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Ultrasound, antibiotic prophylaxis and endocarditis

01 November 2005

Mrs N had a complex medical history; in her early twenties she had a splenectomy, chemotherapy and radiotherapy for treatment of Hodgkin’s disease. This caused ovarian failure and she then developed a pelvic abscess which left her fallopian tubes occluded.

When she was in her mid-forties she was diagnosed as having aortic stenosis, and her cardiologist advised that, in future, she would need antibiotic prophylaxis for any dental, proctological, urological or gynaecological procedures.

A few years after this, Mrs N consulted Dr F with a view to undergoing in vitro fertilisation (IVF). Dr F performed a contrast ultrasound scan, which identified the presence of several endometrial polyps. Although she did not give Mrs N antibiotic prophylaxis for this procedure, there were no problems. Shortly after this, another gynaecologist carried out a hysteroscopic polypectomy under antibiotic cover.

A further endometrial polyp was identified by an ultrasound scan the following month, and this was confirmed by Dr F carrying out a saline ultrasound. This latter procedure caused Mrs N considerable discomfort, requiring three attempts to pass the catheter through the cervix.

Dr F prescribed amoxicillin after the procedure, but Mrs N became unwell that night and was admitted to hospital two days later with pelvic inflammatory disease (PID) and endocarditis.

Although aggressive treatment with antibiotics resolved her endocarditis, Mrs N’s cardiac condition was worsened to the extent that she required an aortic valve replacement. She brought a claim against Dr F, alleging that carrying out the saline ultrasound without first providing antibiotic prophylaxis was negligent.

Expert opinion

We consulted an expert in gynaecology who concluded that, in light of Mrs N’s previous history and her cardiologist’s advice – together with guidelines current at the time – Dr F could be criticised for not providing antibiotic prophylaxis. Although there is no evidence base to support his figure, this expert thought – based on his own experience – that antibiotic prophylaxis in such a patient would have reduced the chance of a flare up of PID to less than 20%.

We settled the claim for the equivalent of £92,000 (US$165,000), with costs of £96,000 (US$170,000). 

Learning points

Endocarditis prophylaxis – Although the evidence base for endocarditis prophylaxis is limited, most guidelines currently recommend antibiotic cover for high- and medium-risk patients undergoing diagnostic and therapeutic interventions that might cause bacteraemia.

The European Society of Cardiology1 lists these as:

  • bronchoscopy (rigid instrument)
  • cystoscopy during urinary tract infection
  • biopsy of urinary tract/prostate
  • dental procedures with the risk of gingival/mucosal trauma
  • tonsillectomy and adenoidectomy
  • oesophageal dilatation/sclerotherapy
  • instrumentation of obstructed biliary tracts
  • transurethral resection of prostate
  • urethral instrumentation/ dilatation
  • lithotripsy
  • gynaecologic procedures in the presence of infection
  1. The Task Force on Infective Endocarditis of the European Society of Cardiology,Guidelines on Prevention, Diagnosis and Treatment of Infective Endocarditis (2004)