Approach to fever work up fever cases
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Approach to Fever Work Up Fever Cases. Pedro M. Calderon PGY-3. Learning Objectives. Definition of pyrexia, hyperpyrexia hyperthermia Pathophysiology of fever Evaluate best methods to measure temperature Diagnostic and therapeutic approach for fever in select patient populations

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Approach to fever work up fever cases

Approach to Fever Work Up Fever Cases

Pedro M. Calderon

PGY-3


Learning objectives

Learning Objectives

Definition of pyrexia, hyperpyrexia hyperthermia

Pathophysiology of fever

Evaluate best methods to measure temperature

Diagnostic and therapeutic approach for fever in select patient populations

Review of IDSA guidelines for important select clinical conditions that cause fevers


Definition

DEFINITION

  • Normal temperature 36.5ºC - 37.5ºC

    • Lowest temperature at 6 AM

    • Highest at 4 - 6 PM

    • Diurnals variations are maintained during illness

  • Hypothalamus control

    • Heat producers: muscle and liver

    • Heat dissipators: skin and lungs

  • Fever

    • A.M. temperature > 37.2 C

    • P.M. temperature > 37.7 C

  • Hyperpyrexia

    • Temp > 40.0ºC -41.5ºC

  • Each 1○C increase = 13% increase O2 consumption (without shivering)

Journal of Infection and Public Health (2011) 4, 108—124


Fever variations

Fever Variations

  • Hyperpyrexia

    • Temp > 40.0ºC -41.5ºC

      • Severe infections

      • CNS hemorrhage

  • Hyperthermia (Heat stroke)

    • Does not involve intrinsic body pyrogens

    • Exertional vs non-exertional

    • Skin: "hot and dry"

  • Drug induced hyperthermia

  • Malignant hyperthermia

  • Neuroleptic malignant syndrome

  • Serotonin syndrome


Where and when to measure

Where and When to Measure

  • Where to measure

  • Women and ovulation

    • Lower temp 2 weeks before ovulation

    • Raises by 0.6 during

  • Higher temperatures after eating


Approach to fever work up fever cases

Steroids

Exogenous

Pyrogens

Antipyretics


Fever symptomatology

Fever symptomatology*

  • Related to phases of fever

  • Initiation phase

    • Elevation of set point  chills/shivering/rigors

  • Plateau phase

    • Tc = Set point

  • Defervescence

    • Tc > set point

    • Patient feels warm  sweating

Tc = Core Temp


Etiologies

Etiologies

  • Non-infectious causes of fevers

    • Connective tissue disease

    • Malignancy

    • Medications

    • Myocardial infarction

    • Pulmonary embolism

  • Fever curve/height does not correlate with etiology

    • Fever > 39.4 F = Greater concern  infection

    • Fever > 40.8 = Tissue damage

  • Fever within 48 hours of admission is often caused by organisms found in the community


Use of fever patterns is controversial

Use of Fever Patterns is Controversial

  • Therapies may interfere with the generation of fevers

    • NSAIDS, steroids, etc.

  • Continuous fever

    • Drugs, RMSF, gram negative pneumonia

  • Remittent fever

    • Malaria, Legionella

  • Intermittent fevers

    • Endocarditis, peritonitis, sepsis, TSS

  • Do not use fever patterns alone to make a diagnosis


Etiology cont d

Etiology – Cont’d

  • Likelihood that fever is due to bacterial infection:

    • Advanced age

    • Indwelling catheter

    • Nursing home residency

    • Leukocytosis

    • Elevated ESR

    • Diabetes

  • Identification of source complicated if difficult history and physical examination

    • Understand potential causes of fever

    • Studied approach


Common acute febrile diseases may be nonfocal

Common Acute Febrile Diseases May Be Nonfocal


General approach to the patient

General Approach to the Patient

EPIDEMIOLOGY

Host Factors

Age

Sex

Local Defenses

Phagocytes

Complement

Antibodies

Cellular Immunity

Recent

Remote

Social Risks

Clinical Manifestations

Physical Exam


General work up of fever

General Work up of Fever


Fever general diagnostic approach clinical microbiology general principles

Fever: General Diagnostic ApproachClinical Microbiology General Principles

  • Blood cultures

    • Mandatory if new fever*

      • Clinical findings cannot exclude bacteremia

    • 2 sets from two different sites

    • 30-60 mins apart

    • Peripheral always preferred

      • Contamination vs bacteremia

    • Volume matters

      • 3% ↑ Sensitivity per mL

    • Contamination:

      • Staph epidermidis, Staph hominis, Bacillus spp, Corynecbacterium

    • Gram negative, fungi, and anaerobes are always pathogenic

    • Document clearance of bacteremia!


