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    4-5 YEARS

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    April 25, 2013

    Dear Physician:

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    ThisJournalfeature begins with a case vignette highlighting a common clinical problem.Evidence supporting various strategies is then presented, followed by a review of formal guidelines,

    when they exist. The article ends with the authors clinical recommendations.

    An audio versionof this article isavailable atNEJM.org

    Infective Endocarditis

    Bruno Hoen, M.D., Ph.D., and Xavier Duval, M.D., Ph.D.

    From Service de Maladies Infectieuses etTropicales, Centre Hospitalier RgionalUniversitaire, and Unit Mixte de Recher-che 6249 Chrono-environnement, CentreNational de la Recherche Scientifique,Universit de Franche-Comt, Besanon(B.H.); Association pour lEtude et laPrvention de lEndocardite Infectieuse,Paris (B.H., X.D.); and INSERM Centre

    dInvestigation Clinique 007, AssistancePubliqueHpitaux de Paris, HpitalUniversitaire Bichat, and INSERM Unit738, Universit Paris Diderot, Paris 7,Unit de Formation et de Recherche deMdecineBichat, Bichat (X.D.) all inFrance. Address reprint requests to Dr.Hoen at Service de Maladies Infectieuseset Tropicales, CHRU de Besanon, 25030Besanon CEDEX, France, or at [email protected].

    Drs. Hoen and Duval contributed equallyto this article.

    N Engl J Med 2013;368:1425-33.

    DOI: 10.1056/NEJMcp1206782Copyright 2013 Massachusetts Medical Society.

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

    THE CLINICAL PROBLEM

    Infective endocarditis has an estimated annual incidence of 3 to 9 cases per 100,000persons in industrialized countries.1-7The male:female case ratio is more than 2:1.The highest rates are observed among patients with prosthetic valves, intracardiacdevices, unrepaired cyanotic congenital heart diseases, or a history of infective endo-carditis, although 50% of cases of infective endocarditis develop in patients with noknown history of valve disease. Other risk factors include chronic rheumatic heartdisease (which now accounts for

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    Coxiella burnetii(the agent causing Q fever), bacte-ria in the HACEK group (haemophilus species,Aggregatibacter [formerly Actinobacillus] actinomy-cetemcomitans, Cardiobacterium hominis, Eikenella cor-rodens, and Kingella kingae), and Tropheryma whip-plei.6,10,11

    PATHOGENESIS

    Normal valvular endothelium is naturally resistantto colonization by bacteria. In the conventionalmodel of native-valve infectious endocarditis, in-fection results from the colonization of damagedvalvular endothelium by circulating bacteria withspecific adherence properties. Endothelial dam-age may result from so-called jet lesions due toturbulent blood f low or may be provoked by elec-trodes or catheters or by repeated intravenous in-jections of solid particles in intravenous-drug users.Chronic inf lammation, as in chronic rheumaticheart disease and degenerative valvular lesions,12may also promote infective endocarditis. How-ever, the conventional model may not accuratelyexplain the pathogenesis of infective endocardi-tis due to intracellular microorganisms, such asC. burnetii, bartonella species, or T. whippelii, in which

    the exposure and immune response of the host mayplay a prominent role.13

    CLASSIFICATION

    Whereas infective endocarditis was previously clas-sified according to its mode of presentation (acute,subacute, or chronic), it is now categorized accord-ing to underlying cardiac conditions, location,the presence of intracardiac devices, or the modeof acquisition. These classif ications overlap, withsome cases of infective endocarditis belonging to

    more than one group. Table 1 in the Supplemen-tary Appendix shows the distribution of cases

    among these categories and the correspondingmicroorganisms.

    OUTCOMES

    In contemporary population-based studies of in-fective endocarditis in industrialized countries, in-hospital mortality ranges from 15 to 22%,5,7and5-year mortality is approximately 40%.14How-ever, rates vary widely across subgroups of pa-tients. For instance, in-hospital mortality is lessthan 10% among patients with right-sided lesionsor oral streptococcal, left-sided, native-valve le-sions, whereas it is 40% or more among patientswith prosthetic-valve infective endocarditis dueto Staphylococcus aureus. In a multivariate analysisassessing risk factors for death among patientswith infective endocarditis, independent predic-tors included higher age, S. aureusinfection, heartfailure, cerebrovascular and embolic events, andhealth careassociated infective endocarditis.5,7

    STR ATEGIES AND EVIDENCE

    PRESENTATION AND DIAGNOSIS

    The diagnosis of infective endocarditis is generallybased on clinical, microbiologic, and echocar-diographic findings. The Duke criteria (Table 1)have sensitivity and specificity of more than 80%and are the reference criteria for diagnosis.15However, they should not replace clinical judg-ment for diagnosis in the individual patient, es-pecially in the first stage of care.

    Fever is common, occurring in 80% of cases.6,7In large, contemporary case series, recognition of

    key Clinical points

    infective endocarditis

    Staphylococci and streptococci account for 80% of cases of infective endocarditis, with staphylococci currently the most

    common pathogens.

    Cerebral complications are the most frequent and most severe extracardiac complications. Vegetations that are large, mo-

    bile, or in the mitral position and infective endocarditis due to Staphylococcus aureusare associated with an increased risk of

    symptomatic embolism.

    Identifying the causative microorganism is central to diagnosis and appropriate treatment; two or three blood cultures

    should routinely be drawn before antibiotic therapy is initiated.

    When infective endocarditis is suspected, echocardiography should be performed as soon as possible.

    Indications for surgery include heart failure, uncontrolled infection, and prevention of embolic events.

    Treatment should involve a multidisciplinary team with expertise in cardiology, cardiac surgery, and infectious disease.

    Indications for antibiotic prophylaxis have been restricted to invasive dental procedures in patients with a prosthetic valve,

    a history of infective endocarditis, or unrepaired cyanotic congenital heart disease.

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    a new murmur and worsening of a known murmurare reported in 48% and 20% of cases, respectively.Other signs are less common: hematuria in 25%of cases, splenomegaly in 11%, splinter hemor-rhages in 8%, Janeways lesions in 5%, Rothsspots in 5%, and conjunctival hemorrhage in 5%.Sepsis, meningitis, unexplained heart failure, sep-tic pulmonary emboli, stroke, acute peripheralarterial occlusion, and renal failure may also bepresenting manifestations.16Elevated inflamma-tory markers (erythrocyte sedimentation rate andC-reactive protein level) are observed in two thirdsof cases, and leukocytosis and anemia in abouthalf the cases.6,17

    Cerebral complications are the most severe ex-tracardiac complications of infective endocarditis,as well as the most frequent (occurring in 15 to20% of patients).18,19They include ischemic andhemorrhagic stroke (preceding the diagnosis of

    infective endocarditis in 60% of patients20,21

    ),transient ischemic attack, silent cerebral embolism,mycotic aneurysm, brain abscess, and meningitis.Specific characteristics of vegetations (those thatare large, mobile, and located in the mitral valve)21and S. aureusinfection21,22have been associatedwith an increased risk of symptomatic embolicevents. Systematic magnetic resonance imaging(MRI) of the brain may reveal cerebral abnormali-ties in up to 80% of patients, including embolicevents (mostly asymptomatic) in 50%.23

    Mycotic aneurysms result from septic arterialembolism to the intraluminal space or vasa vaso-rum and spread of infection through the vesselwall. These aneurysms were reported in 5% ofcases in older case series,24 but they are nowdetected more frequently because of the wider useof imaging. Magnetic resonance angiography isthe best confirmation test.25

    MICROBIOLOGIC DIAGNOSIS

    Identifying the causative microorganism is cen-tral to making the diagnosis of infective endocar-ditis and guiding antimicrobial treatment. Bloodcultures should be performed routinely before theadministration of antibiotics. When three sets ofblood cultures are performed, the pathogen isidentified in about 90% of cases. Serologic testsfor bartonella,C. burnetii, and brucella should beperformed in patients with negative blood cultures

    who have risk factors for these infections. If thecausative pathogen has not been identified bymeans of blood cultures and the patient requiresvalve surgery, gene amplification in cardiac-valvespecimens, as well as immunostaining tech-niques, if available, may yield a microbiologicdiagnosis.10,26,27

    DIAGNOSIS OF VALVULAR LESIONS

    Transthoracic echocardiography is performed firstand is better than transesophageal echocardiog-

    Incidence

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    Enterococci

    Group D streptococci

    Oral and pyogenicstreptococci

    Coagulase-negativestaphylococci

    Staphylococcus aureus

    Figure 1.Incidence of Definite Infective Endocarditis, According to Age and Microorganism.

