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For penicillin-susceptible viridans streptococcal endocarditis (ie, MIC 01 mcg/mL), penicillin G, 2 3 million units intravenously every 4 hours for 4 weeks, is recommended The duration of therapy can be shortened to 2 weeks if gentamicin, 1 mg/kg intravenously every 8 hours, is used with penicillin Ceftriaxone, 2 g once daily intravenously or intramuscularly for 4 weeks, is also effective therapy for penicillinsusceptible strains and is a convenient regimen for home therapy For the penicillin-allergic patient, vancomycin, 15 mg/kg intravenously every 12 hours for 4 weeks, is given The 2-week regimen is not recommended for patients with symptoms of more than 3 months duration or with complications such as myocardial abscess or extracardiac infection Prosthetic valve endocarditis is treated with a 6-week course of penicillin with at least 2 weeks of gentamicin Viridans streptococci relatively resistant to penicillin (ie, MIC > 01 mcg/mL but 05 mcg/mL) should be treated for 4 weeks Penicillin G, 3 million units intravenously every 4 hours, is combined with gentamicin, 1 mg/ kg intravenously every 8 hours for the first 2 weeks In the
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For methicillin-susceptible S aureus, nafcillin or oxacillin, 15 2 g intravenously every 4 hours for 6 weeks, is the preferred therapy Uncomplicated tricuspid valve endocar-
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Table 33 4 Recommendations for administration of bacterial endocarditis prophylaxis for high and moderate risk patients according to type of procedure1
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Prophylaxis Recommended 1 Dental procedures Dental extractions Periodontal procedures Dental implantation Endodontic (root canal) instrumentation or surgery beyond the apex Subgingival placement of antibiotic fibers or strips Initial placement of orthodontic bands but not brackets Intraligamentary local anesthetic injections Cleaning of teeth or implants where bleeding is anticipated 2 Respiratory tract procedures Tonsillectomy, adenoidectomy Surgical operations of intestinal or respiratory mucosa Rigid bronchoscopy 3 Gastrointestinal tract procedures4 Sclerotherapy for esophageal varices Esophageal stricture dilation Endoscopic retrograde cholangiography with biliary obstruction Biliary tract surgery Surgical operations that involve intestinal mucosa 4 Genitourinary tract Prostatic surgery Cystoscopy Urethral dilation Prophylaxis Not Recommended 1 Dental procedures Restorative dentistry (filling cavities, operative and prosthodontic) with or without retraction cord2 Nonintraligamentary local anesthetic injections Intracanal endodontic treatment; post placement and buildup Placement of rubber dams, removable prosthodontic, or orthodontic appliances Postoperative suture removal Taking of oral impression Fluoride treatments Orthodontic appliance adjustment 2 Respiratory tract procedures Endotracheal intubation Flexible bronchoscopy, with or without biopsy3 Tympanostomy (insertion) 3 Gastrointestinal tract procedures Transesophageal echocardiography3 Endoscopy with or without gastrointestinal biopsy3 4 Genitourinary tract Vaginal hysterectomy3 Vaginal delivery3 Cesarean section In the absence of infection: urethral catheterization, uterine dilation and curettage, therapeutic abortion, sterilization procedures, insertion or removal of intrauterine devices 5 Other Cardiac catheterization, including balloon angioplasty; implanting cardiac pacemakers or defibrillators and coronary stents; incision or biopsy of surgically scrubbed skin; circumcision
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Based on recommendations by the American Heart Association JAMA 1997 Jun 11;277(22):1794 801 The procedures listed are not meant to be all-inclusive Clinical judgment may indicate antibiotic use in selected circumstances that may create significant bleeding 3 Prophylaxis is optional for high-risk patients, not recommended for moderate-risk patients 4 Prophylaxis is recommended for high-risk patients, optional for moderate-risk patients
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ditis probably can be treated for 2 weeks with nafcillin or oxacillin alone For penicillin-allergic patients, cefazolin, 2 g intravenously every 8 hours, or vancomycin, 15 mg/kg intravenously every 12 hours, may be used For methicillinresistant strains, vancomycin remains the preferred agent Aminoglycoside combination regimens are probably of no benefit and in general should be avoided The effect of rifampin with antistaphylococcal drugs is variable, and its routine use is not recommended Because coagulase-negative staphylococci a common cause of prosthetic valve endocarditis are routinely resistant to methicillin, -lactam antibiotics should not be used for this infection unless the isolate is demonstrated to be susceptible A combination of vancomycin 1 g intravenously every 12 hours for 6 weeks, rifampin, 300 mg every 8 hours for 6 weeks, and gentamicin, 1 mg/kg intravenously every 8 hours for the first 2 weeks, is recommended for prosthetic valve infection If the organism is sensitive to methicillin, either nafcillin or oxacillin or cefazolin can be used in combination
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with rifampin and gentamicin Combination therapy with nafcillin or oxacillin (vancomycin for methicillin-resistant strains or patients allergic to -lactams), rifampin, and gentamicin is also recommended for treatment of S aureus prosthetic valve infection
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