Teaser: 76 y/o with bacteremia

A 76 year old male with a past medical history of ischemic cardiomyopathy, DM2, HLD, HTN, COPD comes to clinic with a chief complaint of fevers. He denies any other symptoms On physical exam you hear a systolic ejection murmur grade I that has been present for years. He has a fever of 100.9 but all other labwork is negative. Blood cultures are positive for two out of two staphylococcus epidermidis. TEE is obtained which is negative for vegetations. You start him on linezolid for 2 weeks for bacteremia.

Three days later the patient calls and reports persistent fevers — he now is slightly short of breath more than usual but he also went to Denny’s every day this past weekend and Long John’s Texas Steakhouse. He is usually well controlled.

What do you do next?

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The answer is to repeat TEE in 7-10 days — though the sensitivity of TEE in detecting infective endocarditis is high (about 85-90%) there can still be false negatives. In cases of high clinical suspicion repeat TEE! This patient has new onset heart failure in the setting of persistent fevers — think infective endocarditis!



2 Responses

  1. creigh8_wp

    Good point.

    So my original intention was to test the appropriate time to rescreen ECHO someone when suspicion for infective endocarditis remains high after an initial negative TEE because it’s sensitivity is not 100%.

    But you are correct, linezolid is not the best antibiotic choice so it would be better to treat with a bacteriocidal like daptomycin or vancomycin. Furthermore I should have mentioned the patient is a dialysis patient with a clear source (port) and the staph epidermidis grown on each culture are the same and not two different species.

    Thanks for mentioning this!

So, what do you think?


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