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PubMed2003

[Infective endocarditis: clinical echocardiography].

Infective endocarditis is a rare but serious disease. The incidence in western countries is 1.7-6.2 cases/100,000 per year. The mortality rate today is 20-40%. The Duke University incorporates echocardiographic findings as one of the major criteria in the diagnosis of infective endocarditis. In case of suspected infective endocarditis, echocardiography is used to: 1) detect and characterize endocarditic vegetations; 2) detect complications; 3) conduct follow-up after treatment. Sensitivity for detection of vegetations in native-valve endocarditis is < 65% by transthoracic echocardiography, whereas it is 82-100% by transesophageal echocardiography; in infective endocarditis on prosthetic valves, sensitivity is 16-36 and 82-96%, respectively. Echocardiographic studies have demonstrated that highly mobile vegetations with a diameter of > 10 mm are more likely to cause complications (embolism, heart failure, need for surgery, and death). Another important advantage offered by echocardiography is the ability to accurately detect cardiac complications of infective endocarditis: valvular regurgitation, valve rupture, periannular abscess, prosthetic dehiscence, rupture of cardiac fibrosa, septal abscess, hemopericardium, and myocardial infarction. The sensitivity of transthoracic echocardiography for the detection of periannular abscess is 28% whereas that of transesophageal echocardiography is 87%. Finally, echocardiography has an invaluable role in indicating if surgery is required in cases of infective endocarditis with severe complications.

Endocarditis, Bacterial↗
PubMed2004

[Surgical treatment of active infective endocarditis: analysis of 20 years' experience].

OBJECTIVES: Changes in perioperative condition and outcomes of surgically treated patients with active infective endocarditis were evaluated during the last 20 years. METHODS: Between 1983 and 2002, 132 patients with active infective endocarditis underwent surgery at Saitama Medical School. Changes in frequency, pathogens, clinical features, surgical results, and perioperative treatment were compared between four periods of 5 years. RESULTS: The percentage of surgery for infective endocarditis remained almost the same among all cardiovascular procedures. Staphylococcal infective endocarditis increased significantly (p < 0.01), and prosthetic valve infective endocarditis and periannular abscess became more common. Surgery tended to be performed in severely ill patients significantly more frequently (p < 0.01). If all patients were included, hospital mortality did not decrease significantly, at 1.7% in stable patients, but 50% in critically ill patients. Intensive care unit stay became relatively longer. Recurrent infection was observed significantly more frequently in critically ill patients and in patients with prosthetic valve infective endocarditis. Patients were referred for surgery following diagnosis and underwent surgery at increasingly more appropriate timing. However, the diagnosis of infective endocarditis took 1.5 months to establish regardless of the patient's condition or the clinical outcome. Moreover, antibiotics were administered orally in around 90% and intravenously in nearly 70% of the patients without microbiological tests, and negative cultures remained very frequent. CONCLUSIONS: Critically ill patients underwent surgery increasingly more frequently, and surgical outcomes remained unsatisfactory over the last 20 years. Early diagnosis and avoidance of premature antibiotic therapy may be important for future improvement.

Endocarditis, Bacterial↗
PubMed2005

High prevalence of Bartonella quintana endocarditis in Sfax, Tunisia.

Bartonella quintana is a fastidious microorganism associated with blood culture negative endocarditis. In this study, 40 sera with cross-reactivity between Chlamydia species from patients from Sfax, Tunisia, were serologically tested for Bartonella. Thirteen sera were positive for Bartonella with IgG titers >/=1:800. Western blot and cross-absorption confirmed the diagnosis of Bartonella quintana endocarditis in 12 cases and Bartonella henselae endocarditis in 1 case. These sera were also positive by LightCycler nested PCR amplification for the rnpb (7 of 13) and fur (11 of 13) genes. Eleven patients had a definite diagnosis of endocarditis, which represents 9.8% of all endocarditis. Because Bartonella endocarditis seems to be very common in Tunisia, we suggest that its serology be performed systematically whenever endocarditis is suspected.

Adult↗
PubMed2006

[Trend and contributing factors of in-hospital deaths in patients with infective endocarditis over the last twenty years].

