Adult Infectious Diseases Fellowship

Practice session

A 54-year-old man with no prior cardiac history presents with 2 weeks of remittent fever, malaise, and a new holosystolic murmur at the apex radiating to the axilla. Blood cultures grow methicillin-susceptible Staphylococcus aureus (MSSA) in 4 of 4 bottles within 12 hours. Transesophageal echocardiography (TEE) demonstrates a 16-mm mobile vegetation on the anterior leaflet of the mitral valve with severe mitral regurgitation and mild pulmonary venous systolic flow reversal. On hospital day 2, while receiving intravenous cefazolin, he develops sudden-onset left hemiparesis. Brain MRI reveals a 12-mm non-hemorrhagic cortical ischemic infarct in the right middle cerebral artery territory. What is the most appropriate next step in the management of this patient?

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