Endocarditis
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Possible therapeutic alternatives
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| Prophylaxis (Adults). Dental / oral / respiratory tract or Esophageal procedures: |
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| 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. |
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| Prophylaxis (Adults). Genitourinary/ gastrointestinal procedures: |
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| 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.) |
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| 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. |
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| 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 ] |
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