OBJECTIVES: To evaluate the changes in the clinical background to infective endocarditis and identify the contributing factors to in-hospital deaths over the last 20 years. METHODS: Seventy-five patients (mean age 48.2 +/- 24.0 years) with infective endocarditis treated between January 1984 and December 2003 at our hospital were evaluated retrospectively. The patients were divided into two groups (first decade, n = 26 and second decade, n = 49). RESULTS: The infection route was unknown in 65% of the patients, but the oral route was the most common known route (16.0%). Congenital heart disease (24.0%)was the most common background disease, followed by valvular heart disease (22.7%), and post prosthetic valve replacement (22.7%). The mitral valve was most frequently infected(56.0%), followed by the aortic valve (34.7%). Multi-valve infection was present in 13.3% of the patients. Although the frequency of streptococcal endocarditis reduced, that of staphylococcal endocarditis increased in the second decade. The overall in-hospital mortality was 26.7%, but slightly improved in the second decade (34.6% vs 22.4%, p = 0.26). The overall in-hospital mortality was similar between the surgically treated group and the non-surgically treated group (25.0% vs 27.3%, NS). In the surgically treated group, in-hospital mortality was lower in the second decade than the first decade, but higher in the group treated for active infective endocarditis. Multivariate analysis found age > or = 51 years, renal insufficiency, neurological abnormality, and culture negative as predictors of in-hospital mortality. CONCLUSIONS: Rapid and appropriate primary medical treatment are important in the active phase of infective endocarditis. Age > or = 51 years was the strongest predictor of in-hospital infective endocarditis death.

Adolescent↗
PubMed1992

Mitral valve repair for bacterial endocarditis.

Twenty-two patients with mitral insufficiency resulting from native valve endocarditis underwent mitral valve repair. Six patients had acute endocarditis with positive blood cultures and active valve infection. Sixteen patients were cured of active infection, but mitral insufficiency developed as a result of prior infection. Mean age was 48.5 +/- 21.7 years; 13 (59%) were male. Mean New York Heart Association functional class was 2.6 +/- 1.2. Multiple valve lesions were present in 11 (50%) patients. Valve abnormalities included leaflet perforation in 13 patients, chordal rupture or elongation in 14, vegetations in 5; and annular abscess in 1. In patients with acute endocarditis all macroscopically infected tissue was excised. Multiple techniques were required to achieve valve competence. Suture or patch closure of perforation was done in 14 patients, chordal shortening or transfer in 9, leaflet resection and closure in 4, leaflet resection with pericardial patching in 5, and annuloplasty in 15. Mitral valvuloplasty was combined with other procedures in 11 (50%) patients. There were two (9%) hospital deaths, both occurring in patients with healed endocarditis. There was one (9%) death in a patient undergoing an isolated procedure and one (9%) in a patient undergoing a combined procedure. Mean follow-up was 24 +/- 16.8 months and was complete. Seventeen (85%) were in New York Heart Association functional class I, and three (15%) were in class II. There were no late deaths, reoperations, recurrent endocarditis, thromboembolic events, or other valve-related morbidity. We conclude that mitral valve repair for insufficiency resulting from bacterial endocarditis (1) is possible in acute and healed disease, (2) has a low operative mortality, and (3) has resulted in patients free of recurrent infection and valve-related morbidity and mortality. Mitral valve repair is an attractive alternate to valve replacement in bacterial endocarditis.

Endocarditis, Bacterial↗
PubMedDate not supplied

Bioprosthetic valve endocarditis: factors affecting bad outcome.

Prosthetic valve endocarditis (PVE) remains an uncommon but serious complication of cardiac valve replacement. We analysed several risk factors (active or healed, early or late endocarditis, congestive heart failure, arterial emboli etc.) in order to identify the factors which may predict bad outcome. The overall mortality rate was 46.8% (15/32 patients). There was a significantly higher mortality rate in patients with early endocarditis (80%) than in those with late endocarditis (38%) (p less than 0.01). In the group of patients who underwent reoperation, the mortality rate was higher in those with active endocarditis (70%) than in those with healed endocarditis (28.5%) (p less than 0.05). We believe that combined medical and surgical treatment is the best management for bioprosthetic valve endocarditis, with the institution of appropriate preoperative antibiotic therapy, to attempt to achieve sterilization.

Adult↗
PubMed1991

Prognostic significance of valvular regurgitation in patients with infective endocarditis.

