|




 


Jose Ferdinand H. Santos
Doctor of Pharmacy
2010
|    
 |eninges are composed of three
layers of membranes enclosing
the brain and spinal cord.
ë Pia mater is the innermost layer.
It is akin to a tissue paper that
closely adheres to the brain and
spinal cord, dipping into the
various folds and crevices.
ë Arachnoid mater is the middle
layer. It is a filmy membrane that
is joined to the pia mater by fine
threads resembling a cobweb.
ë The dura mater, a parchment-like
membrane, lies on the outermost
part of the meninges and adheres
to the skull and spinal canal.
 The   

 £ SF)
is the fluid that circulates in the
spaces in and around the brain
and spinal cord.

|

 
˜ |eningitis is an inflammation of the
meninges, the membranes that enclose
and protect the brain and the spinal cord.
˜ It is usually caused by infection, most
often with viruses or bacteria.
˜ If not treated, meningitis can lead to brain
swelling and cause permanent disability,
coma, and even death.

è  |



 |eningitis caused by  |eningitis caused by
bacteria is known as other organisms,
septic meningitis. including viruses,
 Bacterial meningitis, fungi, and parasites,
if not diagnosed is called aseptic
early, can cause meningitis.
serious and  Viral meningitis is the
sometimes fatal most common and
complications. mildest form of the
disease, and most
people fully recover
from it without
complications.

è  |



˜ There are several types of bacterial
meningitis. Two types represent the
majority of bacterial meningitis cases:
Ń |eningococcal £Neisseria meningitidis)
Ń Pneumococcal £Streptococcus pneumoniae)

 |


 |



 accounts for
more than half of all cases of bacterial
meningitis in the United States.
|eningococcal disease is caused by bacteria
called Neisseria meningitidis.
 At least 13 serogroups have been described:
A, B, , D, E, H, I, K, L, W-135, X, Y, and Z.
 Strain B causes about 75 percent of the
meningococcal cases and has the highest
fatality rate.

 |


˜ The modes of infection include direct contact or
respiratory droplets from the nose and throat of
infected people. |eningococcal disease most likely
occurs within a few days of acquisition of a new
strain.
˜ The natural habitat and reservoir for meningococci is
the mucosal surfaces of the human nasopharynx and,
to a lesser extent, the urogenital tract and anal canal.
˜ N meningitidis enters the bloodstream. This can lead
to systemic infection in the form of bacteremia,
metastatic infection that commonly involves the
meninges or severe systemic infection with
circulatory collapse and disseminated intravascular
coagulation £DI )

|





˜ 


 is caused by
pneumococcus bacteria, which also cause
several diseases of the respiratory
system, including pneumonia. It also
results in a higher incidence of brain
damage than other forms of the disease.

 |


˜ S pneumoniae usually invades the
meninges via the bloodstream
 S pneumoniae can also directly invade
the meninges after basilar skull
fractures or other trauma that
compromises the dura and is the most
common cause of recurrent bacterial
meningitis in these patients.






 ðther types of bacterial meningitis include:
ë  


 This form affects mostly newborn
babies and is caused by Group B streptococcus bacteria,
commonly found in the intestines.
ë 


 This is a rare, but deadly
form caused by staphylococcus bacteria. It usually
develops as a complication of a diagnostic or surgical
procedure.
ë R   



 R is caused by
haemophilus bacteria. It was once the most common
form of bacterial meningitis, and one of the deadliest
childhood diseases. However, in 1985, an Hib vaccine
was introduced into the routine immunization program
for U.S. children and virtually eliminated Hib meningitis
in the United States.

 |


 Enteroviruses, a group of viruses that
includes several strains of coxsackieviruses
and echoviruses, cause about 90 percent of
cases of aseptic meningitis.
 Enteroviruses commonly are passed from
person to person through contact with
respiratory secretions, by breathing in drops
from someone who is coughing or sneezing,
and from contact with an infected person's
feces or bowel movements.

-|


 Viral meningitis is far
more common than
the bacterial form
and, in most cases,
much less
debilitating.
 |ost people exposed
to viruses that cause
meningitis experience
mild or no symptoms
and fully recover
without
complications.

-|


 |eningitis can also
be caused by the
spread of an
infection occurring
near the brain, such
as from the ears or
the sinuses. It is
also an occasional
complication of
brain, head, or neck
surgery.

