4.02 - Cardiovascular System Infections

A) Adults

Disease / Etiology

Preferred

Alternative

Comments

Infective Endocarditis

 
Native valve, Non IVDU
Strep viridans
Other 
Streptococci
Enterococcus
Staphylococcus

 
Benzylpenicillin 24 MU IV daily divided q4H
+ Cloxacillin 2 gm IV q4H
+ Gentamicin 1 mg/kg IM or IV q8H
 
Cefazolin 2 gm IV q8H
OR
Vancomycin* 25 - 30 mg/kg (max 2 gm) loading dose, then 15 - 20 mg/kg IV q8 - 12H
+ Gentamicin 1 mg/kg IM or IV q8H

Duration: 4 - 6 weeks 
Gentamicin 2 - 4 weeks
    
At least 3 sets of blood cultures from different sites before empiric therapy.

Gentamicin added to beta lactam clears culture earlier but does not change mortality. Avoid in elderly and renal impaired. Discontinue once cultures known except for streptococcal and enterococcal endocarditis.

For Streptococcal IE, once daily dosing of Gentamicin may be used at 3 mg/kg to reduce renal toxicity.

For Enterococcal IE, please check with lab for HLAR (High Level Aminoglycoside Resistance). If present, please stop Gentamicin.

* Vancomycin is used as an alternative to cefazolin for penicillin allergy.

 
Native valve, IVDU
Right sided endocarditis:
Staphylococcus aureus (MSSA)

 
Cloxacillin 2 gm IV q4H
 
Prosthetic valve endocarditis
S epidermidis
S viridans
Strep
S aureus 

Rarely,
Enterobacteriaceae
Diphtheroids
Fungi

 
Vancomycin 25 - 30 mg/kg loading dose (max 2 gm), then 15 - 20 mg/kg IV q8 - 12H 
+ Gentamicin 1 mg/kg IV q8H
+ Rifampicin 600 mg PO q24H

 

Pericarditis (Purulent)

 
Staph aureus
Strep pneumoniae
Group A strep
Enterobacteriaceae


 
Ceftriaxone 2 gm IV q24H
 
Cefepime 2 gm IV q8H
 
Duration: 2 - 6 weeks, drainage required.

If MRSA is suspected, add Vancomycin 25 - 30 mg/kg (max 2 gm) loading dose, then 15 - 20 mg/kg IV q8 - 12H.

Acute Rheumatic Fever

 
With carditis. Post infectious sequelae of Group A strep infection (usually pharyngitis).
 
Penicillin C Benzathine 1.2 MU
OR
Penicillin V 500 mg PO q8H for 10 days

OR

Amoxicillin 500 mg PO q12H for 10 days

OR

Cephalexin 500 mg PO q12H for 10 days

 
Penicillin allergy:

Azithromycin 500 mg orally on Day 1 followed by 250 mg orally on Day 2 through 5

OR

Clindamycin 300 - 450 mg PO q6 - 8H for 5 days
 
Symptomatic relief:
Aspirin 4 - 8 gm/day in divided doses every four to six hours.

Severe Carditis ± Acute Heart Failure:
Prednisolone 2 mg/kg/day in 2 divided doses for 2 - 4 weeks then taper over 2 weeks + Aspirin as above.

Pacemaker / Defibrillator & Ventricular Assist Device Related Infection

 
S aureus
S epidermidis
Aerobic gram negative bacilli
Candida sp
 
Vancomycin 25 - 30 mg/kg loading dose (max 2 gm) 15 - 20 mg/kg IV q8 - 12H
+ Gentamicin 1 mg/kg IV q8H
+ Rifampicin 600 mg PO q24H
 

 
Duration:
Pocket or subcutaneous infection 10 - 14 days.
Lead-associated endocarditis up to 4 - 6 weeks.

Device removal recommended.
Obtain blood culture, wound, drive line, device pocket ± pump cultures.


B) Paediatrics

Disease / Etiology

Preferred

Alternative

Comments

Infective Endocarditis

 
Native v
alve, Non IVDU
Strep viridans
Other Streptococci
Enterococcus
Staphylococcus

 
Benzylpenicillin 50,000 units/kg IV q4H for 4 weeks

+ Gentamicin 1 mg/kg q8H IV for 2 weeks

 
Penicillin allergy:
  
Vancomycin 15 - 20 mg/kg IV q8H for 4 - 6 weeks
+ Gentamicin 1 mg/kg IV q8H for 2 weeks
 
At least 3 sets of blood cultures from different sites before empiric therapy.

