selectivity that gentamicin offers.]]
Answer D	AnswerD::Intravenous ceftriaxone sodium
Answer D Explanation	[[AnswerDExp::Incorrect According to AHA recommendations, a combination of gram positive and gram negative antibiotics (intravenous penicillin G sodium+ gentamicin sulfate), should be used in resistant viridans group streptococci. Ceftriaxone sodium alone does not provide the gram positive and negative selectivity and coverage required for resistant strains.]]
Answer E	AnswerE::Intravenous gentamicin sulfate
Answer E Explanation	[[AnswerEExp::Incorrect A combination of gram positive and gram negative antibiotics (intravenous penicillin G sodium+ gentamicin sulfate), should be used in resistant viridans group streptococci.]]
Right Answer	RightAnswer::B
Explanation	[[Explanation::This is an acute case of Infective endocarditis; it is diagnosed according to the Duke clinical criteria. Treatment regimens according to the latest American Heart Association (AHA) guidelines for viridans group streptococci and streptococcus bovis highly penicillin-resistant include intravenous penicillin G sodium or ceftriaxone plus gentamicin Educational Objective: In cases of infective endocarditis, with viridans group streptococci that is highly penicillin-resistant, a combination of gram positive and gram negative antibiotics (intravenous penicillin G sodium+ gentamicin sulfate) are used as the antibiotic regimen of choice. References: Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America.". Circulation 111 (23): e394-434. doi:10.1161/CIRCULATIONAHA.105.165564]]
Approved	Approved::No
Keyword	[[WBRKeyword::Infective endocarditis]]
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