    Streptococci and staphylococci account for 80% of cases of infective endocarditis, with proportions varying according

    to valve (native vs. prosthetic), source of infection, patient age, and coexisting conditions. The clustering of variouspredisposing factors with age probably explains the higher incidence of infective endocarditis in persons 65 yearsof age or older. Adapted from Selton-Suty et al.7

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    raphy for detecting abscesses in the anterior aortic

    valve in a patient with a prosthetic valve and forassessing the hemodynamic consequences of val-vular dysfunction. Transesophageal echocardiog-raphy has higher sensitivity and specificity overalland is recommended when the results of trans-thoracic echocardiography are negative and thereis a high clinical suspicion, poor imaging quality,and the presence of prosthetic valves or an intra-cardiac device, as well as in cases in which thetransthoracic echocardiographic findings are sug-gestive of infective endocarditis but not definitive.

    Combined transthoracic and transesophageal

    echocardiography shows vegetations (Fig. 2) in90% of cases, valve regurgitation in 60%, para-valvular abscess in 20%,6,7and infrequently, de-hiscence of the prosthesis, pseudoaneurysms, andfistulas. In cases with initially negative findingson echocardiography, repeat examination shouldbe performed if infective endocarditis continuesto be suspected. Repeat transthoracic or trans-esophageal echocardiography is recommended ifa new complication is suspected and when ther-apy has been completed.

    Table 1.Duke Criteria for the Diagnosis of Infective Endocarditis.*

    Definite diagnosis

    Pathological criteria: microorganisms identified by culture or histologic examination of a vegetation, a vegetation that hasembolized, or an intracardiac abscess specimen; or active endocarditis confirmed by histologic examina-tion of vegetation or intracardiac abscess

    Clinical criteria: two major, one major and three minor, or five minor criteria

    Major clinical criteria

    Blood culture positive for infective endocarditis

    Microorganisms typically associated with infective endocarditis identified from two separate blood cultures:viridans streptococci, Streptococcus bovis, bacteria in the HACEK group, or Staphylococcus aureus; orcommunity-acquired enterococci in the absence of a primary focus

    Microorganisms consistent with infective endocarditis identified from persistently positive blood cultures:at least two positive cultures of blood samples drawn >12 hr apart, or positive results of all of three or amajority of four or more separate blood cultures (with first and last samples drawn at least 1 hr apart)

    Single positive blood culture for Coxiella burnetiior IgG antibody titer for Q fever phase 1 antigen >1:800

    Evidence of endocardial involvement

    Echocardiogram positive for infective endocarditis: pendulum-like intracardiac mass on valve or supportingstructures, in the path of regurgitant jets, or on implanted material in the absence of an alternative ana-

    tomical explanation; abscess; or new partial dehiscence of prosthetic valveNew valvular regurgitation (worsening or changing of preexisting murmur not a sufficient criterion)

    Minor clinical criteria

    Predisposition to infective endocarditis, such as a predisposing heart condition, or intravenous drug use

    Fever, defined as a temperature >38C

    Vascular phenomena, such as major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranialhemorrhage, conjunctival hemorrhage, and Janeways lesions

    Immunologic phenomena, such as glomerulonephritis, Oslers nodes, Roths spots, and rheumatoid factor

    Microbiologic evidence: positive blood culture but with no major clinical criterion met or serologic evidence ofactive infection with an organism consistent with infective endocarditis

    Possible diagnosis

    Clinical criteria (see above): one major criterion and one minor criterion or three minor criteria

    Rejected diagnosis

    Firmly established alternative diagnosis; resolution of infective endocarditislike syndrome with antibiotic therapy for4 days; no pathological evidence of infective endocarditis at surgery or autopsy, with antibiotic therapyfor 4 days; or criteria for possible infective endocarditis not met

    * Adapted from Li et al.15HACEK denotes haemophilus species,Aggregatibacter(formerlyActinobacillus)actinomycetem-comitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae.

    Transesophageal echocardiography is recommended in patients with prosthetic valves and possible infective endocarditisaccording to clinical criteria or infective endocarditis complicated by paravalvular abscess; transthoracic echocardiographyis recommended as the first test in other patients.

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    TREATMENT

    The treatment of patients with suspected or con-firmed infective endocarditis should be providedby a multidisciplinary team with expertise in car-diology, cardiac surgery, and infect ious disease.28Successful treatment is dependent on eradicationof the causative agent, which requires prolonged

    bactericidal antibiotic treatment. Surgery may con-tribute to this goal by removing infected materialand draining abscesses.

    Antibiotic Treatment

    Guidelines for appropriate antibiotic treatment ofinfective endocarditis are published by profession-al societies and updated regularly.29-31Table 2 inthe Supplementary Appendix is adapted from theEuropean Society of Cardiology guidelines andreviews antibiotic regimens recommended be-fore an organism is identif ied and for most com-

    mon causative bacteria.30

    For native-valve infective endocarditis due tocommon microorganisms, the duration of anti-biotic treatment ranges from 2 weeks (for un-complicated infective endocarditis due to fullypenicillin-susceptible streptococci treated with abeta-lactam antibiotic combined with an amino-glycoside) to 6 weeks (for enterococcal infectiveendocarditis). For infective endocarditis involvinga prosthetic valve, the duration of antibiotic thera-py is usually 6 weeks, and regimens are basi-cally the same as those for native-valve infectiveendocarditis, with the notable exception of staphy-lococcal prosthetic-valve infective endocarditis,for which the regimen should include both rif-ampin, whenever the strain is susceptible to thisantibiotic, and gentamicin.

    When valve replacement is performed duringantibiotic treatment of native-valve infective endo-carditis, the duration of antibiotic therapy shouldremain the same as the duration recommendedfor native-valve infective endocarditis and shouldnot be switched to that recommended for pros-

    thetic-valve infective endocarditis. In both na-tive-valve and prosthetic-valve infective endocar-ditis, the duration of treatment should becalculated from the first day of appropriate anti-biotic therapy, not from the day of surgery. Aftersurgery, a new full course of treatment should bestarted only if valve cultures are positive.32

    Among aminoglycosides, only gentamicin hasbeen fully evaluated for the treatment of infec-tive endocarditis and should be used when thedisease is caused by gram-positive cocci. Clinical

    trials have shown that a 14-day course of genta-

    micin, given once daily instead of twice daily, incombination with ceftriaxone is effective for thetreatment of uncomplicated cases of streptococcalinfect ive endocarditis involving a native valve.33,34Combination therapy with a beta-lactam antibi-otic and an aminoglycoside should be used forprosthetic-valve infective endocarditis (Table 2 inthe Supplementary Appendix).

    In cases of enterococcal infective endocarditis,whenever the strain does not exhibit high-levelresistance to gentamicin, that drug should be usedin combination with an antibiotic agent that isactive against the bacterial cell wall. Gentamicinis generally given for the full 6-week course ofantibiotic treatment; however, in an observationalstudy, the cure rate of enterococcal infective endo-carditis was as high as 81%, with a median dura-tion of aminoglycoside administration of 15 days.This suggests that shorter courses of aminogly-cosides (2 to 3 weeks), which minimize the riskof renal toxicity, may be effective.35The questionof whether gentamicin should be administeredin divided daily doses continues to be debated;

    clinical data are lacking, and experimental dataare conflicting. The combination of ampicillin(at a dose of 12 g per 24 hours) with ceftriaxone(at a dose of 2 g twice daily) may be effective ininfective endocarditis due to Enterococcus faecalis,regardless of whether the strain is highly resis-tant to gentamicin36or not highly resistant.37

    Gentamicin is no longer recommended forstaphylococcal infective endocarditis involving anative valve, because there is no documentedclinical benefit and there is a risk of nephrotox-

    LA

    LV

    Figure 2.Transesophageal Echocardiogram Showing

    a Large Vegetation on a Native Aortic Valve.