è  |



 Those people at greater risk for meningitis than
the rest of the population include the following:
ë Adults older than 60 years
ë hildren younger than 5 years
ë People with alcoholism
ë People with sickle cell anemia
ë People with cancer, especially those receiving
chemotherapy
ë People who have received transplants and are taking
drugs that suppress the immune system
ë People with diabetes
ë Those recently exposed to meningitis at home
ë People living in close quarters £military barracks,
dormitories)

è  
 The symptoms of meningitis are similar for both bacterial
and viral forms of the disease. Adults and older children
typically experience:
 Fever and chills
 Headache
 Vomiting
 Stiff neck £patient may not be able to curl up in bed with
nose to knees)
 Irritability and drowsiness
 Eyes that are sensitive to light £photophobia)
 Delirium and confusion £uncommon)
 Seizures £rare)
 oma £rare)
 A new rash that often looks like a bruise
è !  
"

|


 Symptoms in infants and young children
include:
ë Whimpering and crying in a high-pitched tone
ë Difficulty in waking and very lethargic when awake
ë Fussiness when being held or cuddled
ë Arching the back and retracting the neck
ë Staring blankly at their surroundings
ë Having a high fever and cold hands and feet
ë Refusing food
ë Vomiting
ë Appearing pale or blotchy

è !  
"

|


 |eningococcal meningitis often causes a
distinctive rashiThis rash is the result of a form
of   £infection in the bloodstream), a
potentially fatal condition.
 Septicemia occurs when the meningococcus
bacteria multiply uncontrollably in the
bloodstream. The bacteria release toxins into the
blood that break down the walls of the blood
vessels, allowing blood to leak into the skin. The
leaking causes a characteristic rash, called a
hemorrhagic rash. The rash can appear
anywhere on the body, including in the eyes and
often between the toes.
è !  
"

|


 The rash starts as a
cluster of tiny blood
spots, which look like
pin pricks in the skin.
If untreated, these
spots gradually grow
and become multiple
areas of bleeding,
resembling fresh
bruises under the
skin surface.
è !  
"

|


 Examination: The doctor performs an early examination to
determine if help is needed with breathing or blood pressure. The
doctor then checks your blood pressure, pulse, and temperature.
 Testing: ðnce the doctor examines you and learns of your
symptoms, further evaluation depends on the doctor's
assessment of the likelihood of meningitis. If the doctor suspects
bacterial meningitis, he or she may order the following:
ë Antibiotics may be given early in the evaluation.
ë A T scan may be performed. This can sometimes determine if the brain is
infected or has an abscess.
ë Blood is drawn to check the white and red blood cell counts.
ë A chest x-ray film may be obtained to look for signs of pneumonia or fluid in
the lungs.
ë ðther tests may be performed to look for other sources of infection.

|

$
 
R# |
R#
 Spinal tap: A spinal tap, or
lumbar puncture, is necessary
to diagnose meningitis. The
results of the spinal tap are
essential to help the doctor
determine both the presence
and then the type of
meningitis. orrectly
diagnosing meningitis is
absolutely essential to guide
treatment decisions. If you
are too sick for a spinal tap,
you will be treated with
antibiotics on the assumption
that you have meningitis. The
spinal tap will be done when
your condition improves.

R# |

$
 

˜ erebrospinal fluid flows through a channel £the
subarachnoid space) between the middle and inner layers
of tissue.
˜ To remove a sample of this fluid, a doctor inserts a small,
hollow needle between two vertebrae in the lower spine,
usually the third and fourth or the fourth and fifth lumbar
vertebrae, below the point where the spinal cord ends.
˜ Usually, the person lies on the side with the knees curled to
the chest. This position widens the space between the
vertebrae, so that the doctor can avoid hitting the bones
when the needle is inserted.
˜ erebrospinal fluid is allowed to drip into a test tube, and
the sample is sent to a laboratory for examination





 The fluid is analyzed in the lab for things like
white and red blood cells and protein and glucose
£sugar) levels. The doctor then interprets the
test results to determine if meningitis is present.
The test results can also indicate if the
meningitis is due to a bacterial infection or a
virus.
 Because the results of the spinal tap can take up
to several hours to return, the treatment often
begins before the results are available. The
doctor focuses early treatment on a medical
opinion of the most likely cause based on your
symptoms and physical examination findings.

