29 2552

. 47230066

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(INFECTIVE ENDOCARDITIS)
infective endocarditis (IE)

vegetation


IE mitral valve, aortic valve, tricuspid valve
pulmonary valve ventricle

(ventricular septal
defect;VSD) ductus arteriosus
infective endarteritis
2 acute bacterial
endocarditis (ABE)

6
subacute bacterial endocarditis
(SBE) viridians
streptococci, Streptococcus epidermidis enterococci

Chlamydia, Rickettsia, Mycoplasma

1. Native valve endocarditis (Native valve IE)


 valve regurgitation, rheumatic
heart disease
aortic stenosis,
mitral regurgitation staphylococci, streptococci,
viridians streptococci, enterococci HACEK organisms
2. Prosthetic valve endocarditis (Prosthetic valve IE)
2 60

early onset 2 12
late onset Coagulase
negative staphylococci (S.epidermidis) S.aureus
late infection streptococci HACEK organisms
3. Nosocomial infective endocarditis


nosocomial IE predisposing factors IE
(venous catheter)


coagulase negative staphylococci, S.aureus, enterococci
MRSA
4. Infective endocarditis in intravenous drug user (IDU infective
endocarditis)
tricuspid valve, aortic
valve, mitral valve S.aureus
IVDU HIV Pseudomonas aeruginosa,

Salmonella spp., Listeria spp.,


(constitutional
symptoms)





(>38C) heart murmur

subconjuctival
hemorrhage, splinter hemorrhage, Oslers node (
) Roths spot ( choroids plexus
retina) Janeways lesion ( )
normocytic
normochromic anemia, WBC

ESR

infective endocarditis
1. vegetation
metabolic rate


bactericidal
vegetation
2.



3. MIC

48-72

3-5

1 native valve endocarditis

viridians group streptococci streptococcus bovis
penicillin (highly penicillin-susceptible; MIC 0.12 g/mL)


Regimen Dosage and route
(
)
Penicillin G 12-18 mU/day IV 4 IA -
sodium Pediatrics; 200,000
U/kg/day IV 65
4-6
renal impairment
hr cranial nerve 8
Ceftriaxone 2 g IV/IM OD 4 IA
sodium Pediatrics; 100 mg/kg
IV/IM OD
Penicillin G sodium 12-18 mU/day IV 2 IB -
4-6 +
gentamicin 3 mg/kg IV OD
cardiac/intracardiac
8 hr abscess
CrCl <
Ceftriaxone sodium 2 g IV/IM OD 2 IB 20 mL/min cranial
Pediatrics; 100 mg/kg IV/IM OD + nerve 8
gentamicin 3 mg/kg IV OD - peak 3-
8 hr 4 L/mL trough < 1.0
 L/mL
Vancomycin 30 mg/kg/day IV 4 IB -
12 hr (
2 g/24 hr)
Pediatrics; 40 penicillin/ceftriaxone
mg/kg/day IV -
8-12 hr

1.Peak 30-45 L/mL(1hr
post dose)
2.Trough 10-15 L/mL
- IV
1


red man syndromes

2 native valve endocarditis

viridians group streptococci streptococcus bovis
penicillins (relatively penicillin-resistant; 0.5 g/mL MIC 0.12
g/mL)
Dosa
Regim ge (

en and )
route
Penicillin G 4 IB -
penicillin
sodium 24
mU/day IV enterococcal
endocarditis
4-6 +
gentamicin 3 Gentamicin 2
mg/kg IV OD Penicillin/ceftriaxone 4
8
hr
Ceftriaxone 4 IB
sodium 2 g
IV/IM OD;
Pediatrics:
100 mg/kg
IV/IM OD +
gentamicin 3
mg/kg IV OD
8
hr
Vancomycin 4 IB -
30 mg/kg/day
IV 12
hr ( 2 peniciliin/ceftriaxone
g/24 hr)
Pediatrics: 40
mg/kg/day IV
8-12
hr

3 prosthetic valve endocarditis prosthetic

materials viridians group streptococci
streptococcus bovis

Regime Dosage

n and route
()
Penicillin-susceptible strain: MIC 0.12 g/mL
Penicillin 24 mU/day 6 IB - gentamicin
G IV 3 mg/kg/day IV OD
sodium Pediatrics: 2 wks
200,000
U/kg/day combination therapy
IV monotherapy

4-6

Ceftriax 2 g IV/IM 6 IB
one OD
sodium Pediatric:
100 mg/kg
IV/IM OD
Vancom 30 6 IB -
ycin mg/kg/day
IV
12 hr penicillin/ceftriaxone
( 2
g/24 hr)
Pediatric:
40
mg/kg/day
IV
8-12 hr
Penicillin-relatively resistant/resistant strain: MIC > 0.12 g/mL
Penicillin G sodium 24 6 IB
mU/day IV; Pediatrics
300,000 U/kg/day
4-6
+ gentamicin 3
mg/kg IV OD
8 hr
Ceftriaxone sodium 2 6 IB
g IV/IM OD;
Pediatrics: 100 mg/kg
IV/IM OD +
gentamicin 3 mg/kg IV
8 hr
Vancomycin 30 6 IB -
mg/kg/day IV
12 hr ( 2 g/24 hr)
Pediatrics: 40 penicillin/ceftriaxone
mg/kg/day IV
8-12 hr

