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Infection

Endocarditis

 

Possible therapeutic alternatives

Prophylaxis (Adults). Dental / oral / respiratory tract or Esophageal procedures:   
Standard regimen:
Amoxicillin 2 grams orally 1 hour before procedure.     
If unable to take oral medications give:
Ampicillin  2 grams IM or IV 30 minutes before procedure.
If allergic to penicillin:  
Clindamycin 600mg orally 1 hour before  or  [Keflex or Duricef: 2 grams 1 hour before]  or  [Zithromax or Clarithromycin: 500mg 1 hour before]. 
If unable to take oral meds  and allergic to penicillin:
Clindamycin 600mg IV 30 minutes before procedure or Cefazolin 1 gram  IM or IV 30 minutes before procedure.   
Prophylaxis (Adults). Genitourinary/ gastrointestinal procedures:   
High risk patients: 
Ampicillin 2 grams IM or IV + Gentamycin 1.5 mg/kg (max 120mg) within 30 minutes of procedure, then in 6 hours give Ampicillin 1 gram IM or IV or Amoxicillin 1 gram orally.
High risk patients allergic to penicillin: 
 Vancomycin 1 gram IV + Gent 1.5 mg/kg IV or IM--complete infusion within  30 minutes of starting procedure.   
Moderate risk patients:  
Amoxicillin 2 grams orally 1 hour before  or ampicillin 2 grams IV or IM 30 minutes before.
Moderate risk + penicillin allergic:  
Vancomycin 1 gram  IV over 1-2hrs  (complete infusion 30 minutes before.)
Native Valve, Subacute:  Common pathogens
Vancomycin 1 gram  ivpb q12h (patient-specific dosing required - target trough 15-20 mcg/ml)  PLUS
Ceftriaxone 2g IV q12-24h
Vancomycin 1 gram  ivpb q12h (patient-specific dosing required - target trough 15-20 mcg/ml)  PLUS 
Gentamicin (for synergy - peak: 4 to 5 mcg/ml)
MRSA not likely:

 [Nafcillin or Oxacillin 2 grams IV q4h]
PLUS 
Gentamicin (for synergy - peak: 4 to 5 mcg/ml)

Ampicillin 2 grams IV q4h + [Nafcillin or Oxacillin 2 grams IV q4h] + Gentamicin
Ampicillin-sulbactam 3g IV q 6h
PLUS  
gent/tobra
Indications for Surgery:

CHF, hemodynamic compromise, fungal etiology, unresolving bacteremia, continuing embolization, progressive heart block, valvular ring abscess, relapse.

Prosthetic Valve:  Common pathogens
Methicillin Sensitive Staphylococcus:
Nafcillin or Oxacillin 2 g IV q4h x 6 weeks plus Rifampin 300 mg PO q8h x 6 weeks plus Gentamicin IV or IM q8h x 2 weeks
Methicillin Resistant Staphylococcus: 
Vancomycin 1 g IV q12h x 6 weeks +
Rifampin 300 mg PO q8h x 6 weeks +  Gentamicin  IV or IM q8h x 2 weeks.
Streptococcus viridans or Enterococci: 
same as for native valve endocarditis.
Pseudomonas aeruginosa: 
Tobramycin  PLUS
[Piperacillin-tazobactam (Zosyn) or Ticarcillin-clavulanic acid (Timentin)  or Ceftazidime ]
Endocarditis