    A large vegetation (white arrow) can be seen near the

    mitral valve (black arrow). LA denotes left atrium, andLV left ventricle.

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    icity.38In cases involving a prosthetic valve, how-ever, a regimen that includes gentamicin for thefirst 2 weeks is recommended, especially in casesof methicillin-resistant S. aureus(MRSA) infection,to mitigate the risk of selection of rifampin-resistant escape mutants.

    Daptomycin (at a dose of 6 mg per kilogram

    of body weight per day, given once daily) wasapproved by the Food and Drug Administrationfor adults with S. aureus bacteremia and right-sided infective endocarditis, on the basis of arandomized trial showing its noninferiority tostandard therapy (vancomycin or an antistaphy-lococcal penicillin).39Observational studies havealso shown the efficacy of daptomycin in pa-tients with left-sided infective endocarditis40and in patients with infective endocarditis in-volving an implanted intracardiac device (withdaptomycin used at a dose of 8 to 10 mg per

    kilogram per day).41Daptomycin has been recom-mended as an alternative to vancomycin for thetreatment of adults with infective endocarditisdue to MRSA.42

    Surgical Treatment

    The rate of early valve replacement or repair (i.e.,surgery performed during the course of antibi-otic treatment for infective endocarditis) has in-creased over the past three decades to approxi-mately 50%.6,7 The main indications for earlyvalve surgery are heart failure, uncontrolled in-fection, and prevention of embolic events (Table2).30Observational studies assessing associationsbetween the timing of surgery and outcomeshave yielded inconsistent results.14

    In a recent randomized trial involving 76 pa-tients with severe left-sided infective endocardi-tis and a large vegetation but no indications foremergency surgery at the time of randomization,the incidence of the composite end point of in-hospital death or embolic events within the first6 weeks after randomization was significantly

    lower among patients assigned to surgery within48 hours after randomization than among thoseassigned to usual care (3% vs. 23%); the benefitwas driven by the reduction in embolic events.43However, it is unclear whether these results shouldbe generalized to support the routine use of earlyvalve surgery, because the patients enrolled in thisstudy were young (mean age, 47 years), with a lowfrequency of coexisting conditions and very lowmortality (

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    tive endocarditis have been restricted to patientswho have a prosthetic valve, a history of infectiveendocarditis, or unrepaired cyanotic congenitalheart disease and who are planning to undergo aninvasive dental procedure; the recommended regi-mens are summarized in Table 3 in the Supple-mentary Appendix.30,50In the United Kingdom,antibiotic prophylaxis against infective endocarditisis no longer recommended in any circumstances.51To date, reports indicate no appreciable increase in

    the incidence of infective endocarditis due to viri-dans group streptococci since the guidelines wererevised to recommend a restricted use of antibi-otic prophylaxis.52,53Good oral, dental, and skinhygiene are recommended to reduce risks.

    AREA S OF UNCERTAINTY

    The appropriate duration of antibiotic therapy, es-pecially aminoglycosides, remains uncertain. Al-though a combination of oral ciprofloxacin and

    rifampin was reported to be effective for S. aureusinfective endocarditis in a study of intravenous-drug users,54oral therapy cannot currently be rec-ommended for infective endocarditis.

    Despite the recent randomized trial suggestinga benefit of early surgery,43the appropriate tim-ing of surgery remains controversial. When sur-gery is performed within the first week of anti-biotic treatment, there may be increased risks ofrelapse and prosthetic-valve dysfunction.55

    The usefulness of systematic brain imaging andthe preferred treatment of patients with infectiveendocarditis and cerebral mycotic aneurysms arealso uncertain. Because unruptured aneurysmsmay resolve with antibiotic therapy alone,24suchpatients should receive antibiotics, with serial an-giography performed to document the resolutionof the aneurysm. Endovascular treatment shouldbe pursued only if the aneurysm is very large(e.g., >10 mm) or if it is not resolving or is en-larging despite treatment with antibiotics.25

    Table 2.Indications for and Timing of Surgery in Patients with Left-Sided, Native-Valve Infective Endocarditis.*

    Indication Timing of Surgery

    Heart failure

    Aortic or mitral-valve infective endocarditis with severe acute regurgitation or obstruction caus-ing refractory pulmonary edema or cardiogenic shock

    Emergency

    Aortic or mitral-valve infective endocarditis with fistula into a cardiac chamber or pericardium

    causing refractory pulmonary edema or cardiogenic shock

    Emergency

    Aortic or mitral-valve infective endocarditis with severe acute regurgitation or obstruction andpersistent heart failure or signs of poor hemodynamic tolerance (early mitral-valve closure orpulmonary hypertension)

    Urgent

    Aortic or mitral-valve infective endocarditis with severe regurgitation and heart failure easily con-trolled with medical treatment

    Elective

    Uncontrolled infection

    Locally uncontrolled infection (abscess, false aneurysm, fistula, enlarging vegetation, or dehis-cence of prosthetic valve)

    Urgent

    Persistent fever and positive blood cultures for >57 days Urgent

    Infection caused by fungi or multidrug-resistant organisms, such as Pseudomonas aeruginosaand other gram-negative bacilli

    Elective

    Prevention of embolism

    Aortic or mitral-valve infective endocarditis with large vegetations (>10 mm in length) after oneor more embolic episodes, despite appropriate antibiotic therapy, especially during the first2 weeks of therapy

    Urgent

    Aortic or mitral-valve infective endocarditis with large vegetations (>10 mm) and other predictorsof complicated course (heart failure, persistent infection, or abscess)

    Urgent

    Isolated, very large vegetations (>15 mm); surgery may be preferred if a procedure preservingthe native valve is feasible

    Urgent

    * Adapted from Habib et al.30

    Emergency surgery was defined as surgery performed within 24 hours after the condition was identified, urgent surgeryas that performed within a few days after the condition was identified, and elective surgery as that performed after atleast 1 or 2 weeks of antibiotic therapy.

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    GUIDELINES

    Guidelines addressing the prophylaxis and man-agement of infective endocarditis have been pub-lished by professional societies in the United Statesand Europe.29-31The recommendations presentedhere are largely consistent with these guidelines.

    CONCLUSIONS

    AND R ECOMMENDATIONS

    The patient in the vignette has evidence of nativemitral-valve infective endocarditis complicated bycerebral emboli. Antibiotic treatment should bestarted immediately after two to three blood cul-tures have been drawn. Pending culture results, anaminopenicillin with beta-lactam inhibitor (eitherampicillin with sulbactam or amoxicillin withclavulanate potassium)29,30 should be given in

    combination with gentamicin. The recent cere-bral embolic events and the large, mobile mitral-

    valve vegetation seen on the echocardiogram areindications for urgent mitral-valve surgery, in theabsence of contraindications. If blood cultures arestill negative at the time of surgery, a sample ofvalve tissue should be obtained for culture, and abroad-range PCR assay should be performed tohelp identify the causative microorganism, with

    adaptation of the antibiotic regimen to the iden-tified microorganism. The patient should be coun-seled concerning the prevention of recurrent in-fective endocarditis (oral and overall hygiene andappropriate use of antibiotic prophylaxis, given thathe will now have both a history of infective endo-carditis and a prosthetic valve).

    Dr. Duval reports receiving grant support through his institu-tion from Pfizer and travel expenses from Roche. No other po-tential conflict of interest relevant to this article was reported.

    Disclosure forms provided by the authors are available withthe full text of this article at NEJM.org.

    We thank Dr. L. Kritharides and Dr. R.W. Sy for sharing datafrom the Australian population-based study on infective endo-carditis.

