Subacute Bacterial Endocarditis (SBE) Prophylaxis
Introduction
The need for antibiotic prophylaxis is a very common question. The outline below is
a list of the most commonly asked questions concerning the need for antibiotics.
Cardiac conditions
The following conditions are more often associated with endocarditis
than others, and so antibiotic prophylaxis is recommended whenever present.
-
Prosthetic cardiac valve of all types.
-
Previous bacterial endocarditis even in the absence of heart disease.
-
Most congenital cardiac malformations.
-
Rheumatic and other acquired valvular dysfunction.
-
Hypertrophic cardiomyopathy.
-
Mitral valve prolapse with valvular regurgitation.
Situations in which endocarditis prophylaxis
is not recommended.
-
Innocent cardiac murmurs without structural heart disease.
-
Isolated secundum atrial septal defect.
-
Surgical repair without residual beyond 6 months for the following:
-
Secundum atrial septal defect
-
Ventricular septal defect
-
Patent ductus arteriosus.
-
Previous coronary artery bypass surgery.
-
Mitral valve prolapse without valvular regurgitation.
-
Cardiac pacemakers and implanted defibrillators.
-
Previous rheumatic fever without valvular dysfunction.
Operational environment
The following list of procedures is likely to be performed aboard ship or in remote
areas and prophylaxis is recommended. This list does not include procedures likely
to be performed in a large clinic or hospital.
-
Dental procedures known to induce gingival bleeding - this includes cleaning.
-
Uretheral catheterization in a patient with a urinary tract infection.
-
Incision and drainage of infected tissue (the antibiotics should be directed at the most
likely bacterial pathogen).
-
Vaginal delivery in the presence of infection.
Endocarditis prophylaxis is not recommended for the following situations.
Standard Oral Regimen
Amoxicillin |
2 gm orally 1 hr before
procedure
None after initial dose. |
For those allergic to Amoxicillin or Penicillin, use either Erythromycin or Clindamycin
|
Erythromycin
|
Erythromycin Ethylsuccinate
800 mg orally or Erythromycin sterate 1.0 gm orally, 2 hrs before the procedure. |
Clindamycin |
300 mg orally, 1 hr before
the procedure
|
Alternate Prophylactic Regimens for
Dental, Oral, or Upper Respiratory Tract Procedures in Patients Who Are at Risk
Drug |
Dosing Regimen* |
For patients
unable to take oral medications
|
Ampicillin |
IV or IM
administration, 2 gm, 30 min before the procedure.
|
Ampicillin, Amoxicillin and Penicillin allergic patients unable to take oral medications
|
Clindamycin |
Intravenous
administration, 300 mg 30 min before the procedure. |
Patients
considered at high risk and not candidates for standard regimens
|
Ampicillin, Gentamicin, or Amoxicillin |
IV or IM
administration of Ampicillin, 2 gm, plus Gentamicin, 1.5 mg/kg (not to exceed 120 mg), 30 min before procedure; followed by Amoxicillin, 1.5 g, orally 6 h after initial dose.
Alternatively, the parenteral regimen may be repeated 8 h after initial dose.
|
Ampicillin, Amoxicillin and Penicillin allergic patients considered at high risk
|
Vancomycin
plus Gentamicin |
IV
administration of Vancomycin 1.0 g over 1 hour, plus Gentamicin1.5 mg/kg IV/IM (not to exceed 120 mg), complete injection/infusion within 30 minutes of starting the procedure: no repeat dose is necessary.
|
Initial pediatric doses are as follows: Ampicillin, 50 mg/kg; Clindamycin, 10 mg/kg; Gentamicin, 1.5 mg/kg; and Vancomycin, 20 mg/kg. Follow-up doses
should be one half the initial dose. No initial dose is recommended in this table for Amoxicillin (25 mg/kg is the follow-up dose).
Regimens for Genitourinary/Gastrointestinal
Procedures
Drug |
Standard Regimen - Dosage Regimen*
|
Ampicillin, Gentamicin, and Amoxicillin |
IV or IM
administration of Ampicillin, 2 gm, plus Gentamicin, 1.5 mg/kg (not to exceed 120 mg), 30
min before procedure; followed by Amoxicillin, 1.5 g, orally 6 hours after initial dose;
Alternatively, the parenteral regimen may be repeated once, 8 hours
after the initial dose. |
Ampicillin, Amoxicillin, and Penicillin allergic patient regimen
|
Vancomycin
and Gentamicin |
IV
administration of Vancomycin, 1 gm, over 1 hour, plus IV or IM administration of Gentamicin, 1.5 mg/kg
(not to exceed 120 mg), 1 hour before procedure.
This may be repeated once, 8 hours after the initial dose. |
Alternate
low-risk patient regimen
|
Amoxicillin |
3.0 gm
orally, 1 hour before the procedure; then 1.5 gm, 6 hours after the initial dose.
|
Initial pediatric doses are as follows: Ampicillin, 50 mg/kg; Amoxicillin, 50 mg/kg; Gentamicin, 2 mg/kg; and Vancomycin, 20 mg/kg. Follow-up doses should be half the initial
dose. The total pediatric dose should not exceed the total adult dose.
Reference
-
Prevention of Bacterial Endocarditis, Recommendations by the American Heart Association,
JAMA, 11 June 1997; 277: 1794-1801.
Reviewed by CAPT K. F. Strosahl, MC, USN, Cardiology/Computer Assisted
Program of Cardiology Specialty Leader, Cardiovascular Disease Division,
Portsmouth Naval Hospital, Portsmouth, VA (1999).
|
Preface
· Administrative Section
· Clinical Section
The
General Medical Officer Manual , NAVMEDPUB 5134, January 1, 2000
Bureau
of Medicine and Surgery, Department of the Navy, 2300 E Street NW, Washington, D.C.,
20372-5300
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