3.02 - Cardiovascular System Infections [updated]

A) Adults

Disease / Etiology

Preferred

Alternative

Comments

Infective Endocarditis

Empiric antibiotic
 
Native valve, Non IVDU
Streptococcus 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 

4 weeks for native valves, 6 weeks for prothetic valves
Gentamicin 2 - 4 weeks
6 weeks for staphylococcus aureus native valve endocarditis

    
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. (Refer below to Enterococcal section).


For Streptococcal IE, once daily dosing of Gentamicin may be used at 3 mg/kg to reduce renal toxicity. (MIC>1.2)

*Rifampicin: To avoid the development of resistance, it should be started after 3-5 days of effective initial cloxacillin therapy and/or once the bacteraemia has been cleared.
 
Prosthetic valve endocarditis
Streptococcus epidermidis
Streptococcus viridans 
Streptococcus sp 
Staphylococcus 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** 450mg PO 12H
Ampicillin 2gm IV q4h


OR 

Ceftriaxone 2gm IV q24h

 

Penicillin Allergy: *Vancomycin 15-20mg/kg (actual body weight) IV q8-12h; not to exceed 2gm/dose

Targeted antibiotics therapy

*For Viridans Streptococci & Streptococcus bovis, MIC estimation needs to be done for these isolates to facilitate management

Streptococci & Streptococcus bovis 

Native and Prosthetic Valves MIC: < 0.125μg/mL

(Penicillin-Susceptible Viridans)

  
Benzylpenicillin 3MU IV q4-6h 		  
Ampicillin 2gm IV q4h

 

OR

Ceftriaxone 2gm IV q24h

 

Penicillin Allergy: *Vancomycin 15-20mg/kg (actual body weight) IV q8-12h; not to exceed 2gm/dose		  

Duration: 4 weeks for native valves

              Endocarditis

               6 weeks for prosthetic valves

              Endocarditis

 

For Penicillin-susceptible viridans streptococci, monotherapy with benzylpenicilin, ampicillin or ceftriaxone is adequate
 

Native and prosthetic Valves MIC: > 0.125μg/mL- 2μg/mL (Penicillin-Relatively Resistant Streptococus Viridans) 

 

 


 

Benzylpenicillin 4MU IV q4h (total 24 MU/24h) or


Benzylpenicillin 24 MU IV continuously

+



 *Gentamicin 3mg/kg IV q24h 		 

Ceftriaxone 2gm IV q24h

 

+

 

*Gentamicin 3mg/kg IV q24h If unable to tolerate Penicillin/Ceftriaxone

 

 **Vancomycin 15-20mg/kg (actual body weight) IV q8-12h; not to exceed 2gm/dose,

+


*Gentamicin 3mg/kg IV q24h for 




Duration (other than Gentamicin):

4 weeks for Native Valves Endocarditis

6 weeks for Prosthetic Valves Endocarditis

 

Penicillin-relatively resistant streptococcus viridans, gentamicin has to be added to the regime. Duration: 2 weeks for Native Valves Endocarditis and 6 weeks for Prosthetic Valves Endocarditis.

 

*Gentamicin: aim for pre-dose (trough) serum level of < 1mg/l

 

Native and Prosthetic Valves MIC > 2μg/mL (Penicillin resistant Streptococcus Viridans & Streptococcus bovis)


 
Treat as resistant enterococcal endocarditis - refer below		 

Therapy for Culture-Negative Endocarditis - Consultation with an infectious disease specialist needed 

HACEK, Brucella, Bartonella, Coxiella

 
Native valve and prosthetic valves;
HACEK organisms (haemophilus parainfluenzae, aggregatibacter (formerly Haemophilus) aphrophilus, cardiobacterium hominis, eikenella corrodens, kingella species, also Bartonella sp.		 
IV ceftriaxone 2gm od 		 

Ampicillin/sulbactam 3gm IV q6h

 

OR

 

Ciprofloxacin 400mg IV or

500mg PO q12h for 4 weeks (native valve) or 6 weeks (prosthetic valve)




Duration: 4 weeks for native valves

              Endocarditis

               6 weeks for prosthetic valves

              Endocarditis

Enterococcus

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

 

Native and Prosthetic Valves

Sensitive to Gentamicin


 

Ampicillin 2gm IV q4h

 

+


*Gentamicin 1mg/kg IV q8h 

 

 

Duration: 4 weeks for native valves

              Endocarditis

              6 weeks for prosthetic valves

              Endocarditis

 

Sensitive to Gentamicin

renal impaired and elderly patients


 

Ampicillin 2gm IV q4h for 6 weeks

+


Ceftriaxone 2gm IV q12h for 6 week		 

 

 
Resistance to penicillin, susceptible to Aminoglycosides and Vancomycin 
 
Vancomycin 15-20mg/kg (actual body weight) IV q8-12h; not to exceed 2 gm/dose

+

**Gentamicin 1 mg/kg IV q8h 

  

