Sandbox ID Cardiovascular

Aortitis, infectious

• Preferred regimen(1): Cefotaxime sodium 1.0 to 2.0 g IV qd.

• Preferred regimen (2): Ciprofloxacin hydrochloride 400 mg IV q12h OR Ciprofloxacin hydrochloride 500 to 750 mg orally q12h OR Levofloxacin 250 to 750 mg IV/oral qd.

• Preferred regimen (3): Oxacillin 1.0 to 2.0g IV or IM q4h / q6h OR Nafcillin 1.0 to 2.0 g IV or IM q4h / q6h OR Dicloxacillin 500 mg to 1.0 g IV or IM q4h /q6h

• Preferred regimen (4): Vancomycin 1.0 g (15 mg/kg, up to 3.0 to 4.0 g/d) IV q12h.

Note: Antimicrobial treatments are most effective when bactericidal, broadspectrum antibiotics are begun after obtaining blood cultures and prior to surgery. 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 oral q6h.

• Penicillin allergy or MRSA Colonisation

• Preferred regimen: Doxycycline 100 mg oral q12h OR Linezolid 600 mg oral q12h OR Clindamycin 450 mg oral q6h.

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 oral q12h OR Linezolid 600 mg oral q12h OR Clindamycin 450 mg oral q6h.

• Uncomplicated generator pocket infection

• Preferred regimen: Vancomycin 1 g IV q12h OR Daptomycin 4 mg/kg IV qd OR Teicoplanin 6 mg/kg to a maximum of 1 g given at 0, 12 and 24 h and then qd.

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

• Preferred regimen: Vancomycin 1 g IV q12h AND Meropenem 1 g IV q8h OR Daptomycin 8–10 mg/kg IV qd AND Meropenem 1 g IV q8h.

Note: Gentamicin or other anti-Gram-negative agents may be appropriate depending on local epidemiology.

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

• Preferred regimen: Vancomycin 1 g IV q12h AND Gentamicin 1 mg/kg IV q12h OR Daptomycin 8–10 mg/kg IV qd AND Gentamicin 1 mg/kg IV q12h.

Note: Duration of antimicrobial therapy should be at least 4 to 6 weeks for complicated infection (ie, endocarditis, septic thrombophlebitis, or osteomyelitis or if bloodstream infection persists despite device removal and appropriate initial antimicrobial therapy.

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Endocarditis, prophylaxis

• Antibiotic Prophylactic Regimens for Dental Procedures

• Oral regimen

• Preferred regimen: Amoxicillin 2 g single dose 30-60 minutes before procedure.

• Pediatric dose: Amoxicillin 50 mg/kg single dose 30-60 minutes before procedure.

• Unable to take oral medication

• Preferred regimen: Ampicillin 2 g IM or IV single dose 30-60 minutes before procedure OR Cefazolin 1 g IM or IV single dose 30-60 minutes before procedure OR Ceftriaxone 1 g IM or IV single dose 30-60 minutes before procedure.

• Pediatric dose: Ampicillin 50 mg/kg; Cefazolin 50 mg/kg; Ceftriaxone 50 mg/kg

• Allergic to penicillins or ampicillin— Oral regimen

• Preferred regimen: Cephalexin 2 g single dose 30-60 minutes before procedure OR Clindamycin 600 mg single dose 30-60 minutes before procedure OR Azithromycin 500 mg single dose 30-60 minutes before procedure OR Clarithromycin 500 mg single dose 30-60 minutes before procedure.

• Pediatric dose: Cephalexin 50 mg/kg single; Clindamycin 20 mg/kg; Azithromycin 15 mg/kg OR Clarithromycin 15 mg/kg.

• Allergic to penicillins or ampicillin and unable to take oral medication

• Preferred regimen: Cefazolin 1 g IM or IV single dose 30-60 minutes before procedure OR Ceftriaxone 1 g IM or IV single dose 30-60 minutes before procedure OR Clindamycin 600 mg IM or IV.

• Pediatric dose: Cefazolin 50 mg/kg IM or IV OR Ceftriaxone 20 mg/kg IM or IV.

• Gastrointestinal/Genitourinary Procedures

• Antibiotic prophylaxis solely to prevent IE is no longer recommended for patients who undergo a GI or GU tract procedure.

Note: Routine administration of prophylactic antibiotics prior to GI and GU procedures including diagnostic esophagogastroduodenoscopy or colonoscopy is not recommended. However, for the high risk patients who already have an established GI or GU tract infection, it is reasonable to administer antibiotics against enterococci which includes the following: Ampicillin 2 g IM or IV single dose, piperacillin, or vancomycin.

• Regimens for Respiratory Tract Procedures

• Oral regimen

• Preferred regimen: Amoxicillin 2 g single dose 30-60 minutes before procedure.

• Pediatric dose: Amoxicillin 50 mg/kg single dose 30-60 minutes before procedure.