    REFERENCES

    1. Correa de Sa DD, Tleyjeh IM, Anave-kar NS, et al. Epidemiological trends ofinfective endocarditis: a population-basedstudy in Olmsted County, Minnesota.Mayo Clin Proc 2010;85:422-6. [Erratum,Mayo Clin Proc 2010;85:772.]2. Duval X, Delahaye F, Alla F, et al.Temporal trends in infective endocarditisin the context of prophylaxis guidelinemodifications: three successive popula-

    tion-based surveys. J Am Coll Cardiol2012;59:1968-76.3. Fedeli U, Schievano E, Buonfrate D,Pellizzer G, Spolaore P. Increasing inci-dence and mortality of infective endocar-ditis: a population-based study through arecord-linkage system. BMC Infect Dis2011;11:48.4. Federspiel JJ, Stearns SC, PeppercornAF, Chu VH, Fowler VG Jr. Increasing USrates of endocarditis with Staphylococcusaureus: 1999-2008. Arch Intern Med 2012;172:363-5.5. Sy RW, Krithar ides L. Health care ex-posure and age in infective endocarditis:

    results of a contemporary population-based profile of 1536 patients in Australia.Eur Heart J 2010;31:1890-7.6. Murdoch DR, Corey GR, Hoen B, et al.Clinical presentation, etiology, and out-come of infective endocarditis in the 21stcentury: the International Collaborationon Endocarditis-Prospective Cohort Study.Arch Intern Med 2009;169:463-73.7. Selton-Suty C, Clard M, Le Moing V,et al. Preeminence of Staphylococcus au-reus in infective endocarditis: a 1-year

    population-based survey. Clin Infect Dis2012;54:1230-9.8. Benito N, Mir JM, de Lazzari E, et al.Health care-associated native valve endo-carditis: importance of non-nosocomialacquisition. Ann Intern Med 2009;150:586-94.9. Tleyjeh IM, Abdel-Latif A, Rahbi H, etal. A systematic review of population-based studies of infective endocarditis.

    Chest 2007;132:1025-35.10. Fournier PE, Thuny F, Richet H, et al.Comprehensive diagnostic strategy forblood culture-negative endocarditis: aprospective study of 819 new cases. ClinInfect Dis 2010;51:131-40.11. Houpikian P, Raoult D. Blood culture-negative endocarditis in a reference center:etiologic diagnosis of 348 cases. Medicine(Baltimore) 2005;84:162-73.12. Stehbens WE, Delahunt B, Zuccollo JM.The histopathology of endocardial sclero-sis. Cardiovasc Pathol 2000;9:161-73.13. Brouqui P, Raoult D. Endocarditis dueto rare and fastidious bacteria. Clin Mi-

    crobiol Rev 2001;14:177-207.14. Bannay A, Hoen B, Duval X, et al. Theimpact of valve surgery on short- and long-term mortality in left-sided infective endo-carditis: do differences in methodologicalapproaches explain previous conflictingresults? Eur Heart J 2011;32:2003-15.15. Li JS, Sexton DJ, Mick N, et al. Pro-posed modifications to the Duke criteriafor the diagnosis of infective endocardi-tis. Clin Infect Dis 2000;30:633-8.16. Richet H, Casalta JP, Thuny F, et al.

    Development and assessment of a newearly scoring system using non-specificclinical signs and biological results toidentify children and adult patients with ahigh probability of infective endocarditison admission. J Antimicrob Chemother2008;62:1434-40.17. Crawford MH, Durack DT. Clinicalpresentation of infective endocarditis.Cardiol Clin 2003;21:159-66.18. Thuny F, Avierinos JF, Tribouilloy C,et al. Impact of cerebrovascular complica-tions on mortality and neurologic out-come during infective endocarditis: a pro-spective multicentre study. Eur Heart J2007;28:1155-61.19. Sonneville R, Mirabel M, Hajage D, etal. Neurologic complications and out-comes of infective endocarditis in criti-cally ill patients: the ENDOcardite enREAnimation prospective multicenterstudy. Crit Care Med 2011;39:1474-81.20. Dickerman SA, Abrutyn E, Barsic B, etal. The relationship between the initiat ionof antimicrobial therapy and the inci-

    dence of stroke in infective endocarditis:an analysis from the ICE Prospective Co-hort Study (ICE-PCS). Am Heart J2007;154:1086-94.21. Thuny F, Di Salvo G, Belliard O, et al.Risk of embolism and death in infectiveendocarditis: prognostic value of echo-cardiography: a prospective multicenterstudy. Circulation 2005;112:69-75. [Erra-tum, Circulation 2005;112(9):e125.]22. Di Salvo G, Habib G, Pergola V, et al.Echocardiography predicts embolic events

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    in infective endocarditis. J Am Coll Car-diol 2001;37:1069-76.23. Duval X, Iung B, Klein I, et al. Effectof early cerebral magnetic resonance im-aging on clinical decisions in infectiveendocarditis: a prospective study. Ann In-tern Med 2010;152:497-504.24. Corr P, Wright M, Handler LC. Endo-carditis-related cerebral aneurysms: radio-

    logic changes with treatment. AJNR Am JNeuroradiol 1995;16:745-8.25. Peters PJ, Harrison T, Lennox JL.A dangerous dilemma: management ofinfectious intracranial aneurysms com-plicating endocarditis. Lancet Infect Dis2006;6:742-8.26. Greub G, Lepidi H, Rovery C, et al.Diagnosis of infectious endocarditis inpatients undergoing valve surgery. Am JMed 2005;118:230-8.27. Lepidi H, Coulibaly B, Casalta JP,Raoult D. Autoimmunohistochemistry:a new method for the histologic diagnosisof infective endocarditis. J Infect Dis2006;193:1711-7.

    28. Botelho-Nevers E, Thuny F, Casalta JP,et al. Dramatic reduction in infective en-docarditis-related mortality with a man-agement-based approach. Arch InternMed 2009;169:1290-8.29. Baddour LM, Wilson WR, Bayer AS,et al. Infective endocarditis: diagnosis,antimicrobial therapy, and managementof complications: a statement for health-care professionals from the Committeeon Rheumatic Fever, Endocarditis, andKawasaki Disease, Council on Cardiovas-cular Disease in the Young, and the Coun-cils on Clinical Cardiology, Stroke, andCardiovascular Surgery and Anesthesia,American Heart Association: endorsed

    by the Infectious Diseases Society ofAmerica. Circulation 2005;111(23):e394-e434. [Errata, Circulation 2005;112:2373,2007;115(15):e408, 116(21):e547, 2008;118(12):e497.]30. Habib G, Hoen B, Tornos P, et al.Guidelines on the prevention, diagnosis,and treatment of infective endocarditis(new version 2009): the Task Force on thePrevention, Diagnosis, and Treatment ofInfective Endocarditis of the EuropeanSociety of Cardiology (ESC): endorsed bythe European Society of Clinical Microbi-ology and Infectious Diseases (ESCMID)and the International Society of Chemo-therapy (ISC) for Infection and Cancer.Eur Heart J 2009;30:2369-413.31. Gould FK, Denning DW, Elliott TS, etal. Guidelines for the diagnosis and anti-biotic treatment of endocarditis in adults:a report of the Working Party of the Brit-ish Society for Antimicrobial Chemother-apy. J Antimicrob Chemother 2012;67:269-89. [Erratum, J Antimicrob Chemother2012;67:1304.]32. Morris AJ, Drinkovi D, PottumarthyS, MacCulloch D, Kerr AR, West T. Bacte-

    riological outcome after valve surgery foractive infective endocarditis: implicationsfor duration of treatment after surgery.Clin Infect Dis 2005;41:187-94.33. Francioli P, Ruch W, Stamboulian D.Treatment of streptococcal endocarditiswith a single daily dose of ceftriaxone andnetilmicin for 14 days: a prospective mul-ticenter study. Clin Infect Dis 1995;21:

    1406-10.34. Sexton DJ, Tenenbaum MJ, WilsonWR, et al. Ceftriaxone once daily for fourweeks compared with ceftriaxone plusgentamicin once daily for two weeks fortreatment of endocarditis due to penicil-lin-susceptible streptococci. Clin InfectDis 1998;27:1470-4.35. Olaison L, Schadewitz K. Enterococ-cal endocarditis in Sweden, 1995-1999:can shorter therapy with aminoglycosidesbe used? Clin Infect Dis 2002;34:159-66.36. Gavald J, Len O, Mir JM, et al. Treat-ment of Enterococcus faecalis endocardi-tis with ampicillin plus ceftriaxone. AnnIntern Med 2007;146:574-9.

