The AHA Guidelines and Scientific Statements Handbook

The AHA Guidelines and Scientifi c Statements Handbook

Table 19.13 Therapy for both native and prosthetic valve endocarditis caused by HACEK microorganisms

Regimen Dosage and route

Duration

(weeks)

Strength of

recommendation Comments

Ceftriaxone sodium
or

ampicillin-sulbactam†
or

ciprofl oxacin†‡

2 g/24 h IV/IM in 1 dose* 4 IB Cefotaxime or another third- or fourth-

generation cephalosporin may be

substituted.

12 g/24 h IV in 4 equally divided

doses

4 IIaB

1000 mg/24 h PO or 800 mg/24 h

IV in 2 equally divided doses

Pediatric dose**: Ceftriaxone

100 mg/kg per 24 h IV/IM once

daily; ampicillin-sulbactam

300 mg/kg per 24 h IV divided

into 4 or 6 equally divided doses;

ciprofl oxacin 20–30 mg/kg per

24 h IV/PO in 2 equally divided

doses

4 IIbC Fluoroquinolone therapy recommended

only for patients unable to tolerate

cephalosporin and ampicillin therapy;

levofl oxacin, gatifl oxacin, or

moxifl oxacin may be substituted;

fl uoroquinolones generally not

recommended for patients <18 years of

age.

Prosthetic valve: Patients with

endocarditis involving a prosthetic

cardiac valve or other prosthetic cardiac

material should be treated for 6 wk.

• Patients should be informed that IM injection of ceftriaxone is painful.
  ** Pediatric dose should not exceed that of a normal adult.
  † Dosage recommended for patients with normal renal function.
  ‡ Fluoroquinolones are highly active in vitro against HACEK microorganisms. Published data on use of fl uoroquinolone therapy for endocarditis caused by HACEK

are minimal.
IM indicates intramuscular, and PO, oral.

embolization appears to occur with vegetations

10 mm in diameter occurring on the anterior
mitral leafl et and during the fi rst 1 to 2 weeks of
therapy.

Congestive heart failure
Many studies during the past three decades have
demonstrated that among the complications of IE,
CHF has the greatest impact on prognosis. Moderate
to severe CHF was identifi ed as one of fi ve baseline
features that were independently associated with 6-
month mortality in an investigation to validate a
prognostic classifi cation system for adults with com-
plicated left-sided native valve IE. In native valve IE,
acute CHF occurs more frequently in aortic valve
infections (29%) than with mitral (20%) or tricuspid

disease (8%). In addition, the degree of tolerance of

CHF is valve dependent, with acute aortic regurgita-

tion being least tolerant and acute tricuspid regurgita-

tion most tolerant. The tolerance for acute mitral

regurgitation is intermediate. CHF may develop

acutely from perforation of a native or bioprosthetic

valve leafl et, rupture of infected mitral chordae, valve

obstruction by bulky vegetations, or sudden intracar-

diac shunts from fi stulous tracts or prosthetic dehis-

cence. Mitral valve preclosure that can be detected by

both physical examination and echocardiography

should be screened for in each case.

Risk of embolization

Systemic embolization occurs in 22% to 50% of

cases of IE. Emboli often involve major arterial beds,