4 staphylococcal endocarditis

prosthetic materials
Dosag
Regime
e and
n ()
route
Oxacilllin-susceptible strains
Nafcillin/oxacillin 6 IA
12 g/day IV Gentamicin 3-5
4-6 Penicillin/nafcillin/oxacillin
6 left/right side
Penicillin G 24 IE 2
mU/day IV umcomplicated right side IE
4-6 hr -clinical benefit AMG
(

penicillin; MIC
0.1 g/mL)
gentamicin 3
mg/kg IV OD
8 hr
Cefazolin 6 6 IB
g/day IV
8 hr ; pediatrics
100 mg/kg/day
IV 8 hr
gentamicin 3
mg/kg Iv
8 hr
Oxacillin resistant strains
Vancomycin 30 6 IB
mg/kg/day IV
12 hr -Peak 30-45 L/mL (1 hr
( 2 g/24 hr) post dose)
Pediatrics: 40 -Trough 10-15 L/mL
mg/kg/day IV
8-12 hr

5 staphylococcal endocarditis
prosthetic heart valve endocarditis
Dosag
Regime
e and
n ()
route
Oxacillin-susceptible strains
Nafcillin/oxacillin 6 IB
12 g/day IV -Gentamicin 2
4 hr -Nafcillin/oxacillin/rifampicin
Penicillin G 24 6
mU/day IV
4-6 hr
(
penicillin; MIC
0.1 g/mL)
+ rifampicin 900
mg/day IV/PO
8 hr
+ gentamicin 3
mg/kg IV OD
8 hr
Cefazolin 6 6 IB
g/day IV
8 hr; pediatrics
100 mg/kg/day
IV 8 hr
+ rifampicin 900
mg/day IV/PO
8 hr
+ gentamicin 3
mg/kg IV OD
8 hr
Oxacillin resistant strains
Vancomycin 30 6 IB
mg/kg/day IV -Gentamicin 2
12 hr - Vancomycin/rifampicin
( 2 g/24 hr) 6
+ rifampicin 900
mg/kg/day IV/PO
8 hr -Peak 30-45 L/mL (1 hr
+gentamicin 3 post dose)
mg/kg IV -Trough 10-15 L/mL
8 hr(2
beta-
wks) lactams
Pediatrics: 40 anaphylaxis/immediate type
mg/kg/day IV
8-12 hr
+ rifampicin 20
mg/kg/day IV/PO
8 hr
+gentamicin 3
mg/kg IV
8 hr (2
wks)

6 Native valve prosthetic valve

endocarditis Enterococci penicillin, gentamicin
vancomycin (Penicillin/gentamicin/vancomycin susceptible strains
of enterococci)
Dosa
Regim ge

en and ()
route
Ampicillin 12 4-6 IA
g/day IV -Native valve IE 4
4 hr
3
PenG 18- 6
3
30 mU/day IV
4 hr -Prosthetic valve IE 6
Continuous
IV
Pediatrics:
ampicillin 300
mg/kg/day IV
4-6 hr
PenG
300,000
mU/kg/day IV
4-6 hr
Continuous
IV + gentamicin
3 mg/kg IV
8 hr
Vancomycin 30 6 IB
mg/kg/day IV -Gentamicin 6
12 hr -Vancomycin 6
( 2 g/24 short
hr) + course AMG (2wks)
gentamicin 3

mg/kg IV

8 hr -
beta-
Pediatrics: 40 lactams
mg/kg/day IV anaphylaxis/immediate type
 8-12
hr + gentamicin
3 mg/kg IV
8 hr

7 Native valve prosthetic valve

endocarditis enterococci penicillin,streptomycin
vancomycin gentamicin
Dosage

Regimen and
()
route
Ampicillin 12 g/day 4-6 IA
IV 4 hr -Streptomycin 4-6
PenG 24 mU/day
IV 4 hr -Ampicillin/pen G 4-6
Continuous IV
+ streptomycin 15 - 4 wks regimen
mg/kg/day IV/IM

12 hr 3
Pediatrics: - 6 wk regimen
ampicillin 300
mg/kg/day IV 3
4-6 hr
PenG 300,000
mU/kg/day IV
4-6 hr
continuosus IV
+ streptomycin 20-
30 mg/kg/day IV/IM
12 hr
Vancomycin 30 6 IB
mg/kg/day IV -streptomycin 6
12 hr -vancomycin 6
( 2 g/24 hr)
+ streptomycin 15


mg/kg/day IV/IM beta-lactams
12 hr anaphylaxis/immediate
Pediatrics: 40 type
mg/kg/day IV
8-12
+ streptomycin 15
mg/kg/day IV/IM
12 hr
 8 Native valve prosthetic valve
endocarditis Enterococcal aminoglycosides
vancomycin penicillin
Dosage and
Regimen
route ()
Beta-Lactamase producing strains
Ampicillin-sulbactam 6 IIaC
12g/day 6 . -Gentamicin
+Gentamicin 3mg/day -Ampicillin-sulbactam 4-6
IV/IM 8 . .