    37. Fernndez-Hidalgo N, Almirante B,Gavald J, et al. Ampicillin plus ceftriax-one is as effective as ampicillin plus gen-tamicin for treating Enterococcus faecalisinfective endocarditis. Clin Infect Dis2013 February 25 (Epub ahead of print).38. Cosgrove SE, Vigliani GA, Fowler VGJr, et al. Initia l low-dose gentamicin forStaphylococcus aureus bacteremia andendocarditis is nephrotoxic. Clin InfectDis 2009;48:713-21.39. Fowler VG Jr, Boucher HW, Corey GR,et al. Daptomycin versus standard therapyfor bacteremia and endocarditis caused byStaphylococcus aureus.N Engl J Med 2006;355:653-65.

    40. Das I, Saluja T, Steeds R. Use of dap-tomycin in complicated cases of infectiveendocarditis. Eur J Clin Microbiol InfectDis 2011;30:807-12.41. Durante-Mangoni E, Casillo R, Ber-nardo M, et al. High-dose daptomycin forcardiac implantable electronic device-related infective endocarditis. Clin InfectDis 2012;54:347-54.42. Liu C, Bayer A, Cosgrove SE, et al.Clinical practice guidelines by the Infec-tious Diseases Society of America for thetreatment of methicillin-resistant Staphy-lococcus aureus infections in adults andchildren: executive summary. Clin InfectDis 2011;52:285-92.43. Kang D-H, Kim Y-J, Kim S-H, et al.Early surgery versus conventional treat-ment for infective endocarditis. N Engl JMed 2012;366:2466-73.44. Tornos P, Almirante B, Mirabet S, Per-manyer G, Pahissa A, Soler-Soler J. Infec-tive endocarditis due to Staphylococcusaureus: deleterious effect of anticoagu-lant therapy. Arch Intern Med 1999;159:473-5.45. Chan KL, Dumesnil JG, Cujec B, et al.

    A randomized trial of aspirin on the riskof embolic events in patients with infec-tive endocarditis. J Am Coll Cardiol2003;42:775-80.46. Chan KL, Tam J, Dumesnil JG, et al.Effect of long-term aspirin use on embol-ic events in infective endocarditis. ClinInfect Dis 2008;46:37-41.47. Pepin J, Tremblay V, Bechard D, et al.

    Chronic antiplatelet therapy and mortali-ty among patients with infective endocar-ditis. Clin Microbiol Infect 2009;15:193-9.48. Snygg-Martin U, Rasmussen RV, Has-sager C, Bruun NE, Andersson R, OlaisonL. The relationship between cerebrovas-cular complications and previously estab-lished use of antiplatelet therapy in left-sided infective endocarditis. Scand J InfectDis 2011;43:899-904.49. Anavekar NS, Tleyjeh IM, AnavekarNS, et al. Impact of prior antiplatelet ther-apy on risk of embolism in infective endo-carditis. Clin Infect Dis 2007;44:1180-6.[Erratum, Clin Infect Dis 2007;44:1398.]50. Wilson W, Taubert KA, Gewitz M, et

    al. Prevention of infective endocarditis:guidelines from the American Heart As-sociation: a guideline from the AmericanHeart Association Rheumatic Fever, En-docarditis, and Kawasaki Disease Com-mittee, Council on Cardiovascular Dis-ease in the Young, and the Council onClinical Cardiology, Council on Cardio-vascular Surgery and Anesthesia, and theQuality of Care and Outcomes ResearchInterdisciplinary Working Group. Circu-lation 2007;116:1736-54. [Erratum, Circu-lation 2007;116(15):e376-e377.]51. Richey R, Wray D, Stokes T. Prophy-laxis against infective endocarditis: sum-mary of NICE guidance. BMJ 2008;336:

    770-1.52. Thornhill MH, Dayer MJ, Forde JM, etal. Impact of the NICE guideline recom-mending cessation of antibiotic prophy-laxis for prevention of infective endocar-ditis: before and after study. BMJ 2011;342:d2392.53. Desimone DC, Tleyjeh IM, Correa deSa DD, et al. Incidence of infective endo-carditis caused by viridans group strepto-cocci before and after publication of the2007 American Heart Associat ions endo-carditis prevention guidelines. Circula-tion 2012;126:60-4.54. Heldman AW, Hartert TV, Ray SC, etal. Oral antibiot ic treatment of right-sidedstaphylococcal endocarditis in injectiondrug users: prospective randomized com-parison with parenteral therapy. Am JMed 1996;101:68-76.55. Thuny F, Beurtheret S, Mancini J, et al.The timing of surgery influences mortal-ity and morbidity in adults with severecomplicated infective endocarditis: a pro-pensity analysis. Eur Heart J 2011;32:2027-33.

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    Outpatient only. South Shore communities. Elec-tronic medical records. Excellent mentorship andpeers/teaching av ailable. Min utes to downtownBoston. [email protected]

    FAMILY MEDICINE, WOLFEBORO, NEW HAMP-SHIRE Enjoy a great balance of work and life!Seeking full-time Family Medicine Physician. 36patient contact hours, four administrative hours,all outpatient. Competitive starting salary plus$20K sign-on bonus. Generous loan repayment,relocation expenses, full benets package. Visacandidates and new grads are welcome to apply.On the eastern shore of Lake [email protected]

    MAINE Bridgton Hospital, part of the CentralMaine Medical family, seeks BE/BC Family Medi-cine physicians to join practices in either Naplesor Fryeburg. The opportunities include both in-patient and outpatient responsibilities with OB.Located 45 miles west of Portland, Bridgton Hos-pital is located in the beautiful Lakes Region ofMaine and boasts a wide array of outdoor activi-ties including boating, kayaking, shing, and

    skiing. Benets include medical student loan as-sistance, attractive call schedule, competitive sala-ry, highly qualied colleagues, and excellent qual-ity of life. For more information, visit their websiteat: www.bridgtonhospital.org. Interested candi-dates should contact: Julia Lauver, Central MaineMedical Center, 300 Main Street, Lewiston, ME04240; call: 800-445-7431; e-mail: [email protected]; or fax: 207-795-5696. Not a J-1 opportunity.

    PRIMARY CARE/URGENT CARE GROUP INMATAWAN, NJ Seeking Board Certied familyphysician, full time. Our well-established practicehas been serving the area for 20 years, providingfull-spectru m ofce-based care to adults and chil-dren. Minimal hospital and no OB. Shifts will in-clude a mix of day, evening, and weekend hours.Benets include malpractice insurance, health,

    dental, and 401k. Not a J-1 or H1-B opportunity.Suburban area, less than an hour drive or trainride from NYC. Please e-mail CV to: [email protected]

    FULL-TIME FAMILY PRACTICE PHYSICIANWANTED, TY LERTOWN, MISSISSIPPI J-1and H-1 Visas accepted. Hospital employed. Sendresumes to: Debbie Thompson, Assistant Direc-tor, Human Resources, Forrest General Hos pital,PO Box 16389, Hattiesburg, MS 39404.

    KENTUCKY BE/BC Family Medicine physi-cian opportunity, we are Family Health Centers,an FQHC with ofces in downtown Louisville.Interested candidates please e-mail your CV to:Dr. Peter Thurman c/o: [email protected]

    MORE THAN $100K IN BONUSES FOR FAMILYPRACTICE IN SOUTH DAKOTA Earn excel-lent pay and great benets, including sign-on bo-nus, loan repay, relocation assistance, and mal-practice with tail. H-1 Visas welcome. Base pay$225K and South Dakota has no state income tax.Please contact Susan Feigin: 203-663-9381; [email protected]. Ref job #213481.

