Endocarditis: Treatment Shannon Famenini

Objectives Know how to treat native valve and prosthetic valve endocarditis Know the indications and treatments for prophylaxis in endocarditis

Treatment in native valve endocarditis Organism Treatment Streptococcus viridans Penicillin G 12-18 units Q24h Ampicillin 2g IV Q4h Ceftriaxone 2g Q24h Vancomycin 30 mg/kg Q24h Streptococcus bovis Same as above Streptococcus pneumoniae Penicilin G 12-18 units Q24h Cefazolin 2g Q8h Enterococcus Ampicilliln 2g IV Q4h or + Gentamicin

Treatment in native valve endocarditis Organism treatment MSSA Nafcillin 3g Q6h Oxacillin 3g Q6h Cefazolin 2g Q8h MRSA Vanocmycin Daptomycin HACEK organisms Ceftriaxone 2g Q24h Ciprofloxacin 500 mg Q12h

Treatment in Prosthetic Valve Endocarditis Organism treatment MSSA Nafcillin or oxacillin 2g Q24h Or Cefazolin 2gQ8h + Rifampin 300 mg Q8h Gentamicin 3mg/kg/24 hrs in 2-3 doses MRSA Vancomycin 30 mg/kg Q24h Gentamicin 3mg/kg Q24hrs in 2-3 weeks

Treatment in prosthetic valve organism treatment Streptococcus viridans Penicillin G 12-18 million units Q24h or Ampicillin 2g IV Q4h Ceftriaxone 2g Q24h +/- Gentamicin 3 mg/kg Q24h Enteroccocus Penicillin G 12-18 million units Q4h + Gentamicin HACEK Ciprofloxacin 500 mg Q12h

Who should receive prophylaxis? HIGH RISK PATIENTS undergoing HIGH RISK PROCEDURES should receive prophylaxis.

High Risk Patients Patients with prosthetic heart valves, including mechanical and bioprosthetic valves A prior history of IE Unrepaired cyanotic congenital heart disease Repaired congenital heart disease with residual shunts or valvular regurgitation at the site or adjacent to the site of the prosthetic valve Valve regurgitation due to a structurally abnormal valve in a transplanted patient

High Risk Procedures Dental Work (examples: tooth extractions, drainage of dental abscess, routine dental cleaning) Procedures that involve incision or biopsy of the respiratory tract mucosa (examples: tonsillectomy, adenoidectomy, bronchoscopy with biopsy) Procedures on infected skin, skin structure, or musculoskeletal tissue GI or GU procedures in patients with ongoing GI or GU tract infection Surgery to place prosthetic heart valve or prosthetic intravascular or intracardiac material

Prophylaxis Situation Agent Regimen Oral Amoxicillin 2 g Unable to take oral medication Ampicillin OR Cefazolin/Ceftriaxone 2g IM or IV 1 g IM or IV Allergic to penicillin Cephalexin Clindamycin Azithromycin/Clarithromycin 2g 600 mg 500 mg Allergic to penicillin and unable to take oral medication Cefazolin or ceftriaxone Vancomycin 600 mg IM or IV 15-20 mg/kg

Case In which of the cases is prophylaxis indicated? Man with bicuspid aortic valve undergoing dental cleaning Man with history of cardiac valve repair undergoing colonoscopy Woman with prior history of IE undergoing vaginal delivery Man with prosthetic heart valve undergoing extraction of a tooth abscess The correct answer is D!

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