Duration: 6 weeks

**Gentamicin: aim for pre-dose (trough) serum level of < 1mg/L

Staphylococcus aureus

 

Native Valves Methicillin-Susceptible Staphylococci (MSSA)


 

Left sided endocarditis or complicated right sided endocarditis: Cloxacillin 2gm IV q4h for 4 to 6 weeks 

 

Right sided endocarditis (tricuspid valve) or uncomplicated endocarditis

Cloxacillin 2gm IV in q4h for* 2 to 4  weeks		 

For β-Lactam allergic patients:

Immediate type hypersensitivity to penicillin (anaphylaxis):

Vancomycin 15-20mg/kg (actual body weight) IV q8-12h; not to exceed 2gm/dose, for 4 to 6 weeks.

 

For non-immediate type hypersensitivity: Cefazolin 2gm IV q8h for 4 to 6 weeks

 

*2 weeks’ regime is sufficient provided the patient fulfils all the following criteria (uncomplicated IE): 

·        MSSA 

·        Absence of associated prosthetic valve or left sided valve infection 

·        Good response to treatment 

·        Absence of metastatic sites of infection or empyema. 

·        Absence of cardiac and extra-cardiac complications

·        < 20 mm vegetation 

·        Absence of severe immunosuppression (<200 CD4 cells/ml) with or without Acquired Immune Deficiency Syndrome (AIDS)

 
Prosthetic Valves Methicillin-Susceptible Staphylococci (MSSA)		 

Cloxacillin 2gm IV in q4h for ≥ 6 weeks

+

 

Gentamicin 1mg/kg IM/IV q8h for 2 weeks +

 

*Rifampicin 300-450mg PO q12h for ≥ 6 weeks

 

For β-lactam allergic patients: 

refer above

 
*Rifampicin: To avoid the development of resistance, it should be started after 3-5 days of effective initial cloxacillin therapy and/or once the bacteraemia has been cleared
 
Native Valves Methicillin-Resistant Staphylococci (MRSA)

 
Vancomycin 15-20mg/kg (actual body weight) IV q8-12h; not to exceed 2gm/dose, for 4 to 6 weeks 		 
**Daptomycin 10mg/kg IV q24h for 4 to 6 weeks		 
Daptomycin is superior to vancomycin for MRSA bacteraemia with vancomycin MIC > 1 mg/l.
 

Prosthetic Valves Methicillin-Resistant Staphylococci (MRSA)

Vancomycin 15-20mg/kg (actual body weight) IV q8-12H; not to exceed 2gm/dose, for ≥ 6 weeks

 

+

 

Gentamicin 1mg/kg IV q8h for 2 weeks

 

+

 

**Rifampicin 300-450mg PO q12h for ≥ 6 weeks*

 

 





**Rifampicin: To avoid the development of resistance, it should be started after 3-5 days of effective initial Vancomycin therapy and/or once the bacteraemia has been cleared

Pericarditis (Purulent)

 

Staphylococcus aureus

Streptococcus pneumoniae
Group A Streptococcus
Enterobacteriaceae

(Need to consider tuberculosis)

Post operation- Staphylococcus aureus and fungi are more common



Cefepime 2gm IV q12H (uptodate)

Vancomycin (15 to 20 mg/kg/dose q8-12H, not to exceed 2 g per dose);

+

Ceftriaxone 2gm IV q24H

Duration: 2 - 6 weeks, pericardiocentesis for source control is crucial

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

Fluconazole 200-400mg IV q24H may be added if patient is severely immunosuppressed or had recent ICU care or had recent broad spectrum antibiotics 

Consider carbapenem if ESBL or MDR is suspected

Acute Rheumatic Fever

Eradication of Group A Streptococcus-

Post infectious sequelae of Group A strep infection (usually pharyngitis or in some cases pyoderma).

 




Secondary prophylaxis-

Patients who have had an attack of ***Acute Rheumatic Fever (ARF) and develop subsequent GAS pharyngitis are at high risk for a recurrent attack of ARFà refer to non surgical prophylaxis guideline.



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

Household contacts should be screened and if confirmed GAS should be given a full course of Antibiotic therapy.

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

Daptomycin 6mg-8mg/kg IV OD

*Rifampicin should be added in 3-5 days after initiation of vancomycin and gentamicin.

Consider adding broader Gram negative coverage with piperacillin-tazobactam or carbapenem in hemodynamic unstable patients.


Fluconazole 200-400mg IV q24H may be added if patient is severely immunosuppressed or patient had recent ICU care or had broad spectrum antibiotics


Duration:
Pocket or subcutaneous infection 10 - 14 days.

Lead-associated endocarditis up to 4 - 6 weeks.