PURPOSE: Doppler ultrasound is a sensitive modality for detecting and quantitating valvular regurgitation in patients with infective endocarditis. Because valvular regurgitation leads to heart failure, we evaluated the prognostic significance of Doppler-detected valvular regurgitation in patients with endocarditis who had not yet developed clinical heart failure. PATIENTS AND METHODS: We reviewed the medical records of 65 patients with a clinical diagnosis of infective endocarditis from May 1985 to March 1990. A total of 49 patients were included in the study: 33 patients with native valve endocarditis and 16 patients with prosthetic valve endocarditis. The initial Doppler echocardiogram was examined in these patients to determine the presence and degree of valvular regurgitation. RESULTS: Significant (moderate to severe) valvular regurgitation was detected in 23 (47%) patients. The presence or absence of significant valvular regurgitation did not predict the development of congestive heart failure, the need for surgery, or death (p = NS). The development of congestive heart failure was significantly associated with the need for surgery (p less than 0.0001) and death (p less than 0.05). CONCLUSION: We conclude that the detection of significant valvular regurgitation in patients with infective endocarditis who have not yet developed heart failure is not predictive of future complications nor does the absence of significant valvular regurgitation identify a group of patients with a more favorable prognosis. In our series, patients who developed congestive heart failure had a significantly higher incidence of surgery and death. Therefore, decisions regarding clinical management in patients with infective endocarditis should not be made solely on the presence or absence of echocardiographically detected valvular regurgitation.

Adult↗
PubMed1990

[10 fatal endocarditis: autopsy observations, causes of death].

Among 841 autopsies realized between january 1982 and september 1988, by the Pathological the department of Amiens University Hospital the ten patients dead of infectious endocarditis have been autopsied. Macroscopic and microscopic observations have two cases of acute endocarditis and eight of subacute endocarditis. For the two patients dead of acute endocarditis, autopsy affirms the cardiovascular etiology of death. For the eight cases of subacute endocarditis, necropsic findings differs from the germs. In the three cases where the germ is a Staphylococcus aureus, the diagnosis of endocarditis was made before death and the cardiovascular etiology of death was affirmed by autopsy. For the other germs (3 Streptococcus sp, 1 Salmonella typhimurium, and 1 germ unknown), the diagnosis of endocarditis was made by autopsy, but necropsy disclosed the cause of death in only two cases.

Adult↗
PubMed1990

[Clinical aspects of staphylococcal endocarditis].

Patients with staphylococcus endocarditis hospitalized at the Cantonal Hospital Lucerne from 1971 to 1988 are reviewed. A total of 50 patients fulfilled the diagnostic criteria (in 60% of the cases the diagnosis was definite, in 26% probable, and in 14% possible). These 50 patients with staphylococcus infection account for 29% of all patients with infective endocarditis seen during this time interval. Staphylococcus endocarditis affected the mitral valve in 48%, the aortic valve in 36% and--unexpectedly often--the tricuspid valve in 30%. In 54% previously normal valves were infected. Diminished host defence (predominantly intravenous drug addiction and diabetes) was a predisposing feature in 52% of the patients. The average duration of symptoms before diagnosis was 11 days, and in patients with right heart endocarditis it was 21 days. In 20% the condition was not diagnosed before autopsy. The clinical picture was relatively nonspecific: 50% of patients had no diagnostic heart murmur and 10% had no fever. The dominant--often misleading--symptoms were due to embolic complications. Two thirds of the cases with right heart endocarditis had pulmonary emboli. In 38% of the patients endocarditis resulted in heart failure. Overall mortality was 51% and correlated with age and the presence of heart failure, uncontrolled infection or cerebral embolism. In contrast to the high mortality in patients with mitral valve infection (61%), only one of the 11 patients with isolated right heart endocarditis died.

Endocarditis, Bacterial↗
PubMed1989

[Clinical evaluations of surgical treatment of infective endocarditis].

