The AHA Guidelines and Scientific Statements Handbook

Chapter 19 Infective Endocarditis

listed in Table 19.19 who undergo a surgical proce-
dure 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 β-hemolytic streptococci, such
as an antistaphylococcal penicillin or a cephalospo-
rin (Table 19.20 for dosage; Class IIb, LOE C).

Vancomycin or clindamycin may be administered to

patients unable to tolerate a β-lactam or who are

known or suspected to have an infection caused by

a methicillin-resistant strain of staphylococcus.

References available online at http://www.Wiley.com/go/

AHAGuidelineHandbook.

Ongoing trials, future directions in the management and prevention of IE

Following publication of the management guidelines, clinical data have been published and support the use of daptomycin

as an alternative treatment option in patients with right-sided IE due to S. aureus. Results of additional study with double

beta-lactam therapy for enterococcal endocarditis are now available. Recent investigations have prompted a re-examination

of anti-platelet therapy as an adjunct to antimicrobial treatment.

Due to the interest in the prevention of dental caries caused by viridans group streptococci, several vaccines are being

developed. It is conceivable that one or more of these vaccines could prove helpful in the prevention of IE in high risk patients

who are immunized. Work in an animal model of endocarditis suggests that infection prevention by this modality is

feasible.

A placebo-controlled, multicenter, randomized, double-blinded study to evaluate the effi cacy of IE prophylaxis in patients

who undergo a dental, GI, or GU tract procedure has not been done. Such a study would require a large number of patients

per treatment group and standardization of the specifi c invasive procedures and the patient populations. This type of study

would be necessary to defi nitively answer long-standing unresolved questions regarding the effi cacy of IE prophylaxis. It is

hoped that the current IE prophylaxis guidelines will stimulate additional studies on the prevention of IE.

Table 19.20 Regimens for a dental procedure

Situation Agent Regimen: single dose 30 to 60 min before procedure

Adults Children

Oral Amoxicillin 2 g 50 mg/kg

Unable to take oral
medication

Ampicillin

Or

2 g IM or IV 50 mg/kg IM or IV

cefazolin or ceftriaxone 1 g IM or IV 50 mg/kg IM or IV

Allergic to penicillins
or ampicillin – oral

Cephalexin*†

Or

2 g 50 mg/kg

clindamycin

Or

600 mg 20 mg/kg

azithromycin or clarithromycin 500 mg 15 mg/kg

Allergic to penicillins
or ampicillin and
unable to take oral
medication

Cefazolin or ceftriaxone

Or

1 g IM or IV 50 mg/kg IM or IV

clindamycin† 600 mg IM or IV 20 mg/kg IM or IV

IM indicates intramuscular; IV, intravenous.

• Or other fi rst- or second-generation oral cephalosporin in equivalent adult or pediatric dosage.
  † Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with penicillins or ampicillin.