Fever general diagnostic approach clinical microbiology general principles1

Fever: General Diagnostic ApproachClinical Microbiology General Principles

  • Sputum – Gram stain and culture

    • Sputum vs saliva

    • New sputum, change in color, amount, thickness, new or progressive pulmonary infiltrate, increased RR, increased in VE, decreased oxygenation.

  • Urine culture

    • Catheter, obstruction, renal calculi, GU surgery, trauma, neutropenia

  • Stool culture

  • Nasal culture

  • Throat culture

  • Spinal fluid culture

  • Wound abscess culture

  • GU culture


Case 1

Case 1

55-year-old man with a history of mitral regurgitation seeks care after an episode of transient weakness in his right arm and speech difficulties. He underwent dental scaling 1 month earlier. He notes recent intermittent fevers and weight loss. On cardiac examination, his regurgitation murmur appears to be unchanged. A TTE shows a mobile, 12-mm mitral-valve vegetation and grade 2 (mild) regurgitation. Magnetic resonance imaging of the brain reveals recent ischemic lesions. How should the patient be further evaluated and treated?

N Engl J Med. 2013 Jun 27;368(26):2536.


Approach to fever work up fever cases

N Engl J Med 2013; 368:1425-1433


Fever caused by endocarditis diagnostic studies

Fever Caused by Endocarditis: Diagnostic Studies

  • 3 sets (aerobic & anaerobic bottles) from different sites

    • One hour apart

  • Repeat blood cultures every 24 hours

  • CBC, ESR, RFP, U/A, Urine culture

  • ECG

  • Imaging


Approach to fever work up fever cases

Circulation 2005;111;e394-e434


Fever caused by endocarditis empiric therapy

Fever Caused by Endocarditis:Empiric Therapy

  • Native valve acute bacterial endocarditis

    • Vancomycin +/- gentamycin

  • Prosthetic valve endocarditis

    • Vancomycin + cefepime + gentamycin

    • **Staphylococcal prosthetic-valve infective endocarditis, the regimen should include rifampin whenever the strain is susceptible + gentamicin

  • Repeat blood cultures until defervescence and blood culture negative

    • Fever may last a week

  • Duration of abx : 4-6 weeks


Fever caused by endocarditis surgical therapy

Fever Caused by Endocarditis:Surgical Therapy

  • Heart failure

  • Uncontrolled infection

    • Abscess, aneurysm, dehiscence

  • Persistent fevers or positive blood cultures for 5-7 days

  • Prevention of embolism from large vegetations (10-15 mm)


Case 2

Case 2

57-year-old man presents with fever, chills, and new lumbar back pain 2 weeks after undergoing a prostate biopsy because of an increased PSA level. His temperature is 39.7°C; he has an enlarged, tender prostate and lumbar spine tenderness. His white-cell count is 9.1, and the CRP level is 3.43 mg/L.

Urine and blood cultures reveal multidrug-resistant, extended-spectrum β-lactamase–producing Escherichia coli susceptible to imipenem. How should he be evaluated and treated?

N Engl J Med 2010;362:1022-9.


Approach to fever work up fever cases

N Engl J Med 2010;362:1022-9.


Fever caused by osteomyelitis diagnostic work up

Fever Caused by Osteomyelitis:Diagnostic Work Up

  • ESR, CRP >95% sensitivity

  • Blood cultures are crucial (30 - 78%)

  • MRI : high signal on T2 weighted image

    • CT or MRI are not 100% specific

  • Biopsy: If blood cultures are negative or if polymicrobial is suspected

    • Open or CT guided

    • Biopsy prior to antibiotics is preferred

  • Drain periosteal abscess


Case 3

Case 3

58 year old man is hospitalized because of fever and chills for the last 2 days. He denies productive cough, shortness of breath, headaches, nausea, vomiting, abdominal pain, diarrhea, dysuria, or rash. According to his wife, he has been "acting differently" for the past 24 hours. He was recently diagnosed with AML. His leukemia is currently in remission, and he is receiving maintenance chemotherapy.