AMG,
Amp/Sul 6
wks
Vancomycin 30 6 IIaC

mg/kg/day IV 12 beta-lactams
. ( 2g/24 hr) anaphylaxis/immediate
+Gentamicin 3 mg/kg/day type
IV/IM 8 .
Intrinsic penicillin resistance
Vancomycin 30 6 IIaC
mg/kg/day IV 12
. ( 2g/24 hr)
+Gentamicin 3 mg/kg/day
IV/IM 8 .

9 Native valve prosthetic valve

endocarditis Enterococci
penicillin, AMG
vancomycin
Regimen Dosage and
route ()
Enteroccus faecium
Linezolid 1200mg/day 8 IIaC - cardiac valve
IV/PO 12 . replacement
-

linezolid
thrombocytopenia
2

-Quinupristin/dalfopristin
severe myalgia


Enterococcus faecalis
Imipenem 2 g/day IV 8 IIbC
6 +Ampicillin
12 g/day 4 .
Ceftriaxone 4 g/day 8 IIbC
IV/IM 12 .
+Ampicillin 12 g/day
4 .

10 Native valve prosthetic valve

endocarditis HACEK organisms
Regimen Dosage and
route ()
Ceftriaxone 2 g/day IV/IM 4 IB gen 3
OD Cephalosporins
ceftriaxone
Ampicillin-sulbactam 4 IIaB
12g/day 6 .
Ciprofloxacin 1000 4 IIbC - fluoroquinolones
mg/day PO 800


mg/day 12 . betalactams
12 . (
2g/24 hr) levofloxacin/moxifloxacin
+Gentamicin 3 mg/kg/day
IV/IM 8 . ciprofloxacin
- FQs

<18
- prosthetic
valve/materials
FQs 6
wks

(Prophylaxis for infective endocarditis)

11

-
palliative shunt conduit
- 6



-





American Heart Association, Rheumatic fever endocarditis
and Kawasaki disease
infective endocarditis

(procedure)

endocarditis infective endocarditis


antimicrobial prophylaxis




(gingival tissue or periapical region )
oral mucosa


orthodontic appliance orthodontic bracket
trauma oral
mucosa

12
infective endocarditis

Amoxicillin 2g 50 mg/kg
Amoxicillin 2 g IV/IM 50 mg/kg
Ceftiriaxone 1 g IV/IM IV/IM
Cefotaxime 1 g IV/IM 50 mg/kg
IV/IM
50 mg/kg
IV/IM

Cephalexin 2g 50 mg/kg
penicillin/ampicillin Clindamycin 600 mg 20 mg/kg
Azithromycin 500 mg IV/IM
Clarithromycin 500 mg 15 mg/kg
IV/IM
15 mg/kg
IV/IM

Cefazolin 1 g IV/IM 50 mg/kg

penicillin/ampicillin Ceftriaxone 1 g IV/IM IV/IM
Clindamycin 600 mg IV/IM 50 mg/kg
IV/IM
50 mg/kg
IV/IM
1 2 Cepphalosporins
st nd cephalexin

penicillin/ampicillin anaphylaxis
angioedema/urticaria cephalosporin

1. Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM,

Levison M, et al. Prevention of infective endocarditis:
Guidelines from the American Heart Association: A guideline
from the American Heart Association Rheumatic Fever,
Endocarditis and Kawasaki Disease Committee, Council on
Cardiovascular Disease in the Young, and the Council on
 Clinical Cardiology, Council on Cardiovascular Surgery and
Anesthesia, and the Quality of Care and Outcomes Research
Interdisciplinary Working Group. J Am Dent Assoc
2007;138:739-60.
2. Baddour LM, Wilson RW, Bayer AS, Fowler VG, Bolger AF,
Levison ME, et al. Infective Endocarditis: Diagnosis,
Antimicrobial Therapy, and Management of Complications: A
statement for Healthcare Professionals From the Committee
on Rheumatic Fever, Endocarditis, and Kawasaki Disease,
Council on Cardiovascular Disease in the Young, and the
Councils on Clinical Cardiology, Stroke, and Cardiovascular
Surgery and Anesthesia, American Heart Association:
Endorsed by the Infectious Disease Society of America.
Circulation 2005;111:e394-e434.