Sandbox ID Cardiovascular

Aortitis, infectious

• Preferred regimen: Cefotaxime sodium 1.0 to 2.0 g administered intravenously every 24 hours. For infectious aortitis, 2.0 g intravenously every 24 hours is recommended OR Ciprofloxacin hydrochloride 400 mg given intravenously every 12 hours or 500 to 750 mg administered by mouth every 12 hours OR Levofloxacin 250 to 750 mg administered either intravenously or by mouth every 24 hours OR Oxacillin 1.0 to 2.0 g administered intravenously or intramuscularly every 4 to 6 hours Nafcillin 1.0 to 2.0 g administered intravenously or intramuscularly every 4 to 6 hours OR Dicloxacillin 500 mg to 1.0 g every 4 to 6 hours OR Vancomycin 1.0 g (15 mg/kg, up to 3.0 to 4.0 g/d) given every 12 hours.

Note: Dose of Cefotaxime sodium should be decreased by 50% in those with a creatinine clearance (CCr) of ≤ 20 mL/min. Ciprofloxacin should be used cautiously in those with a CCr ≤ 50 mL/min or when given concomitantly with drugs whose metabolism may be altered.

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Cardiovascular implantable electronic device infections

• Early post-implantation inflammation

• Preferred regimen: Flucloxacillin 0.5–1 g 6th hourly oral

Note: Benefit of and need for antimicrobial therapy in Early post-implantation inflammation is unclear.

• Early post-implantation inflammation in penicillin-allergic or MRSA-colonized patient

• Preferred regimen: Doxycycline 100 mg BID Oral OR Linezolid 600 mg BID Oral OR Clindamycin 450 mg 6th hourly oral.

• Uncomplicated generator pocket infection

• Preferred regimen: Vancomycin 1 g BID IV OR Daptomycin 4 mg/kg OD IV OR Teicoplanin 6 mg/kg to a maximum of 1 g given at 0, 12 and 24 h and then OD.

• ICED-LI or ICED-IE or complicated generator pocket infection pending blood cultures, e.g. in severe sepsis

• Preferred regimen: Vancomycin 1 g BID IV AND Meropenem 1 g TID IV OR Daptomycin 8–10 mg/kg OD IV AND Meropenem 1 g TID IV.

• ICED-LI or ICED-IE or generator pocket infection with negative blood cultures

• Preferred regimen: Vancomycin 1 g BID IV AND Gentamicin 1 mg/kg BID IV OR Daptomycin 8–10 mg/kg OD IV AND Gentamicin 1 mg/kg BID IV.

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Intravascular catheter-related infections

• Staphylococcus aureus

• Methicillin susceptible

• Preferred regimen: Naficillin 2 g 4th hourly OR Oxacillin, 2 g 4th hourly IV
• Alternative regimen: Cefazolin, 2 g TID; or Vancomycin, 15 mg/kg BID IV.

• Methicillin resistant Staphylococcus aureus

• Preferred regimen: Vancomycin, 15 mg/kg BD OR Daptomycin, 6–8 mg/kg per day, or Linezolid; OR Vancomycin AND (Rifampicin or Gentamycin); or TMP-SMZ alone (if susceptible).

• Coagulase-negative staphylococci

• Methicillin susceptible

• Preferred regimen: Naficillin, 2 g 4th hourly OR Oxacillin, 2 g 4th hourly.:::* Alternative regimen:
• Alternative regimen: First-generation Cephalosporin OR Vancomycin OR TMP-SMZ

• Methicillin resistant

• Preferred regimen: Vancomycin, 15 mg/kg IV BD
• Alternative regimen: Daptomycin 6 mg/kg per day OR linezolid

• Enterococcus faecalis/Enterococcus faecium

• Ampicillin susceptible

• Preferred regimen: Ampicillin, 2 g 4th hourly or 6th hourly;OR Ampicillin 1 mg/kg 8th hourly OR Gentamycin 1 mg/kg 8th hourly.
• Alternative regimen: Vancomycin

• Ampicillin resistant, Vancomycin susceptible

• Preferred regimen: Vancomycin, 15 mg/kg IV BD Template:With or without Gentamycin, 1 mg/kg TID
• Alternative regimen: Linezolid or Daptomycin 6 mg/kg per day.