He has no known drug allergies. Works at a local grocery and denies use of tobacco, alcohol or illicit drug. His temperature is 39.4 ºC, blood pressure 81/45 mm Hg, pulse is 122/min, and respirations 22/min. SaO2 96% on RA.

A Hickman catheter is present in the left IJ and it shows erythema and induration over the insertion site. Two sets of blood cultures are obtained, one from a peripheral vein and second from the catheter port. 3 liters of normal saline are given IV, this improves patient's hemodynamics. CXR shows infiltrates. UA without evidence of infection.


Fever and neutropenia

Fever and Neutropenia

  • Risk factors: Catheters, skin breakdown, GI mucositis, immune defects associated with malignancy

  • Seeding of bloodstream by GI flora*

  • Evaluation: Physical Exam

    • Teeth, eyes, skin, lungs, abdomen, rectum

    • Catheter sites

    • Avoid digital rectal examination

  • Work up : CBC with diff, RFP, CXR, LFTs, UA, at least two sets of blood cultures, CXR, ?C. difficile

  • Low threshold for ordering a CT scan

  • Other:

    • LP if confused, fungal markers*, bronchoscopy


Important cofactors in febrile neutropenia

Important Cofactors in Febrile Neutropenia

  • Type of underlying malignancy

    • Abnormal antibody production

      • High risk for encapsulated organism infection

    • T cell defects (e.g., Hodgkins Lymphoma)

      • High risk of Intracellular infections

  • Breeches in host defenses related to the underlying malignancy

  • The direct effects of chemotherapy on mucosal barriers and the immune system


Key points about bacterial infections in febrile neutropenic patients

Key Points About Bacterial Infections in Febrile Neutropenic Patients

  • Bacteria are the most frequent infectious causes of neutropenic fever

  • Shift from gram-negative bacteria to gram-positive bacteria

  • Gram-negative bacteria (eg, P. aeruginosa) are generally associated with the most serious infections

  • S. epidermidis is the most common gram-positive pathogen

  • An infectious source identified in 20 to 30 %

Ann Intensive Care. 2011;1:22-22.


Neutropenic fever is a hematologic emergency

Neutropenic Fever is a Hematologic Emergency


Fever and neutropenia algorithm

Fever and Neutropenia Algorithm


When to add gram positive coverage to the empirical regimen for neutropenic fever

When to Add Gram Positive Coverage to the Empirical Regimen for Neutropenic Fever

  • Vancomycin or Linezolid*

  • Fever not resolved after 3-5 days

  • Hemodynamically instability / Sepsis

  • CXR with pneumonia

  • Blood culture with gram positive bacteria

  • Suspicion for serious catheter-related infection

    • Chills/rigors with infusion through catheter

    • Cellulitis around catheter

  • Severe mucositis if fluroquinolone as prophylaxis and ceftazidime as empiric therapy

  • MRSA colonization

  • Remember Leuconostoc, Lactobacilus, and Pediococcus not covered with vancomycin


When to add fungal coverage to the empirical regimen for neutropenic fever

When to Add Fungal Coverage to the Empirical Regimen for Neutropenic Fever

  • Fungal colonizers

    • Candida yeast and aspergillus

  • Antifungal therapy after day 5-7

    • Caspofungin *

    • Amphoterecin B

    • Voriconozale

    • Micafungin

  • Do not use fluconazole in this setting

  • Fungal coverage resolves fever in 50% of patients

  • Cryptococus, Fusarium, Mucor, histo, blasto, cocci

  • ?Duration

    • 14 days if source if known

    • Source not known: Until afebrile + ANC > 500 c/µL

  • Role of G-CSF, $$

  • Anaerobic infections are not commonly seen


Tumor and malignancy

Tumor and Malignancy

Lymphoma, especially non-Hodgkin's*

Leukemia

Renal cell carcinoma (20% of cases)

Hepatocellular carcinoma or other tumors metastatic to the liver

Atrial myxomas (30% of cases)


Approach to fever work up fever cases

"“There are no shortcuts to any place worth going.”

