Today we heard a case of a patient with a known history of injection drug use who presented with multiple swollen joints, in the context of a persistant staphylococcal bacteremia. The patient also had a history of previous endocarditis and on exam had evidence of moderate-severe tricuspid regurgitation.
I have reviewed the diagnostic criteria for endocarditis here.
I have previously blogged about staphyloccocal bacteremia here. I will re-iterate that for methicillin sensitive staph aureus vancomycin is INFERIOR to beta-lactam therapy.
Some newer evidence suggests that the risk of using adjuvant gentamicin in native valve staphylococcal bacteremia/endocarditis is greater than the benefit.
An interesting concept, which I am now going to endorse because it is inexpensive and relatively simple, is continuous cloxacillin infusion as opposed to intermittant infusion. In this study the 30 day microbiologic cure was 94% in the CI group as opposed to 79% in the II group (ARR 15%, NNT 8).
There have been several studies looking at treatment options in injection drug users. Long term antibiotic therapy requires indwelling lines and this usually mandates extended hospitalization or "confinement" if ongoing drug use is a concern. These two studies (larger study, smaller study) have evaluated quinolone (ciprofloxacin, though today levofloxacin or moxifloxacin would likely be even more effective) combined with rifampin in right sided IE. These are small studies, so they shouldn't influence practice in general -- but in certain cases may be the only option.
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