When should I order two-dimensional echocardiography to rule out endocarditis in a patient with staphylococcal bacteremia—at the outset or not until after verifying additional positive blood cultures and starting antibiotics?
—Jack Tomasino, MD, Clearwater, Fla.

Consider endocarditis after the diagnosis of bacteremia due to Staphylococcus aureus has been established. Suspicion would be increased by additional positive blood cultures, as well as other clinical factors, such as a murmur or evidence of embolic phenomena. In recent clinical guidelines for endocarditis published by the American Heart Association, transthoracic echocardiography is a reasonable test for patients at lower risk (Circulation. 2005;111:394-434). The timing of echocardiography is not as important; it may be performed immediately or after the commencement of antibiotic therapy.
—Cedric W. Spak, MD, MPH (112-3)

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