Beverly Sills


Case 4

Case 4

20-year-old man who had a history of IV drug use and multiple sexual partners initially presented to the ED with a chief complaint of blood per rectum when he passed stool, and chills for the prior few days. His work-up was normal, including a rapid HIV screen, and he was discharged.

He returned 2 weeks later with constipation, fatigue, myalgias, decreased urination, chills, and a productive cough. His physical examination was most remarkable for temp 39.2, HIV antibody test was negative, but his laboratory tests showed an elevation of CK, amylase, and lipase. His blood count showed a normal hematocrit and white blood cell count. HIV viral load was reported as > 1,000,000 copies/mL.

J Emerg Med. 2013 May;44(5):e341-4


Fever in patients with hiv aids

Fever in Patients with HIV/AIDS

  • Fever almost always accompanies the acute retroviral syndrome

  • Drug adverse effect (Bactrim)

  • Lymphoma

  • Opportunistic disease


Fever in hiv aids patients

Fever in HIV / AIDS Patients

  • Opportunistic infections uncommon if CD4 > 200

    • TB exception

    • M. avium rare if CD4 > 50

  • Neutropenia can develop in patients with HIV

    • Primary infection

    • Secondary infection

    • Bone marrow suppression of therapy

      • Zidovudine

  • HIV + Neutropenia + Fever = Infection*


Predominant causes of fever in hiv aids patients

Predominant Causes of Fever in HIV / AIDS Patients

  • Bacteria:

    • More common in children > adults, Strep. Pneumonia, salmonella, enteric bacteria, pseudomonas, salmonella, enteric bacteria

  • Viruses

    • HSV, CMV, VZV, EPV, Adenovirus, parainfluenza, measles

  • Fungi

    • Candida, cryptococcus, histoplasma, coccidioides, pneumocystis carinii, toxoplasma, cryptosporidia, microsporida


Association of specific sites with fever in hiv aids patients

Association of Specific Sites with Fever in HIV / AIDS Patients


Approach to fever work up fever cases

N Engl J Med. 1999 Sep 16;341(12):893-900


Acute febrile conditions often warranting empiric antimicrobials

Acute Febrile Conditions Often Warranting Empiric Antimicrobials

  • Fever > 40.8

  • Immunosuppresion

    • Neutropenia

    • Asplenia

    • Hypogammaglobulinemia

    • Cirrhosis

  • Elderly

  • Unstable vitals signs

  • Presence of prosthetic device/foreign body

  • Recent bite, travel


Drug fever

DRUG FEVER

  • Fever coinciding with administration Disappearing after the discontinuation

    • Diagnosis of exclusion

    • 6.7% of patients admitted

    • Timing not always helpful: Median 8 days

  • HIV infection increased susceptibility to drug reactions, including fever

  • ↑ Serum/Urine eosinophil (<20% of patients)

  • Causes: Pyrogenic contaminants, hypersensitivity reactions, genetic determinants

  • Stop most probable offending drug first


Fever and connective tissue diseases

Fever and Connective Tissue Diseases

Vasculitis

Giant cell arteritis

Adult still’s disease

Polyarteritis nodosa

Granulomatosis polyangitis

Mixed cryoglobulinemia

SLE

Sarcoidosis


Fever to lower or not to lower

Fever: To Lower or Not to Lower

  • Yes

    • Temperature > 40.8 ºC (Tissue damage)

    • Metabolic stress of fever (e.g., ACS)

  • No

    • Stimulates immune function

    • Decreases iron necessary for pathogen survival

    • Artificially lowering temperature does not allow for monitoring


Approach to fever work up fever cases

“The future belongs to those who believe in the beauty of their dreams.”

–Eleanor Roosevelt


Case 6

Case 6

47 year old man with HTN, HLP, asthma, admitted to the MICU 5 days ago from ED with acute asthma attack which required intubation in the ED. Initial vitals Temp: 38.7, HR 110, BP 90/42, 95% on the vent with 50% FiO2, RR 20 (above vent). Patient has right radial arterial line, right IJ central line, sites which do not appear erythematous or indurated. Pt also has OG. Chest x-ray with new small left lower lobe infiltrate, ETT 3 cm above carina, Right central line with tip in SVC, no pneumothorax. Labs with CBC 15/12/36/253, 79% neutrophils, 2% eosinophils. RFP within normal limits. Patient is on steroids, but no antibiotics.