• Unable to take oral medication

• Preferred regimen: Ampicillin 2 g IM or IV OR Cefazolin 1 g IM or IV OR Ceftriaxone 1 g IM or IV.

• Pediatric dose: Ampicillin 50 mg/kg; Cefazolin 50 mg/kg; Ceftriaxone 50 mg/kg.

• Allergic to penicillins or ampicillin— Oral regimen

• Preferred regimen: Cephalexin 2 g single dose 30-60 minutes before procedure OR Clindamycin 600 mg single dose 30-60 minutes before procedure OR Azithromycin 500 mg single dose 30-60 minutes before procedure OR Clarithromycin 500 mg single dose 30-60 minutes before procedure.
• Pediatric dose: Cephalexin 50 mg/kg single; Clindamycin 20 mg/kg; Azithromycin or Clarithromycin 15 mg/kg.

• Allergic to penicillins or ampicillin and unable to take oral medication

• Preferred regimen: Cefazolin 1 g OR ceftriaxone 1 g IM or IV single dose 30-60 minutes before procedure OR Clindamycin 600 mg IM or IV.
• Pediatric dose: Cefazolin 50 mg/kg IM or IV OR Ceftriaxone 20 mg/kg IM or IV.

• Regimens for Procedures on Infected Skin, Skin Structure, or Musculoskeletal Tissue

• Patients who undergo a surgical procedure that involves infected skin, skin structure, or musculoskeletal tissue, it may be reasonable that the therapeutic regimen administered for treatment of the infection contain an agent active against staphylococci and -hemolytic streptococci, such as an antistaphylococcal penicillin or a cephalosporin.

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Intravascular catheter-related infections

• Pathogen based treatment

• Staphylococcus aureus

• Methicillin susceptible

• Preferred regimen: Naficillin 2 g IV q6h OR Oxacillin, 2 g IV q6h.
• Alternative regimen: Cefazolin, 2 g IV q8h; or Vancomycin, 15 mg/kg IV q12h.
• Pediatric dose:

• Nafcillin

• Neonates

• 0–4 weeks of age and 1200 g- 50 mg/kg/day in divided doses every 12 h
• <7 days and 1200–2000 g- 50 mg/kg/day in divided doses every 12 h
• >7 days of age and > 2000g 75 mg/kg/day in divided doses every 8 h
• >7 days of age and 1200 g - 100 mg/kg/day in divided doses every 6 h

• Oxacillin

• Neonates

• 0–4 weeks of age and 1200 g- 50 mg/kg/day in divided doses every 12 h
• Postnatal age 7 days and 1200–2000 g- 50–100 mg/kg/day in divided doses every 12 h
• Postnatal age 7 days and >2000 g, 75–150 mg/kg/day in divided doses every 8 h
• Postnatal age 7 days and 1200–2000 g- 75–150 mg/kg/day in divided doses every 8 h
• Postnatal age 7 days and >2000 g, 100–200 mg/kg/day in divided doses every 6 h;

• Infants and children Nafcillin 100–200 mg/kg/day in divided doses every 4–6 h

• Methicillin resistant Staphylococcus aureus

• Preferred regimen: Vancomycin, 15 mg/kg IV q12h OR Daptomycin, 6–8 mg/kg per day IV, or Linezolid IV; OR Vancomycin IV AND (Rifampicin IV or Gentamycin IV); or TMP-SMZ IV alone (if susceptible).

• Coagulase-negative staphylococci

• Methicillin susceptible

• Preferred regimen: Naficillin, 2 g IV q4h OR Oxacillin, 2 g IV q4h.
• Alternative regimen: First-generation Cephalosporin OR Vancomycin OR TMP-SMZ

• Methicillin resistant

• Preferred regimen: Vancomycin, 15 mg/kg IV q12h
• Alternative regimen: Daptomycin 6 mg/kg per day IV OR linezolid IV

• Enterococcus faecalis/Enterococcus faecium

• Ampicillin susceptible

• Preferred regimen: Ampicillin, 2 g IV q4h/ q6h;OR Ampicillin 1 mg/kg IV q8h OR Gentamycin 1 mg/kg IV q8h.
• Alternative regimen: Vancomycin

• Ampicillin resistant, Vancomycin susceptible

• Preferred regimen: Vancomycin, 15 mg/kg IV q12h ± Gentamycin, 1 mg/kg IV q8h.
• Alternative regimen: Linezolid 6 mg/kg per day IV or Daptomycin 6 mg/kg per day IV.

• Ampicillin resistant, Vancomycin resistant

• Preferred regimen: Linezolid IV 600 mg q12h OR Daptomycin 6 mg/kg per day IV.
• Alternative regimen: Quinupristin/Dalfopristin 7.5 mg/kg IV q8h.

• Gram-negative bacilli

• Escherichia coli and Klebsiella species

• ESBL negative

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

• ESBL positive

• Preferred regimen: Ertapenem 1 g per day IV OR Imipenem 500 mg IV q6h OR Meropenem 1 g IV q8h OR Doripenem 500 mg IV q8h.
• Altered regimen: Ciprofloxicin IV OR Aztreonam IV.