R# |

$
 

 Antibiotics are not  ðnce a case of
used to treat viral meningitis is known
meningitis because to be viral, rest and
it is caused by a pain medication for
virus, not bacteria. body aches and
headache can help
the person feel
better until the
infection resolves
on its own.

R# |

$
 

 omplications from viral meningitis are not as
common as those from bacterial meningitis, but they
can include inflammation and swelling of the brain.
Sometimes, permanent learning disability and other
brain damage can result.
ë    are sudden bursts of disorganized electrical
activity that interrupt the normal functioning of the brain,
often leading to uncontrolled movements in the body and
sometimes a temporary change in consciousness.
ë   is a localized or walled off accumulation of pus
caused by infection that can occur anywhere in the body.
ë  is a potentially serious spreading of infection,
usually bacterial, through the bloodstream and body.
ë   is a serious condition in which blood pressure is very
low and not enough blood flows to the body's organs and
tissues. Untreated, shock may result in death.
è 


|

 
 Hospitalization for
meningitis depends on
the cause.
 If you appear to have
viral meningitis,
treatment is usually
less aggressive and
consists of measures to
make you more
comfortable.
 Viral meningitis is often
treated at home with
acetaminophen and
other pain medications.

|  

 If you have bacterial meningitis, you are
often admitted to the intensive care unit, for
either a short period of observation or a
longer period if you are more ill. are of
bacterial meningitis begins by ensuring that
your breathing and blood pressure are
adequate.
 Steroids may be given to try to decrease the
severity of the disease.
 steroids reduces both mortality and neurological
sequelae in adults with bacterial meningitis, without
detectable adverse effects

|  

 Prompt diagnosis and treatment of meningitis is
essential. Therefore, if you suspect that you or
someone you know has meningitis based on the
symptoms, seeking immediate medical attention is
critical. If you cannot take the person to the hospital,
it is advisable to call an ambulance.
 Emergency care: While taking someone to the
hospital's emergency department or waiting for an
ambulance, basic treatment involves these
procedures:
ë Give acetaminophen £Tylenol) for fever.
ë Keep the person in a darkened, quiet area.
ë If the person is vomiting, lay the person on one side to
prevent him or her from inhaling vomit.

 
%

% R
 Home care is only
recommended if the
person has mild viral
meningitis.
 If the doctor determines
that the person is
suffering from mild viral
meningitis, medications
may be needed for control
of headache and fever.
This is often accomplished
with acetaminophen
£Tylenol) or stronger pain
medications.
 Antibiotics are not helpful
for viral meningitis.

 
%

% R
 ë If someone is sent home from the doctor with viral
meningitis, it is essential for that person to be seen
by his or her regular doctor in the next one to two
days for a checkup.
ë When someone with viral meningitis is treated at
home, watching for signs of a worsening condition
is essential. If any of these occur, seek the care of a
doctor immediately:
 Profuse or uncontrollable vomiting
 Worsening headache or fever
 Seizures
 Weakness or numbness of any extremities
 Difficulty speaking, swallowing, or walking

 
%

% R
 Apart from vaccination, there is no known
way to protect against meningitis.
 Although there is little people can do to
prevent meningitis, they can limit its
devastating health effects by recognizing
the symptoms of the disease and seeking
immediate medical treatment.


|

  
 

 Some forms of bacterial meningitis can be prevented
through immunization. These vaccines include:
 R   



  The Hib vaccine,
which has reduced Hib meningitis cases by 95 percent
since 1985, is given to U.S. children in three doses
£at 2, 3, and 4 months old).
 |



 

!&
&'
è The vaccine currently offers no
protection against strain B, and it's effective for only
3 to 5 years. It is recommended for:
ë All college students £unless pregnant), especially those ages
18 to 24.
ë People in close contact with individuals suffering from these
strains of meningitis.

-


 The pneumonia vaccine may
provide protection against
some types of meningitis
caused by Streptococcus
pneumoniae.
 It is recommended primarily
for people at risk for
pneumonia, but may provide
some protection from
meningitis caused by
Streptococcus pneumoniae
as well. People who may
benefit from the pneumonia
vaccine include all persons
over 65 years of age, as well
as:
ë People with chronic lung disease
ë Debilitated people
ë People with sickle cell anemia

-


 In the event that there is no vaccination available £for example,
in cases of strain B meningococcal meningitis) people in close
contact with the infected person are often given 
i
 üifampicin to keep them from acquiring the dangerous germ.
ë üifampicin may cause mild stomach upset and a darkening of the urine. It
usually must be taken for just two days and provides significant protection.
ë üifampicin may also be given to the infected person if there is a chance that
the germ may still be present following recovery from a meningitis infection.
 Sometimes the families of small children with serious
haemophilus infections are given a four-day course of rifampicin.
 ºiprofloxacin, may be given to older children and adults.

