The newer antifungal agents, capsofungin, and voriconazole are less toxic and appear to be
effective alternatives to amphotericin (255,256). Table 24 presents the sensitivities of various
strains ofCandida. Table 25 presents an approach to the patient at risk of candidal endocarditis.
ANTICOAGULATION IN INFECTIVE ENDOCARDITIS
The use of anticoagulation with a variety of agents (warfarin, heparin, and aspirin) has been
examined for the treatment of IE since the beginning of an antibiotic therapy. This approach
would hopefully decrease the size of the vegetation; however, there is an unacceptably high
incidence of cerebral hemorrhage. In patients with PVE of mechanical valves, maintenance
anticoagulation should be continued. If hemorrhage does occur, warfarin has to be stopped. A
reasonable approach would be to substitute intravenous heparin for Coumadin during the first
two weeks of treatment, the time of the greatest risk for embolization. Anticoagulation by this
mode can easily and quickly be reversed (193). Even the use of aspirin appears not to be safe
and offers no therapeutic benefit (258).
PROPHYLAXIS OF IE IN THE CCU
Guidelines for the antibiotic prophylaxis of endocarditis have recently been published
(259,260). It seems most appropriate that prophylaxis of IE in the CCU should focus on
reducing the rate of CRBSI. In 2002, the CDC issued guidelines for the prevention of
intravascular catheter-related infections (261). This is a rapidly expanding field of interest. It
Table 21 Suggested Representative Antibiotic Therapy of IE Caused byEnterobacteriaceaeand the HACEK
Organisms
Organism Antibiotic Dosage regimena,b,c
Escherichia coliandProteus mirabilis Ampicillin 12 grams/day
Gentamicin 5 mg/kg/day
or
Ceftriaxone 1–2 g/day
or
Ciprofloxacin 400 mg IV q12h
Enterobacterspp.Klebsiellaspp. Ticarcillin/clavulanic acid 6 gm (ticarcillin) IV of q6h
Citrobacterspp.d,Providenciaspp. Meropenem 2 g IV q8h
or
Ceftriaxone 2 g IVq 12h
or
Cefipime 2 g q12h
plus
Gentamicin 5 mg/kg/day
Serratia marcescense Cefipime 2 g IV q8h
pr
Imipenem 1 g IV q6 h
or
Ciprofloxacin 400 mg IV q12h
plus
Amikacin 7.5 mg/kgIV q12h
Salmonellaspp. Ceftriaxone 2 g IVq12h
or
Ciprofloxacin 400 mg IV q12h
aFor patients with normal renal function.
bDuration of therapy at least 6 wk.
cFinal selection must be based on sensitivity testing.
dC. freundimost resistant species ofCitrobacter.
eHigh frequency of multidrug resistance. Amikacin sensitivity usually preserved. Plasmid-mediated resistant to
third and fourth generation cephalosporins and carbapenems. Extended spectrumb-lactamases encountered.
Quinolone resistance occurs.
Source: From Ref. 222.
246 Brusch