RISK FACTORS: Underlying conditions LIKE Prosthetic cardiac valves, Previous bacterial endocarditis, even in the absence of heart disease, Most congenital cardiac malformations, Rheumatic and other acquired valvular dysfunction
GENERAL MEASURES :
. Treat CHF if it occurs
. Oxygen treatment as needed
. Consider hemodialysis
SURGICAL MEASURES :
. Valve replacement may be performed before antibiotic treatment course is completed when any of the following are present:
. CHF due to valve incompetence
. Multiple major systemic emboli
. Infection is caused by resistant organisms, e.g., fungus, Pseudomonas aeruginosa
. Dehiscence of infected prosthetic valve
. Relapse of prosthetic valve endocarditis
. Persistent bacteremia despite antibiotics
PATIENT EDUCATION : Importance of dental hygiene, Antibiotic prophylaxis when undergoing certain dental/surgical procedures
DRUG(S) OF CHOICE :
β’ Penicillin-susceptible streptococci: Penicillin 2-4 million UIV q4h, plus gentamicin for 2 weeks (6 weeks for
prosthetic valve endocarditis). In patients with native valve endocarditis: patient > 65 years of age, those with
impairment of the eighth nerve or of renal function, or those with central nervous system involvement, use
penicillin only, in the same dosage alone for 4 weeks.
β’ Enterococci: Penicillin 5-10 million U q4h, plus gentamicin or streptomycin for 4-6 weeks (6 weeks for
prosthetic valve endocarditis). Test the enterococcal strain in vitro for high-level resistance to gentamicin
and streptomycin (minimal inhibitory concentration [MIC] > 2000 Γ¬g/mL). Use streptomycin, 1 gm IM q24h,
instead of gentamicin if there is high-level resistance to gentamicin and not to streptomycin.
β’ Staphylococcus of native valve: Oxacillin or nafcillin 2 g IV q4h for 6 weeks. For the fi rst 3-5 days, add gentamicin.
β’ Staphylococcus of prosthetic valve: Vancomycin 15 mg/kg (usual dose 1 g) IV infused over 1 h q12h, plus
rifampin 300 mg po q8h, both for 6 weeks, plus gentamicin for the fi rst 2 weeks
β’ HACEK organisms: ceftriaxone 2 gm IM or IV q24h for 4 weeks
CONTRAINDICATIONS: For patients who are allergic to penicillin, use alternative drugs
PRECAUTIONS:
β’ In patients with renal impairment, dosage adjustment should be made for penicillin G, gentamicin, cefazolin,
vancomycin
β’ Rapid infusion of vancomycin (less than one hour) may cause βred-neck syndromeβ. This is due to histamine
release and not an allergic reaction. It will disappear when the rate of infusion is reduced.
ALTERNATIVE DRUGS :
. For patients allergic to penicillin
. Penicillin-susceptible streptococci: ceftriaxone 2 g IM or IV qday for 4 weeks or ceftriaxone 2 g IV plus
gentamicin 3 mg/kg qday for 2 weeks (not to be used in patients with immediate type hypersensitivity to
penicillin), or vancomycin 15 mg/kg (usual dose 1 g) IV over 1 hr q12h for 4 weeks (6 weeks for prosthetic
valve endocarditis)
. Enterococci: Desensitization to penicillin should be considered. Vancomycin 15 mg/kg (usual dose 1 g) IV infused over 1 hr q12h, plus gentamicin (see Other Notes) for 4-6 weeks (6 weeks for prosthetic valve
endocarditis).
. Staphlococcus of native valve: Cefazolin 2 gm IV q8h (not to be used in patients with immediate-type
hypersensitivity to penicillin), or vancomycin 15 mg/kg (usual dose 1 g) IV infused over 1 hr q12h, for
6 weeks
PATIENT MONITORING :
. Check gentamicin peak (approx 3 MCG/mL) and trough (<1 MCG/mL) levels if used for more than 5 days, and in patients with renal dysfunction.
. Check vancomycin peak (30-45 MCG/mL) and trough (<10 MCG/mL) levels in patients with renal dysfunction.
. Perform twice weekly BUN and serum creatinine while the patient is receiving gentamicin
. Consider audiometry baseline and follow-up during long-term aminoglycoside therapy
PREVENTION/AVOIDANCE :
. Treat dental caries while the patient is being treated for endocarditis
. Maintain good oral hygiene
. Give antibiotic prophylaxis to patients undergoing procedures that may cause transient bacteremia
. Antibiotic regimen for dental/oral/upper respiratory tract procedures: (may be used in patients with prosthetic
valves)
. Amoxicillin 2 g po (or for penicillin allergic patients, clindamycin 600 mg po) 1 hr before procedure
. Alternative: Ampicillin 2.0 g IV (or IM) (or for penicillin allergic patients clindamycin 600 mg IV) 30 minutes
before procedure
. Antibiotic regimen for GU/GI procedures
. Ampicillin 2 g IV (or IM) plus gentamicin 1.5 mg/kg IV (or IM) (not to exceed 120 mg) 30 minutes before
procedure
. For patients allergic to penicillin: vancomycin 1.0 g IV infused over 1 hr plus gentamicin 1.5 mg/kg IV
(or IM) (not to exceed 120 mg); complete infusion 30 minutes before procedure
. Alternate oral regimen for moderate-risk patients undergoing GU/GI procedures
. Amoxicillin 2.0 g po 1 hr before or ampicillin 2 g IV (or IM) 30 minutes before procedure
. For patients who are allergic to penicillin: vancomycin 1.0 g IV infused over 1 hr; complete infusion 30
minutes before procedure
POSSIBLE COMPLICATIONS :
. Arterial emboli and infarcts (e.g., MI, mesenteric, splenic, cerebral infarct)
. Infectious emboli (e.g., abscesses of heart, lung, brain, meninges, bone, pericardium)
. Inflammatory/immune disorders (e.g., arthritis, myositis, glomerulonephritis)
. Miscellanous complications (e.g., congestive heart failure, ruptured valve cusp, sinus of Valsalva aneurysm,
cardiac arrhythmia, ruptured mycotic aneurysm)
EXPECTED COURSE/PROGNOSIS :
. Staphylococcal endocarditis, fever and positive blood cultures may persist up to 10 days after appropriate
treatment started
. Streptococcal endocarditis, clinical response expected within 48 hours of antibiotic treatment and blood
cultures negative soon after antibiotics
. Prognosis depends largely on complications