!

 There is no
immunization
available against viral
meningitis. However,
routine childhood
vaccinations against
mumps and polio
have virtually
eliminated infection
from those viruses,
which cause the most
serious types of viral
meningitis.

 

(-|


 Since most cases of viral
meningitis are caused by
enteroviruses , you can
prevent infection by
washing your hands
regularly, especially after
changing diapers or
coming into contact with
feces.
 It can also be prevented
by carefully washing and
preparing food. This
includes eating foods by
the "sell by" or "eat by"
dates, and by thoroughly
reheating chilled foods
before consumption.

 

(-|


 The prognosis of meningitis depends on the
severity and the cause of the illness.
ë In those with severe bacterial meningitis or a very fast
onset of illness, the death rate can be as high as 90%. If
the person survives, even with proper treatment, long-
term disabilities can result, including deafness, seizures,
paralysis, blindness, or loss of limbs.
ë In those with less severe cases of bacterial meningitis,
the death rate can still approach 25%. Long-term
disabilities are possible. The person may require a
prolonged period of hospitalization and rehabilitation.
ë For a person with viral meningitis, full recovery can take
place in seven to 10 days.

"
 |eningitis is an inflammation of the protective membrane lining
the brain and spinal cord caused most often by a viral or bacterial
infection that crosses the body's blood-brain barrier.
 |eningitis is diagnosed by a 
 , in which a small
amount of fluid is collected from the spinal column.
 There are two main types of meningitis: bacterial and viral.
Bacterial meningitis is less common, but more serious.
 Bacterial meningitis is treated with antibiotics and the majority of
patients make a full recovery.
 Viral meningitis usually requires no treatment beyond painkillers.
 |ost patients make a full recovery from meningitis. A small
number of infected people end up with hearing or vision loss or
brain damage.
 Vaccinations against some forms of meningitis are available. They
are recommended for children under age 5, people in close
contact with someone who has developed meningitis, college
students, and people travelling to certain overseas destinations.



 (  - 
$"!)$  
˜ The heart is made up of
three cellular layers:
Ń the epicardium
£outermost layer)
Ń the myocardium £middle,
muscular layer)
Ń the endocardium
£innermost layer)
˜ The endocardium lines all
of the chambers and valves
of the heart, and its cells
are continuous with those
of blood vessels leaving the
heart.

(  -  $"!)$  
˜ an inflammation or infection of the
endocardium and most commonly, the
valves of the heart

$ (   ""( (  - 
$"!)$  
˜ Bacteria or other infectious substance can
enter the bloodstream during certain
medical procedures, including dental
procedures, and travel to the heart, where
it can settle on damaged heart valves.
˜ The bacteria can grow and may form
infected clots that break off and travel to
the brain, lungs, kidneys, or spleen.
è  

 




˜ lumps of infecting
organisms, fibrin and
platelets, known
collectively as
³vegetations´,
develop on the
affected heart valve.
˜ These may destroy
the valve cusps and
lead to regurgitation
of blood flow if the
valve becomes
incompetent.

è  

 




˜ Endocarditis can be broken down into the
following categories:
Ń Native valve endocarditis
Ń Prosthetic valve endocarditis
Ń Endocarditis related to intravenous drug use
Ń Healthcare-associated endocarditis
Ń Fungal endocarditis

 

˜   


Ń Rheumatic valvular disease £30% of native valve endocarditis

[NVE]) - Primarily involves the mitral valve followed by the aortic
valve
Ń ongenital heart disease £15% of NVE) - Underlying etiologies
include a patent ductus arteriosus, ventricular septal defect,
tetralogy of Fallot, or any native or surgical high-flow lesion.
Ń |itral valve prolapse with an associated murmur £20% of NVE)
Ń Degenerative heart disease - Including calcific aortic stenosis due
to a bicuspid valve, |arfan syndrome, or syphilitic disease
Ń Approximately 70% of cases are caused by Streptococcus species
including Streptococcus viridans, Streptococcus bovis, and
enterococci. Staphylococcus species cause 25% of cases and
generally demonstrate a more aggressive acute course.