Gentamicin added to beta lactam clears culture earlier but does not change mortality. Avoid in elderly and renal impaired. Discontinue once cultures known except for streptococcal and enterococcal endocarditis.
 
Native valve, IVDU
Right sided endocarditis:
Staphylococcus aureus (MSSA, MRSA)
 
For MSSA IE:
Cloxacillin 50 mg/kg IV q6H for 6 weeks
+ Gentamicin 1 mg/kg q8H for 2 weeks

For MRSA IE:
Vancomycin (Monotherapy)
15 - 20 mg/kg IV q8H for 4 - 6 weeks

 
For MSSA IE:
Cefazolin 25 mg/kg q8H IV for 6 weeks
+ Gentamicin 1 mg/kg IV q8H for 2 weeks

 
Prosthetic valve endocarditis:

S epidermidis (MSSE / MRSE)
S viridans 
Staph aureus 

Rarely,
Enterobacteriaceae
Diphtheroids
Fungi

 
Vancomycin
15 - 20 mg/kg q8H IV for 6 weeks
+ Rifampicin 20 mg/kg/day (max 600 mg/day) PO in 3 divided doses for 6 weeks
+ Gentamicin 1 mg/kg IV q8H for 2 weeks
 

Pericarditis (Purulent)


Staph aureus
Strep pneumoniae
Haemophilus influenzae
Other Streptococci
Gram negative bacteria


 
Cloxacillin 50 mg/kg IV q6H for 4 - 6 weeks
+ Gentamicin 1 mg/kg IV q8H for 2 weeks

Vancomycin 15 - 20 mg/kg IV q8H for 4 - 6 weeks
+ Gentamicin 1 mg/kg IV q8H for 2 weeks
 
Duration: minimum 4 weeks

Early surgical consult for possibly intervention. Ceftriaxone / Cefotaxime may be considered in place of Gentamicin.

Rheumatic Fever

 
With carditis. Post infectious sequelae of Group A strep infection (usually pharyngitis).
 
Benzylpenicillin 50,000 units/kg IV q6H for 10 - 14 days
OR
Penicillin V 10 - 15 mg/kg PO q6H for 10 - 14 days

Followed by Penicillin V prophylaxis:
<5 years old 125 mg BD
>5 years old 250 mg BD
 
Penicillin allergy:

Erythromycin: 12.5 mg/kg PO q6H for 10 - 14 days followed by Erythromycin 12.5 mg/kg PO q12H

Mild / No carditis:
Aspirin 80 - 100 mg/kg/day in 3 - 4 divided doses for 2 - 4 weeks then taper over 4 weeks.

Moderate / Severe carditis:
Prednisolone 2 mg/kg/day in 2 divided doses for 2 - 4 weeks then taper over 2 weeks with addition of Aspirin as above.

# Please refer to the appropriate Rheumatic Fever Guideline for the management of carditis.

Pacemaker / Defibrillator & Ventricular Assist Device Related Infection


S aureus
S epidermidis
Aerobic gram negative bacilli
Fungal


 
Vancomycin
15 - 20 mg/kg IV q8H for 6 weeks
+ Gentamicin 1 mg/kg IV q8H for 2 weeks
 
Linezolid (Monotherapy)
10 mg/kg IV q8H for 4 - 6 weeks

IV to PO switch possible after clinical improvement.

Fungal infection rare. For proven fungal infections Amphotericin B or Voriconazole equally effective.

Infective Endocarditis Prophylaxis Guideline for Dental Procedure


Viridans group streptococci

Oral:
Amoxicillin 50 mg/kg
(60 minutes before procedure)

Parenteral (IV or IM):
Ampicillin 50 mg/kg
OR
Cefazolin / Ceftriaxone
50 mg/kg
(30 minutes before procedure) 
 
Single dose

Oral:
Clindamycin 20 mg/kg
(60 minutes before procedure)
OR
Cephalexin 50 mg/kg
(30 - 60 minutes before procedure)
OR
Azithromycin / Clarithromycin 15 mg/kg
(30 - 60 minutes before procedure)

Parenteral (IV / IM):
Clindamycin 20 mg/kg
(30 minutes before procedure)

 
Cardiac conditions in which prophylaxis for dental procedures is recommended.
1. Prosthetic cardiac valve
2. Previous IE
3. Unrepaired cyanotic CHD, including palliative shunts and conduits
4. Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure
5. Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)
6. Cardiac transplantation recipients who develop cardiac valvulopathy