{"id":9056,"date":"2019-01-22T22:15:40","date_gmt":"2019-01-23T03:15:40","guid":{"rendered":"https:\/\/blogs.nejm.org\/hiv-id-observations\/?p=9056"},"modified":"2019-01-23T14:23:58","modified_gmt":"2019-01-23T19:23:58","slug":"unanswerable-questions-in-infectious-diseases-treatment-duration-in-endocarditis-4-weeks-6-weeks-other","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/unanswerable-questions-in-infectious-diseases-treatment-duration-in-endocarditis-4-weeks-6-weeks-other\/2019\/01\/22\/","title":{"rendered":"Unanswerable Questions in Infectious Diseases — Treatment Duration in Endocarditis: 4 Weeks, 6 Weeks, Other?"},"content":{"rendered":"
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National Library of Medicine<\/p><\/div>\n

Time to get back to some tough clinical decisions. It’s been a while.<\/p>\n

We’ve done The Abdominal Collection and Duration of Antimicrobial Therapy,<\/a>\u00a0Persistent MRSA Bacteremia<\/a>, and\u00a0The Positive Cultures for Candida in an ICU Patient<\/a>.<\/p>\n

However, that series of posts appeared here in early 2014, which means it’s been 5 years with no “Unanswerable Questions.”<\/p>\n

Lest you think that all Unanswerable Questions have<\/em> been answered — ha — here’s another one, inspired by a flurry of papers recently on a favorite topic, duration of antimicrobial therapy.<\/a><\/p>\n

To summarize virtually all of them — shorter is usually as good, if not better, than longer. Nice editorial here.<\/a><\/p>\n

Before we get to the case, an up-front apology that the question might seem simple. But I assure you, the answer is anything but straightforward. Bold prediction: there will be a substantial divergence in responses.<\/p>\n

Additionally, while the question may not seem like such a big deal, there are many interested parties eagerly awaiting our answer — including\u00a0our hospitalist, cardiology, and primary care colleagues, diverse insurance plans, homecare companies, outpatient pharmacies, and skilled nursing facilities. Most importantly, our patients and their families care a lot, too.<\/p>\n

And even though the correct answer to “How long should I treat?” is “Long enough” (thank you,\u00a0Bob Rubin!<\/a>), this doesn’t change the fact that consulting services really want to know a precise answer.<\/em> Ironic, huh?<\/p>\n

Here’s the case, an amalgam of many seen over the years:<\/p>\n

A 52 year old man is admitted with fever. On exam, he has a temperature of 101.5F and a loud systolic murmur. Two sets of admission blood cultures grow methicillin-sensitive Staph aureus.\u00a0<\/em>A cardiac ECHO shows a bicuspid aortic valve with a 0.5-cm vegetation.<\/p>\n

He is treated with oxacillin; follow-up blood cultures are negative by hospital day 3, and fevers slowly resolve. A peripherally inserted central catheter (PICC) is placed on hospital day 5, and cefazolin replaces oxacillin in anticipation of discharge home on IV antibiotics.<\/p>\n

The patient, the medical team, the homecare company, and your OPAT colleagues all await a specific “stop date” for the IV cefazolin.<\/p><\/blockquote>\n

The question:<\/p>\n

If he has a clinically stable course (no further positive cultures, no recurrent fevers, and no metastatic sites of infection), how long would you treat him with intravenous antibiotics?<\/strong><\/em><\/p>\n

Before you answer, you’re welcome to look at the guidelines — this is an open-book blog, after all:<\/p>\n