This paper shows the clinical evaluations of surgical and medical treatment of infective endocarditis (IE). IE occurred in 33 cases (10.1%) among 372 cases of valve replacement. Of all the 33 patients, IE was consisted of native valve endocarditis (NVE) and prosthetic valve endocarditis (PVE). IE was evaluated as for the microorganism, complication, operative indication and operative mortality. At first, all of NVE underwent surgical treatment, active phase endocarditis 4 and healed endocarditis 14. Microorganism was streptococcus aureus in an overwhelming majority. Operative indications was congestive heart failure in almost all cases, next to vegetation and infection resistant to medical treatment. Operative mortality was 5.6% (1 out of 18 cases), which case was in the septic shock and cerebral bleeding prior to the surgical treatment. The others was satisfactory condition postoperatively. Next of PVE, PVE happened in 15 cases, in which there were 5 cases of bioprosthetic PVE and 10 cases of mechanical valve PVE. Microorganism for PVE was staphylococcus epidermidis in the major part (60%). Mortality in PVE was 53.3% (8 out of 15), but mechanical valve PVE was worse in prognosis than bioprosthetic PVE. Cerebral complications occurred in 3 cases of mechanical valve PVE, on the other hand there was no cerebral complication in bioprosthetic PVE. As for the hemodynamic change in PVE, mechanical valve PVE had the tendency to take the prompt or sudden deterioration of hemodynamics caused by endocarditis surrounding the suture ring, especially in mitral position, on the contrary hemodynamic deterioration was gradually proceeded in bioprosthetic PVE. UCG made much of the diagnosis of PVE, especially in mechanical valve PVE, in which cases endocarditis was recognized only surrounding the suture ring. PVE takes the miserable outcome in many cases, so carefully observation is necessary in order not to lose the timing of the surgical treatment.

Adult↗
PubMed1988

Hospital-acquired infective endocarditis.

Nosocomial endocarditis occurred in 22 patients who were discharged from a university hospital, a veterans' hospital, and a community hospital during the period of January 1976 to December 1985. Nosocomial episodes were 14.3% of the total endocarditis cases seen. Fourteen (63.6%) of 22 nosocomial endocarditis episodes occurred in patients over the age of 60 years, compared with 39 (29.5%) of 132 episodes of community-acquired endocarditis during the same period. Nosocomial endocarditis was due predominantly to Staphylococcus aureus or coagulase-negative staphylococci (77.4%) and, less often, to streptococci (13.6%). Intravascular devices were the source of bacteremia in ten (45.5%) of the nosocomial endocarditis episodes. The overall mortality rate was 40.9%, 50% in patients over the age of 60 years. Improved care of intravascular devices or prophylaxis before procedures could probably have prevented endocarditis in 12 of the 22 patients.

Catheters, Indwelling↗
PubMed1979

Extracardiac manifestations of bacterial endocarditis.

Bacterial endocarditis is an elusive disease that challenges clinicians' diagnostic capabilities. Because it can present with various combinations of extravalvular signs and symptoms, the underlying primary disease can go unnoticed.A review of the various extracardiac manifestations of bacterial endocarditis suggests three main patterns by which the valvular infection can be obscured. (1) A major clinical event may be so dramatic that subtle evidence of endocarditis is overlooked. The rupture of a mycotic aneurysm may simulate a subarachnoid hemorrhage from a congenital aneurysm. (2) The symptoms of bacterial endocarditis may be constitutional complaints easily attributable to a routine, trivial illness. Symptoms of low-grade fever, myalgias, back pain and anorexia may mimic a viral syndrome. (3) Endocarditis poses a difficult diagnostic dilemma when it generates constellations of findings that are classic for other disorders. Complaints of arthritis and arthralgias accompanied by hematuria and antinuclear antibody may suggest systemic lupus erythematosus; a renal biopsy study showing diffuse proliferative glomerulonephritis may support this diagnosis. The combination of fever, petechiae, altered mental status, thrombocytopenia, azotemia and anemia may promote the diagnosis of thrombotic thrombocytopenic purpura. When the protean guises of bacterial endocarditis create these clinical difficulties, errors in diagnosis occur and appropriate therapy is delayed. Keen awareness of the varied disease presentations will improve success in managing endocarditis by fostering rapid diagnosis and prompt therapy.

Bone Diseases↗
PubMed1982

Anaerobic bacteria in septicaemia and endocarditis.

