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HACEK organisms are slow-growing, fastidious gramnegative coccobacilli or bacilli that are normal oral flora and cause less than 5% of all cases of endocarditis They may produce -lactamase, and thus the treatment of choice is ceftriaxone (or some other third-generation cephalosporin), 2 g intravenously once daily for 4 weeks Prosthetic valve endocarditis should be treated for 6 weeks In the penicillin-allergic patient, experience is limited, but trimethoprim-sulfamethoxazole, quinolones, and aztreonam have in vitro activity and should be considered; desensitization may be preferable
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Table 33 5 American Heart Association recommendations for endocarditis prophylaxis in high- and moderate-risk patients1
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Dental, Respiratory, or Esophageal Procedures Oral Penicillin allergy Amoxicillin Clindamycin or Cephalexin or cefadroxil or Azithromycin or clarithromycin Parenteral Penicillin allergy Ampicillin Clindamycin or Cefazolin 1 g IM or IV 30 minutes before procedure (contraindicated if there is history of a lactam immediate hypersensitivity reaction) Ampicillin, 2 g IM or IV, plus gentamicin, 15 mg/kg IV or IM (120 mg maximum) 30 minutes before procedure; 6 hours later, ampicillin, 1 g IM or IV, or amoxicillin, 1 g orally For the penicillin-allergic patient, instead of ampicillin, use a single dose of vancomycin, 1 g IV over 1 2 hours with completion of infusion 30 minutes before procedure Amoxicillin, 2 g orally 1 hour before procedure, or ampicillin, 2 g IM or IV 30 minutes before starting procedure For the penicillin-allergic patient instead of ampicillin use vancomycin, 1 g IV over 1 2 hours with completion of infusion 30 minutes before procedure; complete infusion 30 minutes before procedure 500 mg 1 hour before procedure 2 g IM or IV 30 minutes before procedure 600 mg IV 1 hour before procedure 2 g 1 hour before procedure (contraindicated if there is history of a -lactam immediate hypersensitivity reaction) 2 g 1 hour before procedure 600 mg 1 hour before procedure
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Gastrointestinal (Except Esophageal) or Genitourinary Procedures High-risk patient (Table 33 3) Ampicillin plus gentamicin or vancomycin plus gentamicin (for penicillin allergy) Amoxicillin or ampicillin or vancomycin (for penicillin allergy)
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See JAMA1997 Jun 11;277(22):1794 801 for details
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While many cases can be successfully treated medically, operative management is frequently required Acute heart failure unresponsive to medical therapy is an indication for valve replacement even if active infection is present, especially for aortic valve infection Infections unresponsive to appropriate antimicrobial therapy after 7 10 days (ie, persistent fevers, positive blood cultures despite therapy) are more likely to be eradicated if the valve is replaced Surgery is nearly always required for cure of fungal endocarditis and is more often necessary with gram-negative bacilli It is also indicated when the infection involves the sinus of Valsalva or produces septal abscesses Recurrent infection with the same organism prompts an operative approach, especially with infected prosthetic valves Continuing embolization presents a difficult problem when the infection is otherwise responding; surgery may be the proper approach Particularly challenging is a large and fragile vegetation demonstrated by echo in the absence of embolization Most clinicians favor an operative approach, vegetectomy with valve repair if the patient is a good candidate Embolization after bacteriologic cure does not necessarily imply recurrence of endocarditis
The role of anticoagulant therapy during active prosthetic valve endocarditis is more controversial Reversal of anticoagulation may result in thrombosis of the mechanical prosthesis, particularly in the mitral position On the other hand, anticoagulation during active prosthetic valve endocarditis caused by S aureus has been associated with fatal intracerebral hemorrhage One approach is to discontinue anticoagulation during the septic phase of S aureus prosthetic valve endocarditis In patients with S aureus prosthetic valve endocarditis complicated by a central nervous system embolic event, anticoagulation should be discontinued for the first 2 weeks of therapy Indications for anticoagulation following prosthetic valve implantation for endocarditis are the same as for patients with prosthetic valves without endocarditis (eg, nonporcine mechanical valves and valves in the mitral position)
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