Antibiotics Prescription Issue Involving Treatment for Endocarditis

This case involves a 69-year-old female with a long medical history including: DM, COPD, CAD, HTN, hyperlipidemia, lung cancer with wedge resection, AVR, and MVR. She presented to the hospital with complaints of lethargy and dizziness that persisted for one week. The patient was admitted due to high fever secondary to UTI and possible urosepsis and was promptly started on broad spectrum antibiotics. The patient was discharged soon after her fever subsided but found herself back in the ER a few days later with similar symptoms. On this admission, a cardiologist was consulted and his immediate impression was probable prosthetic valve endocarditis. The patient deteriorated quickly after admission and it was suggested by the cardiologist that she be transferred to a tertiary facility. After transfer, a TEE was completed which showed vegetation’s on both aortic and mitral valves with evidence of spread to her myocardium. The patient was started on Gentamycin and Nafcillin for coverage at the recommendation of ID. CT surgery was consulted but felt that she was too unstable. Due to her complaints of neck pain, she was sent for MRI of the neck and brain to look for a cervical abscess or septic emboli. There were multiple small areas of the brain that were concerning for possible infectious process. She continued to decline and the family was consulted. They decided that there should be no escalation in the level of care and made her comfort measures only. She passed away later that day. The cause of death was listed as endocarditis with secondary sepsis.

Question(s) For Expert Witness

1. What was the appropriate course of antibiotics given her history of prosthetic valves?

2. When a patient has 2 prosthetic valves and demonstrates + blood cultures, should longer IV antibiotic therapy have been provided?

3. Was her treatment aggressive enough given her history of 2 prosthetic valves?

Expert Witness Response E-000168

There seem to be many issues with the antibiotics prescribed in this case. A negative echocardiogram would not have ruled out endocarditis, which was likely, given the symptoms. A week of Cipro is not appropriate if she tested positive for a staph infection, and she should have been given 4-6 weeks of antibiotics.