• Ampicillin resistant, Vancomycin resistant

• Preferred regimen: Linezolid, 600 mg BD; OR Daptomycin 6 mg/kg per day
• Alternative regimen: Quinupristin/Dalfopristin 7.5 mg/kg TID

• Gram-negative bacilli

• Escherichia coli and Klebsiella species

• ESBL negative

• Preferred regimen: Ceftriaxone 1–2 g per day
• Altered regimen: Ciprofloxicin OR Aztreonam

• ESBL positive

• Preferred regimen: Ertapenem 1 g per day OR Imipenem 500 mg 6th hourly OR Meropenem 1 g 8th hourly OR Doripenem 500 mg 8th hourly
• Altered regimen: Ciprofloxicin OR Aztreonam

• Enterobacter species and Serratia marcescens

• Preferred regimen: Ertapenem 1 g per day OR Imipenem 500 mg 6th hourly OR Meropenem 1 g 8th hourly
• Altered regimen: Cefepime OR Ciprofloxacin

• Acinetobacter

• Preferred regimen: Ampicillin/Sulbactam 3 g 6th hourly OR Imipenem 500 mg 6th hourly OR Meropenem 1 g 8th hourly.

• Stenotrophomonas maltophilia

• Preferred regimen: Trimethoprim-sulfamethoxazole 3–5 mg/kg 8th hourly
• Altered regimen: Ticarcillin AND Clavulanate

• Pseudomonas aeruginosa

• Preferred regimen: Cefepime, 2 g 8th hourly OR Imipenem 500 mg 6th hourly OR Meropenem 1 g 8th hourly OR piperacillin and tazobactum 4.5 g 6th hourly OR Amikacin 15 mg/kg once a day OR Tobramycin 5–7 mg/kg once a day.

• Burkholderia cepacia

• Preferred regimen: Trimethoprim-sulfamethoxazole 3–5 mg/kg 8th hourly OR Imipenem 500 mg 6th hourly OR Meropenem 1g 8th hourly.

• Fungi

• Candida albicans or other Candida species

• Preferred regimen: Capsiofungin 70-mg loading dose, then 50 mg per day OR micafungin, 100 mg per day OR anidulafungin, 200 mg loading dose followed by 100 mg per day OR fluconazole, 400–600 mg per day.
• Altered regimen: Lipid amphotericin B preparations.

• Uncommon pathogens

• Corynebacterium jeikeium (group JK)

• Preferred regimen: Vancomycin 15 mg/kg twice daily
• Altered regimen: Linezolid

• Chryseobacterium (Flavobacterium)

• Preferred regimen: Levofloxacin 750 mg once daily.
• Altered regimen: Trimethoprim-sulfamethoxazole OR Imipenem OR Meropenem

• Ochrobacterium anthropi

• Preferred regimen: Trimethoprim-sulfamethoxazole 3–5 mg/kg 8th hourly OR ciprofloxacin 400 mg twice daily

• Malassezia furfur

• Preferred regimen: Amphotericin B
• Altered regimen: Voriconazole

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Pericarditis, fungal

• Fungal Pericarditis

• Empiric therapy : Fluconazole, Ketoconazole, Itraconazole, Amphotericin B, Liposomal amphotericin B or Amphotericin B lipid complex is indicated.

• Histoplasmosis

• Preferred regimen: Nonsteroidal anti-inflammatory drugs given during 2–12 weeks.

Note: Corticosteroids and NSAIDs can support the treatment with antifungal drugs. Pericardiocentesis or surgical treatment is indicated for haemodynamic impairment. Pericardiectomy is indicated in fungal constrictive pericarditis.

• Nocardiosis

• Preferred regimen: Sulfonamides are the drugs of choice.

Note: Corticosteroids and NSAIDs can support the treatment with antifungal drugs. Pericardiocentesis or surgical treatment is indicated for haemodynamic impairment. Pericardiectomy is indicated in fungal constrictive pericarditis.

• Actinomycosis

• Preferred regimen: Combination of three antibiotics including Penicillin.

Note: Corticosteroids and NSAIDs can support the treatment with antifungal drugs. Pericardiocentesis or surgical treatment is indicated for haemodynamic impairment. Pericardiectomy is indicated in fungal constrictive pericarditis.

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Pericarditis, tuberculous

• Preferred regimen: 2 months of Isoniazid 5 mg/kg (300 mg) OD AND Rifampicin 10 mg/kg (600 mg) OD AND Pyrazanamide 1,500 mg OD AND Ethambutol 1,200 OD followed by 4 months of Rifampicin 10 mg/kg (600 mg) OD AND Pyrazanamide 1,500 mg OD. Prednisolone 1–2 mg/kg per day for 5–7 days is also given and is progressively reduced to discontinuation in 6–8 weeks.
• Pediatric dose: Isoniazid 10–15 mg/kg (300 mg); Rifampin 10–20 mg/kg (600 mg); Pyrazinamide 15–30 mg/kg (2.0 g); Ethambutol 15–20 mg/kg daily (1.0 g).

