A 45-year-old woman comes to the physician due to a 4-month history of vague abdominal pain that is unrelated to food intake. The pain occasionally occurs in the middle of the night. She has had loss of appetite during this period but no nausea, vomiting, weight loss, or blood in the stool. Three years ago, the patient had aortic valve replacement with a mechanical valve for bicuspid aortic valve and aortic root repair. Her only medication is daily warfarin. Recent laboratory results showed hemoglobin of 11.2 g/dL and an INR of 2.5. Echocardiography 4 weeks ago revealed normal left ventricular function and a normally functioning prosthetic aortic valve. She is scheduled for upper gastrointestinal endoscopy to evaluate her abdominal pain. The decision is made not to interrupt her anticoagulation. Which of the following is the best additional recommendation before this patient's procedure?

Question

A 45-year-old woman comes to the physician due to a 4-month history of vague abdominal pain that is unrelated to food intake.  The pain occasionally occurs in the middle of the night.  She has had loss of appetite during this period but no nausea, vomiting, weight loss, or blood in the stool.  Three years ago, the patient had aortic valve replacement with a mechanical valve for bicuspid aortic valve and aortic root repair.  Her only medication is daily warfarin.  Recent laboratory results showed hemoglobin of 11.2 g/dL and an INR of 2.5.  Echocardiography 4 weeks ago revealed normal left ventricular function and a normally functioning prosthetic aortic valve.  She is scheduled for upper gastrointestinal endoscopy to evaluate her abdominal pain.  The decision is made not to interrupt her anticoagulation.  Which of the following is the best additional recommendation before this patient's procedure?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c11a_0118_8f63_27a011fdf3ce_MD0005_00 This patient has a high-risk cardiac condition (mechanical prosthetic aortic valve), which increases the risk of developing infective endocarditis (IE). However, even in patients with high-risk cardiac conditions, the absolute risk of developing IE from a gastrointestinal (GI) or genitourinary (GU) tract procedure (eg, esophagogastroduodenoscopy, urethral stricture dilation) is low. Therefore, the administration of antibiotics to prevent IE is not recommended in most patients undergoing such a procedure. Only patients with a high-risk cardiovascular condition and ongoing GI or GU infection should receive appropriate antibiotic therapy, including an agent active against enterococci (eg, ampicillin, vancomycin), prior to the procedure. Procedures that warrant antibiotic prophylaxis for IE in patients with high-risk cardiac conditions in the absence of active infection include: Dental procedures that involve manipulation of gingival tissue or the periapical region of teeth (eg, routine dental cleaning) or perforation of the oral mucosa Respiratory tract procedures that involve incision or biopsy of the respiratory mucosa (eg, tonsillectomy, bronchoscopy with biopsy) Surgical placement of prosthetic cardiac material (Choices A, B, D, and E) Unless there is active GI or GU infection, the administration of antibiotics for the prevention of IE is not indicated prior to a GI or GU tract procedure, even in patients with high-risk cardiovascular conditions (eg, prosthetic heart valve). Educational objective: Antibiotic prophylaxis to prevent infective endocarditis is not recommended in patients undergoing gastrointestinal (GI) or genitourinary (GU) tract procedures, even in the setting of a high-risk cardiovascular condition. However, patients with a high-risk cardiovascular condition and an ongoing GI or GU infection should receive appropriate antibiotics, including an agent active against enterococci (eg, ampicillin, vancomycin), prior to the procedure. References: Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. (http://www.ncbi.nlm.nih.gov/pubmed/17446442) Infective endocarditis prevention: update on 2007 guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/18501225)

A 45-Year-Old Woman Comes to the Physician Due to a 4-Month