  


˜   


Ń Early disease, which presents shortly after surgery, has a different

bacteriology and prognosis than late disease, which presents in a
subacute fashion similar to native valve endocarditis.
Ń Infection associated with aortic valve prostheses is particularly
associated with local abscess and fistula formation, and valvular
dehiscence. This may lead to shock, heart failure, heart block,
shunting of blood to the right atrium, pericardial tamponade, and
peripheral emboli to the central nervous system and elsewhere.
Ń Infection that occurs early after surgery may be caused by a
variety of pathogens, including S aureus and S epidermidis. These
nosocomially acquired organisms are often methicillin-resistant
£|RSA). Late disease is most commonly caused by streptococci.

  


˜
   



Ń This condition most commonly involves the tricuspid valve,

followed by the aortic valve.
Ń Two thirds of patients have no previous history of heart
disease and no murmur on admission. A murmur may not
be heard in patients with tricuspid disease because of the
relatively small pressure gradient across this valve.
Ń S aureus is the most common £
50% of cases) etiologic
organism. ðther causative organisms include streptococci,
fungi, and gram-negative rods £eg, pseudomonads, Serratia
species).8 |ethicillin-resistant S aureus £|RSA) accounts for
an increasing portion of S aureus infections and has been
associated with previous hospitalizations, long-term
addiction, and nonprescribed antibiotic use.

   




˜ Healthcare-associated endocarditis
Ń Endocarditis may be associated with new
therapeutic modalities involving intravascular
devices such as central or peripheral
intravenous catheters, rhythm control devices
such as pacemakers and defibrillators,
hemodialysis shunts and catheters, and
chemotherapeutic and hyperalimentation lines.

R   % 


˜ Fungal endocarditis
Ń Fungal endocarditis is found in intravenous
drug users and intensive care unit patients who
receive broad-spectrum antibiotics.
Ń Blood cultures are often negative, and
diagnosis frequently is made after microscopic
examination of large emboli.

(



˜ Infective endocarditis generally occurs as a
consequence of nonbacterial thrombotic
endocarditis, which results from turbulence or
trauma to the endothelial surface of the heart.
Transient bacteremia then leads to seeding of
lesions with adherent bacteria, and infective
endocarditis develops.
˜ Pathologic effects due to infection can include
local tissue destruction and embolic phenomena.
In addition, secondary autoimmune effects, such
as immune complex glomerulonephritis and
vasculitis, can occur.

 


˜ Patients with prosthetic heart valves are
vulnerable to infection
˜ Patients with an internal pacemaker are
susceptible
˜ Staphylococcal infections from the skin
and from conditions such as chronic
eczema may cause the disease
˜ Patients with severe tooth decay or
inflamed gums and after dental
procedures or surgery

è  




˜ Fever and chills £most common)
˜ Abnormal urine color
˜ Excessive sweating £may be severe)
˜ Fatigue
˜ Joint pain
˜ |uscle aches and pains
˜ Nail abnormalities £splinter hemorrhages under the nails)
˜ Paleness
˜ Red, painless skin spots on the palms and soles £Janeway lesions)
˜ Red, painful nodes £ðsler's nodes) in the pads of the fingers and
toes
˜ Shortness of breath with activity
˜ Swelling of feet, legs, abdomen
˜ Weakness
˜ Weight loss


*




*



˜ |yocardial infarction, pericarditis, cardiac
arrhythmia
˜ ardiac valvular insufficiency
˜ ongestive heart failure
˜ Sinus of Valsalva aneurysm
˜ Aortic root or myocardial abscesses
˜ Arterial emboli, mycotic aneurysms
˜ Arthritis
˜ Acute renal failure
˜ Stroke syndromes
˜ |esenteric or splenic abscess or infarct



˜ Diagnosis is usually
suspected based
upon the patient's
history, symptoms,
and findings such
as a new murmur.
˜ Testing includes
laboratory studies
and imaging
studies.