How would you work up and manage fever in this patient?


Fever in the critically ill patient

Fever in the Critically Ill Patient

  • 50% of patients admitted to the ICU

  • Fever associated with mortality in ICU

  • Classifications

    • Hyperthermia syndromes

      • Heat stroke, malignant hyperthermia

    • Infectious

      • Bacterial, protozoa, fungal, viral, parasitic

    • Non-infectious

      • Transfusion reactions, drugs, VTE, hematomas, MI, pancreatitis, neurogenic fever

J Intensive Care Med. 2012 Sep-Oct;27(5):290-7.


Fever in the critically ill patient1

Fever in the Critically Ill Patient

  • Compromised natural host defenses

    • Invasive monitoring

      • Violation of skin barrier

      • Microbial colonization

    • Endotracheal intubation

      • Retards mucociliary clearance

    • Nasogastric tubes

      • Splints open GE junction  aspiration of gastric contents

    • TPN

    • Already on antibiotics  resistant infections


Fever in the icu non infectious causes

Fever in the ICU: Non-Infectious Causes

  • Non-infectious causes

    • More so if temp > 41

  • Without Shock

    • Transfusion reactions

    • Drug fever

    • Acalculous cholecystitis

    • Mesenteric ischemia

    • Pancreatitis

    • Thromboembolic disease

  • Without Shock

    • Adrenal crisis

    • Thyroid storm

    • Acute hemolytic transfusion reaction


Major decision making in the febrile critically ill patient

Major Decision Making in the Febrile Critically Ill Patient

  • Empiric antibiotics

    • Deteriorating

    • Shock

    • Neutropenic

    • LVAD

    • Fever > 38.9 C(102 F)

  • Removal of lines


Fever of unknown origen

Fever of Unknown Origen

  • Definition:

    • Temp: > 38.3ºC

    • Lasting >3 weeks

    • 1 week of intensive studying*

      • History, PE, CBC with diff, LFTs, blood cultures (3 sets from different sites without abx), hepatitis serology, UA, CXR

  • Same major categories:

    • Infectious, malignancies, connective tissue dz


Fever of unknown of origin

Fever of Unknown of Origin

  • True FUO are uncommon

  • Typical distribution:

    • Non-infectious 22%

    • Infection 16%

    • Malignancy 7%

    • Miscellaneous 4%

    • No diagnosis 51%

  • Contributing factors: Age, AIDS, Neutropenia

  • No diagnosis in 10-50% of cases

    • Good prognosis, mortality ~1%


Additional diagnostic testing

Additional Diagnostic Testing

  • ESR or CRP

  • Serum lactate dehydrogenase

  • Tuberculin skin test or interferon-gamma release assay

  • HIV antibody assay and HIV viral load for patients at high risk

  • Three routine blood cultures drawn from different sites over a period of at least several hours without

  • Administering antibiotics, if not already performed*

  • Rheumatoid factor

  • Creatine phosphokinase

  • Heterophile antibody test in children and young adults

  • Antinuclear antibodies

  • Serum protein electrophoresis

  • CT scan of chest, abdomen, pelvis


Nuclear medicine testing in fever of unknown origin

Nuclear Medicine Testing in Fever of Unknown Origin

  • Controversial and nonspecific

  • Highly sensitive: Gallium-67 and indium-111 Leukocyte scan

    • Compared to CT / US covers a larger body area

  • In series of 145 cases of FUO:

    • Useful in 29% of cases

    • Fall positives 11-20% of cases

  • Reserve nuclear evaluation if initial eval remains negative and a screening “look” at whole body is desired

  • Be aware of false and true positive rates


Conclusion

Conclusion

  • Temperature should be measured with precision and consistency

  • Approach to patient with fever requires evaluation of clinical manifestation, host factors and epidemiology

  • Neutropenic fever is a medical emergency

  • In all cancer patients presenting with neutropenic fever, empiric antibacterial therapy should be initiated immediately