Note: Intrapericardial drainage is done if needed. If constriction develops inspite of medical therapy, pericardiectomy is indicated.

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Pericarditis, viral

• Viral pericarditis

• CMV pericarditis

• Preferred regimen: immunoglobulin 1 time per day 4 ml/kg on day 0, 4, and 8; 2 ml/kg on day 12 and 16.

Note: Symptomatic treatment is given to the patients with viral pericarditis while in large effusions and cardiac tamponade pericardiocentesis is necessary. The use of corticosteroid therapy is contraindicated except in patients with secondary tuberculous pericarditis, as an adjunct to tuberculosis treatment. Drainage, if needed is done.

• Coxsackie B pericarditis

• Preferred regimen: Interferon alpha or beta 2,5 Mio. IU/m2 surface area s.c. 3×per week.

Note: Symptomatic treatment is given to the patients with viral pericarditis while in large effusions and cardiac tamponade pericardiocentesis is necessary. The use of corticosteroid therapy is contraindicated except in patients with secondary tuberculous pericarditis, as an adjunct to tuberculosis treatment. Drainage, if needed is done.

• Adenovirus and parvovirus B19 perimyocarditis

• Preferred regimen: Immunoglobulin 10 g intravenously at day 1 and 3 for 6–8 hours

Note: Symptomatic treatment is given to the patients with viral pericarditis while in large effusions and cardiac tamponade pericardiocentesis is necessary. The use of corticosteroid therapy is contraindicated except in patients with secondary tuberculous pericarditis, as an adjunct to tuberculosis treatment. Drainage, if needed is done.

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Rheumatic fever, primary prophylaxis

• Preferred regimen: Penicillin V (Phenoxymethyl penicillin) 500 mg 2 to 3 times daily oral for 10 days OR Amoxicillin 50 mg/kg once daily (maximum 1 g) oral for 10 days OR Benzathine penicillin G IM 600 000 U for patients ≤27 kg (60 lb); 1 200 000 U for patients >27 kg (60 lb) once.
• Alternative regimen: Narrow-spectrum Cephalosporin†(Cephalexin, Cefadroxil) oral for 10 days OR Clindamycin 20 mg/kg per day divided in 3 doses (maximum 1.8 g/d) oral for 10 days OR Azithromycin 12 mg/kg once daily (maximum 500 mg) oral for 5 days OR Clarithromycin 15 mg/kg per day divided BID (maximum 250 mg BID) oral for 10 days.

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Rheumatic fever, secondary prophylaxis

• Preferred regimen: Penicillin G benzathine 1.2 million units IM every 4 wk OR Penicillin V potassium 250 mg orally BID OR Sulfadiazine 1 g orally once daily OR Macrolide or Azalide antibiotic (for patients allergic to Penicillin and Sulfadiazine) varied dose.
• Note: Duration of secondary prophylaxis for rheumatic fever differs for different scenarios. For Rheumatic fever with carditis and residual heart disease (persistent VHD) 10 y or until patient is 40 y of age (whichever is longer). For Rheumatic fever with carditis but no residual heart disease (no valvular disease) 10 y or until patient is 21 y of age (whichever is longer). For Rheumatic fever without carditis 5 y or until patient is 21 y of age (whichever is longer).

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Septic pelvic vein thrombophlebitis

• Based on the CT and MRI findings septic pelvic vein thrombophlebitis is classified into following categories for management..

• Right ovarian vein thrombosis

• Preferred regimen: Ertapenem 1 g daily for 7 days AND Enoxaparin (1 mg/Kg) initially AND 3–6 months of Warfarin (INR 2.5) OR Gentamicin 4 mg/kg AND Ampicillin 2 g AND Clindamycin 1200 mg for 7 days AND Enoxaparin (1 mg/Kg) initially AND 3–6 months Warfarin (INR 2.5).

Note: Repeat CT scan after 3 months. If negative, stop anticoagulation. If still positive for thrombi, anticoagulate for 3 additional months.

• Pelvic branch vein thrombosis

• Preferred regimen: Ertapenem 1 g daily for 7 days AND Enoxaparin (1 mg/Kg) for 2 weeks OR Gentamicin (4 mg/kg) AND Ampicillin 2 g AND Clindamycin 1200 mg for 7 days AND Enoxaparin (1 mg/Kg) for 2 weeks.

• Negative for pelvic thrombi

• Preferred regimen: Ertapenem 1 g daily for 7 days AND Enoxaparin (1 mg/Kg) for 1 weeks OR Gentamicin (4 mg/kg) AND Ampicillin 2 g AND Clindamycin 1200 mg for 7 days AND Enoxaparin (1 mg/Kg) for 1 weeks.

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