    Gastroenterology

    GASTROENTEROLOGIST, MASSACHUSETTS Physician. 45 minutes to Boston. Excellent oppor-tunity, full or part-time. Worcester Region, suc-cessful ve-group practice. New state-of-the-artofce/endoscopy suite. Primarily ofce basedconsultations with procedures. Salary competi-tive, full benets. Premiere MSG, large networkof physicians. Metro West area, excellent schools,affordable housing. [email protected]

    GASTROENTEROLOGIST, MASSACHUSETTS 45 minutes Boston. Excellent opportunity, fullor part-time. Join the nest organization in cen-tral Massachusetts with a history of excellence,excellent compensation, and the best of col-leagues. 260 physicians, 20 ofce locations. Lifebalance with minimal call. Culture-rich commu-nity. Excellent schools, colleges. [email protected]

    MAINE Looking for a better lifestyle and a pro-fessional culture that values your clinical skills?Consider moving to physician friendly Maine!Central Maine Medical Center is seeking a BC/BEgeneral gastroenterologist (ERCP not necessary)to join our established team of eight dedicatedphysicians. Located in south central Maine, thisexceptional 100% GI position offers candidates acompetitive salary and generous benets package

    and 1:9 weekend call. Close to the ocean, lakes,and mountains, this opportunity offers the out-door enthusiast unlimited recreational possibili-ties. Enjoy the professional challenge offered in asophisticated medical community along with the

    wonderful recreational opportunities and qualityof life in Maine. Please forward CV and cover let-ter to: Babette Irwin, CMMC, 300 Main Street,Lewiston, ME 04240; e-mail: [email protected];fax: 207-755-5855; or call: 800-445-7431.

    IF YOURE SEEKING AN OUTSTANDING GAS-TROENTEROLOGY OPPORTUNITY We canmake that happen. See Saint Francis Hospital andMedical Center in the display section.

    GASTROENTEROLOGIST BC/BE To joinsuburban Washington, DC busy 100% outpatientconsultative GI group practice with adjacent ac-

    credited endoscopy center. Practice includes on-site capsule endoscopy small bowel studies.

    We have state -of- the-art EMR. Applicant mustbe experienced in all endoscopic procedures.Early pathway to partnership. E-mail resume to:[email protected]; or fax: 301-897-5290.

    GASTROENTEROLOGY POSITION Excellentopportunity to join well-established Gastroenter-ology practice in Miami, Florida. Availablenow through July 2013. ERCP required. Compet-itive salary, full benets. Reasonable call sched-ule. Board Certied/Board Eligible. Bilingual/

    working knowledge of Spanish desired. ASC part-nership available. No recruiters please. Send CV:[email protected]

    Geriatrics

    GERIATRICS, LEWISTON AND PORTLANDREGION, SOUTHERN MAINE Great loca-tion! Four-day work week. Call 1:8, telephone callonly. Five weeks vacation, full benets includinghealth and dental, 401k matching retirementplan, and prot sharing. This is a private groupcovering skilled rehab, long term care, and assist-ed living facilities. [email protected]

    HOSPITAL EMPLOYED GERIATRIC POSITION,PHILADELPHIA SUBURBS A very well-respected, established, and hospital employed Ger-iatrician seeks a Geriatrician to join a thriving ger-iatric practice. You will enjoy quick practice growthand a great deal of professional and personal satis-faction. Both Fellowship trained Geriatricians andexperienced Internists, who desire a geriatric prac-tice, are welcome to respond. A very competitivesalary and benet package are offered. BucksCounty is one of Philadelphias most highly-desiredareas to live with outstanding schools, beautifulhomes, and great suburban living. Thirty minutesfrom Center City Philadelphia and one hour and ahalf from New York City. Contact Ken Sammutat: 888-372-9415; [email protected]; or:

    www.cejkasearch.com. ID#145280NJ.

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    Classified Advertising Thenew england journalofmedicine Vol. 368 No. 17 April 25, 2013

    ERICKSON HEALTH MEDICAL GROUP Medical Director opportunity at Wind Crest inDenver, Colorado. Staff Physician opportunitiesin Glen Mills, Pennsylvania and Dallas, Texas. If

    you are seeking an opportunity to practice andlead the delivery of high quality geriatric medi-cine with all the support of a company commit-ted to best practices and health care innovation,

    please cons ider a position with Erickson Living,

    Amer icas largest developer of continuing careretirement communities. A job with Erickson

    provides professional satisfaction, nancial se-curity, and a lifestyle unmatched by traditional

    pract ice sett ings. Other Erickson Liv ing loca-tions include NJ, Kansas, Maryland, Massachu-setts, Michigan, and Virginia. Please call us tollfree: 443 -297-3131 or forward your CV/cover let-ter to: Donna Rachuba, Director Medical StaffServices; e-mail: [email protected]; fax: 410-204-7273. Please enjoy our website: www.ericksonliving.com

    Hematology-Oncology

    HE MATOLOGY/ONCOLOGY, MASSACHU-SETTS Springeld region. Well-establishedMedical Center is in need of hematology/oncologist,

    employed position. Call schedule is split betweenphysicians in area. 200-bed hospital, up-to-datetechnology, and cohesive physician organization.Service area: approx. 180,000. Outstanding pri-

    vate schools at all levels. [email protected]

    HEMATOLOGY/ONCOLOGISTS, PROVIDENCE,RHODE ISLAND Outpatient and inpatientservices at the hospital and in clinical and basicresearch with University. Recent Academicexperience and publications are a must. Thiscommunity-based academic medical center afli-ated with Boston University School of [email protected]

    HEMATOLOGY/ONCOLOGY, NEW HAMP-SHIR E Physician, Seacoast region. Salary verycompetitive. Full benets. Large referral basis,64- slice CT scanners, Electronic Medical Records

    System. Minutes to Boston. Affordable houses,great schools systems. [email protected]

    GROUP OF TWO PHYSICIANS Well-establishedOncology Hematology practice is seeking BC/BEcandidate to join. Beautiful Hudson Valley location.Ninety minutes to New York City. Excellent salary/benet package. E-mail CV: [email protected]

    SOUTHERN FLORIDA, PALM BEACH COUN-TY Well-established four-physician Hematology/Oncology practice is looking for a BE/BC candi-date. Excellent benets leading to partnership.E-mail: [email protected]; or fax: 561-968- 0483.

    CHICAGO, ILLINOIS Illinois Cancer Special-ists is seeking a BC/BE hematologist/oncologistto join our location in Arlington Heights. With

    18 board certied physicians, we offer convenient,compassionate care in ve locations includingArlington Heights, Bolingbrook, Chicago, Hins -dale, and Niles. We offer a competitive salaryand benets with path to partnership. Visit our

    website at : www.illinoiscancerspeciali sts.com; callDean Walker at: 800-381-2634; or e-mail your CVto: [email protected]

    TEXAS ONCOLOGY, PA The states largestprivate practice oncology group, has several open-ings for BC/BE Oncologists available throughoutthe state. Access to clinical research, competitivestarting package, and partnership track. ContactDean Walker: 800-381-2637; or: [email protected]

    LOS ANGELES AREA ONCOLOGY Private

    oncology group seeking BC/BE on cologist to joinfour-physician group. Must possess Cal ifornia li-cense. Competitive salary and benets. E-mail CV:

    [email protected]

    Hospitalist

    HOSPITALIST, MASSACHUSETTS Boston re-gion. Minutes from Boston; $300k plus, plus po-tential. Most desired re gions of Boston, excellentschools. Salary: $202k base, newly graduating phy-sicians and $220k for experienced. RVU Bonus

    with potential additional $80k. No ICU coverage.24-Hour Critical Care Anesthesia services provid-ed. Full benets program with 40 with very strongleadership. [email protected]

    HOSPITALIST, MASSACHUSETTS Physician

    needed. Daytime Hospitalists, central Massachu-setts. Visa compatible. Daytime Hospitalist oppor-tunity. 150+ bed Hospital located in centralMassachusetts, just over an hour from Boston.Block schedule, with full-time consisting of14 shifts per month. Physicians will see 15 patientsper day. Competitive base salary, an attractive pro-ductivity bonus, and excellent benets package,and relocation assistance. H1-b and J-1 compati-ble. [email protected]

