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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 ]

References - Infectious Disease Section

Infectious Disease References

Disclaimer

The authors make no claims of the accuracy of the information contained herein; and these suggested doses are not a substitute for clinical judgement. Neither GlobalRPh Inc. nor any other party involved in the preparation of this program shall be liable for any special, consequential, or exemplary damages resulting in whole or part from any user's use of or reliance upon this material.
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