  • Have a low threshold for antibiotics in the critically ill patient


Which fevers you should not treat

Which fevers you should not treat…

Love fever

Barrel fever

Buck fever

Staff fever

Cabin fever

Disco fever (boogie fever)

Gate fever

Bieber fever


Acknowledgments

Acknowledgments

  • Muriel Ghosn, MD

  • Salim Thabet, MD


Approach to fever work up fever cases

"I do not actually remember which one of my parents taught me this, but one of them told me: 'Son, in this world there are stupid people and there are smart people; there are mean people and there are nice people. If you are smart and nice, you will do well in your work and have a lot of friends. If you are smart and mean, you will be successful but not happy. If you are stupid and nice, you will not be successful but at least you will be happy. But if you are stupid and mean, you will not get anywhere in life.' knowing my limitations, I have always aspired to be the nicest person I can ever be."

--Chin-to Fong , MD

University of Rochester


References

References

  • Porat R, Weller PF, Thomer AR. Pathophysiology and treatment of fever in adults. UpToDate UptoDate 2013. Last accessed 2013.

  • Wingard JR, Marr KA, Thorner AR. Diagnostic Approach to the adult presenting with Neutropenic Fever. UpToDate 2013. Last accessed 2013.

  • Barbour AG, Sexton DJ, Mitty J. Clinical features, diagnosis, and management of relapsing fever. UptoDate 2013. Last accessed 2013.

  • Henker R, Kramer D. Fever. AACN Clinical Issues 1997. 8(3): 351-367.

  • http://en.wikipedia.org/wiki/File:Biological_clock_human.svg

  • Pizzo PA. Fever in Immunocompromised Patietns. NEJM (1999) 341(12): 893-900.

  • Ogoina DO. Fever, fever pattern and diseases called "fever" - A review. Journal of Infection and Public Health (2011) 4, 108—124.

  • Arnold BM, Casal G, Higgins. Apathetic thyrotoxicosis. Can Med Assoc J. (1974), 111(9): 957–958.

  • Clinician's Pocket Medicine. Chapter 7: Clinical Microbiology.

  • Levinson W. Chapter 9. Laboratory Diagnosis.

  • Review of Medical Microbiology & Immunology, 12th ed. New York: McGraw-Hill;2012.

  • Legrand M, Max A, Schlemmer B, Azoulay E, Gachot B.The strategy of antibiotic use in critically ill neutropenic patients. Ann Intensive Care. 2011 Jun 15;1(1):22.

  • Naurois J, NOvitzky, Gill MJ, Marti M, Cullen MH, Roila. Management of febrile neutropenia: ESMO Practice Guidelines. Clinical Practice Guidelines. Annals of Oncology 21 (Supplement 5): v252-v256, 2010.

  • Flowers CR, Seidenfeld J, Bow EJ, Karten C, Hawley DK, Langston AA, Marr, K. Antimicrobial Prophylaxis and Outpatient Management of Fever and Neutropenia in Adults Treated for Malignancy: American Society of Clinical Oncology Clinical Practice Guideline. J Oncol Pract. Pages: 1-35.

  • Syrjala M, Valtonen V, Liewendahl, Myllyla G. Diagnostic Significance of Indium-111 Granulocyte Scintigraphy in Febrile Patients. J Nuc Med 28: 155-160, 1987

  • Baddour et al. Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement of Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association. Circulation 2005; 111; e394-e434.

  • Niven DJ, Léger C, Stelfox HT, Laupland KB.Fever in the critically ill: a review of epidemiology, immunology, and management. J Intensive Care Med. 2012 Sep-Oct;27(5):290-7.

  • O'Grady NP, Barie PS, Bartlett JG, Bleck T, Carroll K, Kalil AC, Linden P, Maki DG, Nierman D, Pasculle W, Masur H; American College of Critical Care Medicine; Infectious Diseases Society of America. Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of America. Crit Care Med. 2008 Apr;36(4):1330-49.

  • Lyman GH, Rolston KV. How we treat febrile neutropenia in patients receiving cancer chemotherapy. J Oncol Pract. 2010 May;6(3):149-52.

  • Hoen B, Duval X. Clinical practice. Infective endocarditis. N Engl J Med. 2013 Apr 11;368(15):1425-33.


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