    HOSPITALIST, MASSACHUSETTS MinutesBoston. Desired re gion Boston. Excellent schools .Salary: $202k base, newly graduating physicians;$220k for experienced. RVU bonus with potentialadditional $80k. 17 total shifts per month. No call,no ICU coverage. 24-Hour Critical Care/Anesthesia

    provided by hospital. Strong leadership/[email protected]

    HOSPITALIST, NEW HAMPSHIRE Dartmouth-Hitchcock Medical Center, Lebanon. FacultyBC/BE Hospitalists to join growing AcademicSection of Hospital Medicine within Departmentof Medicine. Inpatient and consultative care, resi-dent and student teaching, academic service.Full-time/part-time candidates, faculty appoint-ment. Outstanding quality of life. [email protected]

    COASTAL BAR H ARBOR 7 on/7 off schedule.Competitive compensation, full benets, vaca-tion, CME, loan assistance. Exceptional, state-of-the-art facilities. Experienced medical/support

    staff. 25-bed critical access hospital. ExquisiteCoastal Acadia at your doorstep. Exceptional rec-reation and cultural amenities. Unique downtownshops and dining. Less than one hour from Ban-gor, metro city. Contact Celena Knapp: 207-866-5680; [email protected]

    IF YOURE SEEKING AN OUTSTANDING HOS-PITALIST OPPORTUNITY We can make thathappen. See Saint Francis Hospital and MedicalCenter in the display section.

    HOSPITALIST, CONNECTICUT Physician,Central Connecticut. U Conn afliate. High earn-ing potential. Hartford area: Large group addingthree FTE to 11 FTE Hospitalist group. Day posi-tion: 7on/7off. 12-Hour blocks. Will consider H-1candidates for nocturnist. [email protected]

    HOSPITALISTS Yale-New Haven Hospitalseeks daytime, nighttime, and weekend hospital-ists. Daytime hos pitalists attend on internal medi-cine patients with PAs/APRNs and may have su-pervisory, teaching, and quality improvement re-sponsibilities. Nighttime hospitalists work a veryexible schedule of nights and weekend days, ad-mitting to and providing coverage for the hospi-talist service. Weekend hos pitalists are needed to

    work weekend days and nights. Applicants musthave demonstrated excellent teaching and patientcare abilities and be BE/BC in internal medicine.Please send your CV to: Lara Hauslaib, Sen iorManager, Hospitalist Service, Northeast MedicalGroup Inc., 20 York Street, CB 2041, New Haven,CT 06510; or e-mail it to: [email protected] specify if interested in days, nights, or

    weekends. Any questions, please call: 203-688-4748.

    HOSPITALIST OPPORTUNITY Summit Med-ical Group, Central New Jersey. Summit MedicalGroup (SMG), a 200+ physician multispecialtymedical group, seeks a board certied/board eli-gible physician to provide inpatient services. SMGphysicians refer their patients to the SMG Hospi-talist Service which ensures collaborative and in-

    tegrated care for SMG patients that are hospital-ized. Our Hospitalist Service attains some of thenations highest clinical and quality outcomesthrough this unique design. In this position, you

    will join an existing group of ve Hospitalists work-ing in a continuity of care model specializing incaring for the hospita lized pa tient. Each physicianparticipates in 24-hour call rotation. They super-

    vise residents who assist with admissions. Addition-ally, they utilize electronic medical record access,two PAs, a discharge coordinator, and a dedicatedpatient advocate. The selected candidate must beable to work as a team and possess excellent com-munication skills. Position offers competitivecompensation and comprehensive benets. Tolearn more, visit: www.summitmedicalgroup.com.To learn more, contact Danise Cooper at: 800-678-7858, x63006; or: [email protected].

    ID#149900NJ.HOSPITALIST, EASTERN PENNSYLVANIA/NW NJ/CENTRAL NJ Looking for an IM/FPto join an established practice. Will sponsor H-1.Please contact: [email protected]

    WASHINGTON, DC, AREAS PREMIER HOSPI-TALIST GROUP Seeks BC/BE hospitalists andnocturnists for positions in Maryland suburbs.Competitive salary, full benets, no Visa sponsor-ship. E-mail CV to: [email protected]

    NOCTURNIST Cuyuna Regional MedicalCenter in Crosby, Minnesota seeks two noct-urnists for a 7 on/7 off schedule. 25-bed criticalaccess hospital that provides services and technol-ogies to rival much larger facilities. Outdoor ac-tivities abound including a nationally recognized

    mountain bike trail system, kayaking, shing,hunting, x-country skiing, snowmobiling, iceshing, and much more. The Twin Cities ofMinneapolis/St. Paul are only a short drive away.Excellent compensation package. Contact CindyStokes: 800 -678-7858, x64517; [email protected]; or visit: www.cejkasearch.com. ID#149699NJ.

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    Vol. 368 No. 17 April 25, 2013 Thenew england journalofmedicine Classified Advertising

    Infectious Disease

    INFECTIOUS DISEASE, 15 MILES NORTH OFBOSTON North Shore Medical Center andNorth Shore Physicians Group, members of theaward-winning Partners HealthCare System ofBoston, are seeking an Infectious Disease Physi-cian to join two other ID physicians in this busyand growing multispecialty group practice in Sa-

    lem, Massachusetts. Inpatient consults and someoutpatient clinic. Potential for leadership oppor-tunity. Interested candidates must be BC/BE inInfectious Disease and should forward their CVto: Louis Caligiuri, Director of Physician Servicesat: [email protected]. No Visas or agenciesplease.

    INFECTIOUS DISEASE, MASSACHUSETTS Physician needed, north of Boston. PartnersHealthCare System of Boston. Join two other IDphysicians and practice 100% ID. Both inpatientand outpatient. Option to teach Residents. Em-ployed position. Excellent compensation andcomprehensive benets. Collegial and supportiveenvironment. [email protected]

    IF YOURE SEEKING AN OUTSTANDINGADULT INFECTIOUS DISEASE OPPORTUNI-TY We can make that happen. See Saint Fran-cis Hospital and Medical Center in the displaysection.

    INFECTIOUS DISEASE, CONNECTICUT Hartford, physician needed, Central Connecti-cut. Excellent opportunity, join expanding with25 providers. 80/20 mixture of ID and IM. Mon-day through Friday work-week. Excellent salaryand benets package is offered. Great location,two hours to Boston or NYC and easy drive toConnecticut seashore. *Visa candidates will beconsidered. [email protected]

    ASSISTANT/ASSOCIATE/FULL PROFESSORPOSITIONS, INFECTIOUS DISEASES Uni-

    versity of Minnesota. The Department of Medicine,Division of Infectious Diseases and International

    Medicine, is seeking two general infectious diseasesspecialists and one transplant infectious diseasesspecialist to serve as clinician/educators in the clini-cal scholar track. A successful candidate at the Asso-ciate or Full Professor levels will have opportunitiesto serve as a Master Clinician and provide leader-ship and oversight of the divisions clinical pro-grams, clinical educational, quality improvement,and junior faculty mentorship. These positions willhave both inpatient and outpatient duties at theUniversity of Minnesota Medical Center-Fairview,including attending on inpatient consult services,providing outpatient infectious diseases services,and educational responsibilities, which will includeteaching residents, students, and infectious diseasesfellows during their clinical rotations. There is alsothe opportunity to collaborate on clinical research

    studies run by divisional colleagues. A competitivesalary, excellent fringe benets, and an intellectual-ly exciting environment are offered. Requirementsfor the position include an MD degree and board-eligibility or board-certication in infectious dis-eases. Advanced training in transplant infectiousdiseases is highly desirable for the transplant infec-tious diseases specialist. Applicants for this positionshould demonstrate excellence in patient care andscholarly activity, enthusiasm for medical educa-tion, and strong teaching skills. To apply for this po-sition on-line, go to: http://www1.umn.edu/ohr/employment. Applicants may also send introductoryletter and CV to: Dr. Paul Bohjanen, MD, Director,ID Division, University of Minnesota, MMC 250, 420Delaware Street, SE, Minneapolis, MN 55455. TheUniversity of Minnesota is an Equal OpportunityEmployer and Educator.