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




B) Paediatrics



Disease / Etiology

Preferred

Alternative

Comments

Infective Endocarditis

Native valve, Non IVDU, prosthetic valve


Strep viridans
Other Streptococci

MIC < 0.125ug/ml
Benzylpenicillin 50,000 units/kg/dose IV q6H for 4 weeks (6 weeks for prothestic)

 

 

 

MIC > 0.125 to 2 ug/ml
ADD Gentamicin 1 mg/kg/dose IV q8H for 2 weeks (6 weeks for prothestic)

MIC < 0.125ug/ml

Ampicillin 75mg/kg/dose IV  q6H for 4 weeks (6 weeks for prothestic)

OR

 

Ceftriaxone 100mg/kg/dose IV q24H for 4 weeks (6 weeks for prothestic)

MIC > 0.125 to 2 ug/ml
ADD Gentamicin 1 mg/kg/dose IV q8H for 2 weeks (6 weeks for prothestic)

At least 3 sets of blood cultures from different sites before empiric therapy.

Penicillin allergy:
Vancomycin 15mg/kg/dose IV q8H for 4 weeks (6 weeks for prothestic)


+ Gentamicin 1 mg/kg IV q8H for 2 weeks (6 weeks for prothestic)

Native valve

Left sided endocarditis:

Staphylococcus aureus (MSSA, MRSA)

For MSSA IE:
Cloxacillin 50 mg/kg/dose IV q6H for 4-6 weeks

For MRSA IE:
Vancomycin 15mg/kg/dose IV q8H for 4 - 6 weeks

For MSSA IE:
Cefazolin 30mg/kg/dose IV q8H for 4-6 weeks

 

Native valve
Right sided endocarditis:


Staphylococcus aureus (MSSA, MRSA)

For MSSA IE:
Cloxacillin 50 mg/kg/dose IV q6H for 4 weeks

For MRSA IE:
Vancomycin
15mg/kg/dose IV q8H for 4-6 weeks                                                                       

 

Prosthetic valve endocarditis:
Staphylococcus aureus (MSSA)

 

Cloxacillin 50 mg/kg/dose IV q6H for >6 weeks

AND

Rifampicin 20 mg/kg/day PO q8H for >6 weeks

AND
Gentamicin 1 mg/kg/dose IV q8H for 2 weeks

 

 

Rifampicin has better penetration. However to avoid the development of resistance, it should be started after 3-5 days of effective initial cloxacillin therapy and/or once the bacteraemia has been cleared.

 

Prosthetic valve endocarditis:
Staphylococcus aureus (MRSA)

 

Vancomycin 20 mg/kg/dose IV q8H for > 6 weeks


AND

 

Rifampicin 20 mg/kg/day  PO q8H for  >6 weeks

 

AND


Gentamicin 1 mg/kg/dose IV q8H for 2 weeks

 

Rifampicin has better penetration. However to avoid the development of resistance, it should be started after 3-5 days of effective initial vancomycin therapy and/or once the bacteraemia has been cleared.

Pericarditis (Purulent)

Staph aureus
Strep pneumoniae
Haemophilus influenzae
Other Streptococci
Gram negative bacteria

Cloxacillin 50 mg/kg/dose IV q6H for 4 - 6 weeks

AND

 

Gentamicin 1 mg/kg/dose IV q8H for 2 weeks

Vancomycin 15/kg/dose IV q8H for 4 - 6 weeks

 

AND

 

Gentamicin 1 mg/kg/dose 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

Post infectious sequelae of Group A strep infection

Benzylpenicillin 50,000 units/kg/dose IV q6H for 10 - 14 days


Followed by Penicillin V prophylaxis:
<5 years old 125 mg q12H
>5 years old 250 mg q12H

Penicillin allergy:

Erythromycin: 15mg/kg/dose PO q6H for 10 - 14 days

 

Followed by Erythromycin 15 mg/kg PO q12H

Pacemaker / Defibrillator & Ventricular Assist Device Related Infection

S aureus
S epidermidis
Aerobic gram negative bacilli
Fungal

Vancomycin
15/kg/dose IV q8h for 6 weeks
+ Gentamicin 1 mg/kg/dose IV q8h for 2 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/dose
(60 minutes before procedure)

Parenteral (IV):
Ampicillin 50 mg/kg/dose
(30 minutes before procedure) 

Allergy to penicillin/ ampicillin

Oral:
Clindamycin 20 mg/kg/dose
(60 minutes before procedure)

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

Cardiac conditions in which prophylaxis for dental procedures is recommended.
1. Prosthetic cardiac valve

2. Native valvular heart disease including established rheumatic heart disease
3. Previous IE
4. Unrepaired cyanotic CHD, including palliative shunts and conduits
5. Completely repaired CHD with prosthetic material or device, for the first 6 months after the procedure
6. Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or device (which inhibit endothelialization)
7. Cardiac transplantation recipients who develop cardiac valvulopathy