4.02 - Cardiovascular System Infections - UMMC Pharmacy Portal v2

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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).	Benzathine Benzylpenicillin 1.2 MU IM single dose 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 valve, 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