    COLORA DO INFECTIOUS DISEASES Join agrowing practice with a well-established referralbase. Potential for above average income plus ex-cellent lifestyle. Mild sunny climate. Nearbymountains, skiing. E-mail CV to: [email protected]; con tact: 719-369-7767.

    INFECTIOUS DISEASE, CALIFORNIA Look-ing for BC/BE ID full-time physician to join twoID specialists. Hospital based private practice inSan Bernardino, California. 100% Hospital IDconsultation. Please e-mail CV to: nshahatto@

    yahoo.com; or fax to: 909 -824 -7124.

    Internal Medicine/Pediatrics

    INTERNAL MEDICINE, PEDIATRICS PHYSI-CIAN MGH health center north of Bostonseeking part-time med-peds physician, BC/BE.Dynamic multidisciplinary group, culturally andsocio-economically diverse patient population.Comprehensive benets package. Harvard teach-ing appointment. Not a J-1 position. E-mail/faxCV to: [email protected]; or: 781-485-6200.

    IM/PED, SOUTHERN NEW HAMPSHIRE Elliot Health System seeks additional BC/BEMED/PED physician interested in joining one of

    the largest IM-Peds Call group in New England.Shared call 1:9 w/access to MED/PED hospital-ists. Join group of three physicians and one NP for32 patient-hour week. No C-section coverage re-quired. Manchester, New Hampshire offers taxfree living within an hour of Boston, the ocean,and moun tains! Contact Molly Alderson at:800-678-7858 x64507; or via e-mail: [email protected]. ID#149263NJ.

    Internal Medicine(see also FM and Primary Care)

    ADULT MEDICINE PHYSICIAN MWA, PCd/b/a RiverBend Med ical Group has a positionavailable in Chicopee, Massachusetts for a BE/BC(Board Eligible or Board Certied) internal med-icine physician to provide medical care to adult

    patients and diagnose and provide non-surgicaltreatment of diseases. Send applications to: River-Bend Medical Group, Attn: Suzanne Jones, Physi-cian Recruiter, 1109 Granby Road, Chicopee, MA01020.

    FANTASTIC OPPORTUNITY For BC/BE IMor FP physicians to work at Wing Memorial Hospi-tal and Medical Centers, part of UMass MemorialHealth Care nestled in the Pioneer Valley. (Rheu-matology Fellowship a plus). Physicians will prac-tice in state-of-the-art outpatient only hospitalbased Medical Centers. We are very well posi-tioned to become a Medical Home in an ACO

    with an EHR that meets Meaningful Use Stan-dards. If healthcare reform worries you and youdesire to work with a team dedicated to providingquality care while receiving an excellent salary

    (170-200K) and benets, send CV and letter of in-terest to: [email protected]; or call: 413-284-5228.

    FAMILY PRACTITIONER/INTERNAL MEDI-CINE PHYSICIAN Caring Health Center inSpringeld, Massachusetts, is seeking a FamilyPractitioner or Internist for an outpatient prac-tice with no hospital calls. This is an opportunityto join a team committed to providing qualityhealthcare to those with socio-economic, linguis-tic, or cultural barriers. Applicants must beBC/BE and licensed or eligible to be licensed inMassachusetts. Caring Health Center offers com-petitive salar ies, a generous benet package, andparticipates in HRSAs National Health Serviceloan repayment program. Send questions andsubmit CV to: [email protected]

    CLINICIAN-EDUCATOR OPPORTU NI TY INBOS TON The Section of General In ternalMedicine at Boston University School of Medicineis seeking a talented and dedicated cl i nician edu-cator to join our faculty. Responsibilities includedirect patient care, resident precepting, studentteaching, and attending on the inpatient serviceat Boston Medical Center. Please send by e-mail acover letter and CV to: [email protected]

    INTERNAL MEDICINE, MASSACHUSETTS North of Boston. Lahey Clinic afliation. Excel-lent earnings potential, comprehensive benetspackage. Academic afliation. 220-bed desirableseacoast community. International airport andmajor universities. [email protected]

    INTERNAL MEDICINE, MASSACHUSETTS Physician needed north of Boston, Andoverregion. Outpatient only. Brand new ofce build-ing. Part of one of the largest physician organiza-tions with more than 300 providers. Employedposition, excellent benets. Great location,25 miles downtown Boston, minutes to the sea-coast. [email protected]

    IN TERNAL MEDICINE, MASSACHUSETTSGENERAL HOSPITAL Physician: Revere and

    Waltham. Coastal community. Join group of threephysicians or ve, planning expansion. EMR full-time position for eight outpatient sessions. Newphysician would feel very comfortable in the prac-tice. Opportunity to teach medical students andResidents. Loan reimbursement, exceptionalhealth care plan, very competitive income guaran-tee. Compensation for teaching. [email protected]

    INTERNAL MEDICINE, MASSACHUSETTS South of Boston/easy access to the city. Outpa-tient only. Reputable group located minutes southof Boston. Stable multispecialty group, more than60 physicians. All electronic medical records.On-site MRI and CT scan. Shared call from homeonly. [email protected]

    INTERNAL MEDICINE, MASSACHUSETTS Arlington/Waltham/Boston. Physician. Vibrantregional teaching hospital closely afliated withHarvard Medical School. Boston suburb, greatlocation. Harvard teaching. Excellent earningspotential! Academic appointment available. Out-patient only. Shared call. Join three, with full pa-tient panel of 2000. Full electronic medical rec-ords. Outstanding public and private schools.Four weeks vacation. [email protected]

    INTERNAL MEDICINE Webster, Spencer,Leominster, Worcester, Outer Boston suburbs,central Massachusetts. Join the nest organiza-

    tion in central Massachusetts with a history ofexcellence, excellent compensation, and thebest of colleagues. 260 physicians, 20 ofce loca-tions. Life balance with minimal call. Culture-rich community. Excellent schools, [email protected]

    INTERNAL MEDICINE, SITE CHIEF, CENTRALMASSACHUSETTS Worcester area. Leader-ship role. Seeking experienced phy sician special-izing in Internal Medicine or Family Medicine.

    Join the nest organization in central Massachu-setts with a history of excellence, excellent com-pensation, and the best of colleagues. 260 physi-cians, 20 ofce locations. Life balance with minimalcall. Culture-rich community. Excellent schools, col-leges. [email protected]

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    Classified Advertising Thenew england journalofmedicine Vol. 368 No. 17 April 25, 2013

    INTERNAL MEDICINE, MASSACHUSETTS Physician, Springeld region. Outpatient only.Excellent earnings, potential above $200k. Bene-ts. Light call, 1:15, phone coverage only. 200-bedhospital, up-to-date technology, and cohesive phy-sician organization. Service area: approx.180,000. Outstanding private schools at all [email protected]

    INTERNAL MEDICINE, MASSACHUSETTS Boston region, Southshore region. Incredible liv-ing area the new Best of Boston. Primary care,exceptional pay, easy access to the Boston orCape. Exceptional living area. Outpatient only.South Shore communities. Electronic medicalrecords. Excellent mentorship/teaching available.Minutes to downtown Boston. [email protected]

    SEEKING WOUND CARE SURGEON, SOUTH-ERN NEW HAMPSHIRE Elliot Health System,Manchester, NH, is seeking to employ an addi-tional surgeon in our beautiful Hyperbaric

    Wound Care Center, M-F, 7:30-5:30. Telephoniccall shared with APRNs, and offers a quality life-style in (tax-free) NH, one hour to Boston, theseacoast, and the White Mountains! For addition-al information, please contact Molly Alderson at:800-678-7858, x64507 or via e-mail: [email protected]. ID#149706NJ.

    INTERNAL MEDICINE, NEW HAMPSHIRE Physician, southern New Hampshire, outpatientonly. Less than one hour Boston and short driveto beaches, seacoast, mountains, skiing, andmore. One of largest groups in state, empl