Anaerobic septicaemia is often a complication of preexisting anaerobic sepsis which is commonly a complication of surgical interference. The predominant anaerobic bacterial isolate in septicaemia if Bacteroides fragilis. Anaerobic cocci and clostridia are not infrequently found as causes of septicaemia. The incidence of polymicrobial septicaemia varies in the different reports. The clinical features of septicaemia due to anaerobic Gram-negative rods vary little from those due to facultative anaerobic Gram-negative rods. The entry portal of bacteroides and clostridia is the gastrointestinal tract and the female genital tract. The portal of entry of anaerobic cocci is the respiratory tract. Anaerobic septicaemia include a high incidence of jaundice, septic thrombophlebitis and metastatic abscess formation. When appropriate antibacterial agents are used for the treatment of anaerobic septicaemia, a mortality rate of 10% is seen while in the absence of treatment the mortality is high, 60-80%. Anaerobic bacteria is an uncommon but important cause of endocarditis. Most cases of anaerobic endocarditis are caused by anaerobic cocci, Propionibacterium acnes and B. fragilis. Predisposing factors and signs and symptoms of endocarditis caused by anaerobic bacteria are similar to those seen in endocarditis with facultative anaerobic bacteria with the following exceptions. There is a lower incidence of preexisting valvular heart disease, a higher incidence of thromboemboli events and a higher mortality rate with anaerobic endocarditis. The article is a review of our present knowledge of the normal anaerobic human microflora in relation to development of septicaemia and endocarditis, virulence factors in anaerobic bacteria, antibiotic susceptibility patterns of anaerobic bacteria and clinical findings in patients with anaerobic septicaemia respectively endocarditis.

Anti-Bacterial Agents↗
PubMed1982

Experimental animal endocarditis.

The results of studies performed with animal models of experimental infective endocarditis have provided valuable information about the pathophysiology, natural history, and treatment of this infection. The Freedman rabbit model of experimental infective endocarditis is relatively simple to perform, is reproducible, and with minor modifications has become the standard model for the study of experimental endocarditis. The following are the major advantages of the Freedman model: (1) its relatively low cost and simplicity permit the study of large numbers of animals required for statistical analysis of results; (2) the model enables accurate control of the timing of the onset of infection, the administration of antimicrobial agents, and the duration of infection and treatment before the animal is killed; and (3) the experimental infection in rabbits histologically resembles the pathologic changes that occur in this infection in humans. This model has some disadvantages: (1) the artificially induced trauma to rabbit cardiac valves is different pathophysiologically from the conditions that predispose humans to infective endocarditis; (2) a larger inoculum of bacteria is required to produce infections in rabbits than that which causes human endocarditis; and (3) the rabbit model is a more severe, acute form of infection than human infective endocarditis, and survival of untreated animals for longer than 2 weeks is unusual. One should exercise considerable caution in extrapolating the results obtained from animal experimental infective endocarditis to human infection.

Animals↗
PubMed1980

[Infective endocarditis: a complication of idiopathic hypertrophic subaortic stenosis (author's transl)].

The idiopathic hypertrophic subaortic stenosis (IHSS) is thought to be infrequently complicated by infective endocarditis. Because IHSS is a disorder of the myocardium and not endocardium is not generally considered to have increased risk of infective endocarditis. Some Authors found, however, that approximately 5% of patients with IHSS develop bacterial endocarditis, because hemodynamically IHSS is like to valvular diseases. Therefore the incidence of endocarditis in IHSS is the same of valvular diseases. The vegetations can be found on anterior mitral valve leaflet, aortic cusps and subaortic endocardium. Some patients have dental surgery prior to the onset of endocarditis and others are infected with oral streptococci. For these reasons prophylactic antibiotics should be administered to patients with IHSS undergoing dental manipulation and in other settings where the risk of developing bacteremia is high. We describe one case of IHSS complicated with streptococcus viridans endocarditis. Vegetations, determined with echocardiography, were present on anterior mitral valve leaflet, aortic right coronary cusp and interventricular septum. In a review of literature we are been able to find twenty-seven cases of IHSS complicated with endocarditis.

Cardiomyopathy, Hypertrophic↗
PubMed1995

[Comparative outcome of aortic valve endocarditis with or without annular abscess].