• Enterobacter species and Serratia marcescens

• Preferred regimen: Ertapenem 1 g per day IV OR Imipenem 500 mg IV q6h OR Meropenem 1 g IV q8h.
• Altered regimen: Cefepime IV OR Ciprofloxacin IV.

• Acinetobacter

• Preferred regimen: Ampicillin/Sulbactam 3 g IV q6h OR Imipenem 500 mg IV q6h OR Meropenem 1 g IV q8h.

• Stenotrophomonas maltophilia

• Preferred regimen: Trimethoprim-sulfamethoxazole 3–5 mg/kg IV q8h.
• Altered regimen: Ticarcillin IV AND Clavulanate IV.

• Pseudomonas aeruginosa

• Preferred regimen: Cefepime, 2 g IV q8h OR Imipenem 500 mg IV q6h OR Meropenem 1 g IV q8h OR piperacillin IV and tazobactum 4.5 g IV q6h OR Amikacin 15 mg/kg once a day IV OR Tobramycin 5–7 mg/kg once a day IV.

• Burkholderia cepacia

• Preferred regimen: Trimethoprim-sulfamethoxazole 3–5 mg/kg IV q8h OR Imipenem 500 mg IV q6h OR Meropenem 1g IV q8h.

• 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 IV q12h.
• Altered regimen: Linezolid IV.

• Chryseobacterium (Flavobacterium)

• Preferred regimen: Levofloxacin 750 mg IV qd.
• Altered regimen: Trimethoprim-sulfamethoxazole IV OR Imipenem IV OR Meropenem IV.

• Ochrobacterium anthropi

• Preferred regimen: Trimethoprim-sulfamethoxazole 3–5 mg/kg IV q8h OR ciprofloxacin 400 mg IV q12h.

• Malassezia furfur

• Preferred regimen: Amphotericin B IV.
• Altered regimen: Voriconazole IV.

Note

• Scheduled replacement of intravascular catheters has been proposed as a method to prevent phlebitis and catheter related infections. No specific recommendation can be made regarding routine replacement of catheters that need to be in place for >7 days
• Peripheral Venous Catheters: Short peripheral catheter sites commonly are rotated at 72–96-hour intervals. There is no need to replace peripheral catheters more frequently than every 72-96 hours to reduce risk of infection and phlebitis in adults. Replace peripheral catheters in children only when clinically indicated. Replace midline catheters only when there is a specific indication.
• Midline Catheters: Midline catheters were in place a median of 7 days, but for as long as 49 days.
• Hemodialysis Catheters: Hemodialysis catheters should be avoided in favor of arteriovenous fistulas and grafts. If temporary access is needed for dialysis, a cuffed catheter is preferable to a noncuffed catheter, even in the ICU setting, if the catheter is expected to stay in place for >3 weeks.
• Pulmonary Artery Catheters: Pulmonary Artery Catheters typically remain in place an average of 3 days.
• An umbilical catheter may be replaced if it is malfunctioning, and there is no other indication for catheter removal, and the total duration of catheterization has not exceeded 5 days for an umbilical artery catheter or 14 days for an umbilical vein catheter.

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Mediastinitis, acute

• Treatment secondary to cardiac infection and surgery.

• Preferred regimen: Clindamycin 450 mg IV q 6 h plus Ceftriaxone 2 g once/day, for at least 2 weeks

• Prophylaxis

• Methicillin susceptible staphylococcus aureus infection

• Preferred regimen: Second generation cephalosporin.

• Methicillin susceptible staphylococcus aureus infection

• Preferred regimen: Vancomycin

Note

• Preoperative antibiotics should be administered to all patients to reduce the risk of mediastinitis in cardiac surgery.
• A deep sternal wound infection should be treated with aggressive surgical debridement in the absence of complicating circumstances.
• Primary or secondary closure with muscle or omental flap is recommended. Vacuum therapy in conjunction with early and aggressive debridement is an effective adjunctive therapy.
• Use of a continuous intravenous insulin protocol to achieve and maintain an early postoperative blood glucose concentration less than or equal to 180 mg/dL while avoiding hypoglycemia is indicated to reduce the risk of deep sternal wound infection.
• The use of intranasal mupirocin is reasonable in nasal carriers of S. aureus.

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Myocarditis, viral

Note

• Mainstay of therapy for myocarditis is supportive care and standard management of CHF. Ribavarin and interferon alpha improved survival in mice with acute myocarditis.
• Temporary pacemaker insertion is indicated in patients with symptomatic bradycardia and/or heart block during the acute phase of myocarditis.
• ICD implantation is not indicated during the acute phase of myocarditis.
• ICD implantation can be beneficial in patients with life-threatening ventricular arrhythmias who are not in the acute phase of myocarditis, as indicated in the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices.
• Antiarrhythmic therapy can be useful in patients with symptomatic NSVT or sustained VT during the acute phase of myocarditis.

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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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