$


 6
 
˜ Blood cultures are the
key to investigating
endocarditis.
˜ Three samples are
usually taken over a 24-
hour period before
antibiotics are given in
order to identify the
infecting organism.
˜ These may reveal
typical complexes of
immune system cells.
˜ Send baseline studies, such as B , electrolytes, creatinine, BUN,
glucose, and coagulation panel, to the laboratory for testing.
˜ Anemia of chronic disease is common in subacute endocarditis
˜ Erythrocyte sedimentation rate £ESR), while not specific, is
elevated in more than 90% of cases.
˜ Proteinuria and microscopic hematuria are present in
approximately 50% of cases.
˜ Leukocytosis is observed in acute endocarditis.
˜ Anemia is present in subacute endocarditis.
˜ Decreased 3, 4, and H50 are evident in subacute
endocarditis.
˜ Rheumatoid factor is noted in subacute endocarditis.
˜ Serology for ºhlamydia, Q fever £ºoxiella), and Bartonella may
be useful in culture-negative endocarditis.

6
 
 
 
˜ Echocardiography
Ń This test is particularly
indicated with culture-
negative cases, such as
in fungal endocarditis.
Ń Visible vegetation
suggests a worse
prognosis.
˜ Echocardiography, is
highly useful to assess
local complications,
such as abscesses.
˜ hest radiography
Ń Pulmonary embolic
phenomena strongly
suggest tricuspid
disease


 
 
 
˜ Ventilation/perfusion
£V/Q) scanning
Ń This may be useful in
right-sided endocarditis.
˜ omputed tomography
£ T) scanning
Ń This imaging modality has
proven most useful for
localizing abscesses. With
new advanced multislice
techniques, T can now
also be used to identify
valvular abnormalities and
vegetations.
˜ Electrocardiography
Ń Nonspecific changes are common.
Ń First-degree AV block and new interventricular
conduction delays may signal septal
involvement in aortic valve disease; both are
poor prognostic signs.


 
˜  

$ 

˜ Focus ED care on making the correct ) !| 
diagnosis and stabilizing the patient with
acute disease and cardiovascular
instability.
˜ In most cases, the etiologic microbial
agent is not known while the patient is in
the ED.
˜ General recommendations include drawing
3 sets of blood cultures over a few hours,
and then empiric antibiotic therapy may
be administered. The choice of empiric
therapy can be tailored to the patient's
history and circumstances.
˜ General measures
Ń Treatment of congestive heart failure
Ń ðxygen
Ń Hemodialysis £may be required in patients
with renal failure)
˜ Empiric antibiotic therapy is
chosen based on the most likely | $ ! "
infecting organisms. Native valve
disease has often traditionally
been treated with penicillin G and
gentamicin for synergistic coverage
of streptococci.
˜ Patients with a history of IV drug
use have been treated with
nafcillin and gentamicin to cover
for methicillin-sensitive
staphylococci.
˜ The emergence of methicillin-
resistant Staphylococcus aureus
and penicillin-resistant streptococci
has led to a change in empiric
treatment with liberal substitution
of vancomycin in lieu of a penicillin
antibiotic.
˜ Infection of a prosthetic
valve may include
methicillin-resistant
Staphylococcus aureus or
coagulase-negative
staphylococci7 ; thus,
vancomycin and gentamicin
may be used, despite the
risk of renal insufficiency.
˜ Rifampin also may be helpful
in patients with prosthetic
valves or other foreign
bodies; however, it should be
used in addition to
vancomycin or gentamicin.

| $ ! "
˜ The American Heart Association recommends preventive antibiotics
for people at risk for infectious endocarditis before:
Ń ertain dental procedures
Ń Surgeries on respiratory tract or infected skin, skin structures, or
musculoskeletal tissue
˜ Antibiotics are more likely to be recommended those with the
following risk factors:
Ń Artificial heart valves
Ń ertain congenital heart defects, both before or possibly after
repair
Ń History of infective endocarditis
Ń Valve problems after a heart transplant
˜ ontinued medical follow-up is recommended for people with a
previous history of infectious endocarditis.
˜ Persons who use intravenous drugs should seek treatment for
addiction. If this is not possible, use a new needle for each injection,
avoid sharing any injection-related paraphernalia, and use alcohol
pads before injecting to reduce risk.

 



˜ onsultations
Ń Admit all patients with
suspected infectious
endocarditis to the
hospital for IV
antibiotics while blood
cultures are pending.
Ń Appropriate
consultations could
include cardiology,
cardiothoracic surgery,
and infectious disease
services.




 +$" ,