Annular abscess is a not uncommon but serious complication of aortic valve endocarditis. The aim of this retrospective study was to evaluate the prognosis of aortic valve endocarditis with and without annular abscess. Between January 1981 and 1989, 122 consecutive cases of aortic endocarditis fulfilling the diagnostic criteria of Duke University were admitted to hospital. Group I included 40 cases with aortic ring abscess confirmed at surgery, in 35 patients; group II comprised 43 cases of operated aortic valve endocarditis without annular abscess in 41 patients and group III comprised 38 cases of aortic valve endocarditis treated medically without echocardiographic or angiographic signs of annular abscess in 36 patients. The patients in group III were significantly older than those in group I (57 +/- 14 years vs 44 +/- 17 years; p < 0.001). From the clinical point of view, endocarditis of prosthetic valves was slightly more common, but without reaching statistical significance, in group I, but the abscess was associated with more severe cardiac failure. Systemic embolism, atrioventricular block and pericardial effusion were equally common in the three groups. On the other hand, endocarditis with annular abscess was more often the result of infection with streptococci A, B, C or pneumoniae, than forms without abscess (22.5% vs 5% and 3% respectively in the 3 groups; p < 0.05). Of the patients treated surgically, destructive lesions of the valves were more common in cases of abscess (57.5% vs 35%; p < 0.05): the hospital mortality was higher in cases of abscess (17.5% vs 7%).(ABSTRACT TRUNCATED AT 250 WORDS)

Abscess↗
PubMed1994

[Infectious endocarditis induced by Actinobacillus actinomycetemcomitans. 8 new cases].

A commensal organism of the buccal cavity, Actinobacillus actinomycetemcomitans (AAC) has been responsible for at least four new cases of infectious endocarditis by year in France. This retrospective study was based on 90 new cases of infectious endocarditis by AAC, including 8 personal observations. One third of patients had no known cardiac disease before their infectious endocarditis, the portal of entry of which was usually dental. In cases of suspected infectious endocarditis, rapid and severe weight loss (43% of cases) and, less commonly, anicteric cholestasis (8%) should alert the physician for the possible pathological role of AAC. The echocardiographic appearances are non-specific. The diagnosis is confirmed on blood cultures but the organism grows slowly in CO2 enriched atmosphere. Initially, the course of the disease was favourable in one third of patients but, in two thirds of cases, complications were observed almost renal (26%), cardiac (24%) and neurological (18%). Two thirds of patients were cured by the time they were discharged whereas the remainder had sequellae, mainly valvular and neurological. The hospital mortality was 9%; late mortality was 6%. Therefore, the prognosis of AAC endocarditis, seems to be better than that of other bacteriological forms. A combination of cephalosporin and aminoside, or even a simple third generation cephalosporin antibiotic therapy for at least 4 weeks are usually effective. The complementary surgical indications are the same as for other forms of infectious endocarditis. Prophylaxis depends on strict prophylactic amoxicillin therapy for all cardiac patients at risk of infectious endocarditis before dental treatment and on good bucco-dental hygiene.

Actinobacillus Infections↗
PubMed1994

Endocarditis with pericardial bioprostheses: clinico-pathologic characteristics, immediate and long term prognosis.

Between 1977 and 1992, 30 consecutive episodes of infective endocarditis in 28 patients involving pericardial bioprostheses were diagnosed and treated in our hospital. Eleven (37%) were early pericardial valve endocarditis occurring in the first 60 days following valve surgery, and 19 (63%) were late endocarditis. In both the early and late groups, more aortic that mitral valves were affected (19/30). The most frequent pathogen in the early cases was staphylococcus, (S. epidermidis in five cases, S. aureus in one). The most frequent pathogen among late cases was streptococcus: (St. viridans in four, St. faecalis in two, St. bovis in one). In four cases (13%) no pathogen was isolated. Twelve patients received antibiotic treatment alone, six specific for the pathogen and other six only arbitrarily chosen regimen. All patients were cured in the former and all patients died in the latter group (four with negative blood cultures and two in whom identification of the pathogen was delayed-Proteus mirabillis in one case and Brucella mellitensis in the other). Valve replacement during the infective endocarditis episode was necessary in 18 cases, either because of failure of the antibiotic treatment or because of heart failure secondary to prosthetic malfunction. Peri-annular abscess was present in five cases. Surgical mortality was 22.2% (4/18). In all, 11 patients (39%) died during the active stage of infective endocarditis. The most frequent cause of death was heart failure (45.5%). All four patients with negative blood cultures died. The most advisable strategy for treating bacterial endocarditis of pericardial bioprostheses is a combination of antibiotic therapy and early surgery, especially in cases of staphylococcus endocarditis.(ABSTRACT TRUNCATED AT 250 WORDS)

Anti-Bacterial Agents↗