Infective Endocarditis

2. Diagnosis: Infective endocarditis

3. Condition:

4. Vital signs: q4h. Call physician if BP systolic >160/90, <90/60; P >120, <50; R>25, <10; T >38.5°C

5. Activity: Up ad lib

6. Diet: Regular

7. IV Fluids: Heparin lock with flush q shift.

8. Special Medications:

Subacute Bacterial Endocarditis Empiric Therapy:

-Penicillin G 3-5 million U IV q4h or ampicillin 2 gm IV q4h AND Gentamicin 1-1.5/mg/kg IV q8h. Acute Bacterial Endocarditis Empiric Therapy

-Gentamicin 2 mg/kg IV; then 1-1.5 mg/kg IV q8h AND Nafcillin or oxacillin 2 gm IV q4h OR

Vancomycin 1 gm IV q12h (1 gm in 250 mL of D5W over 1h). Streptococci viridans/bovis:

-Penicillin G 3-5 million U IV q4h for 4 weeks OR Vancomycin 1 gm IV q12h for 4 weeks AND Gentamicin 1 mg/kg q8h for first 2 weeks. Enterococcus:

-Gentamicin 1 mg/kg IV q8h for 4-6 weeks AND Ampicillin 2 gm IV q4h for 4-6 weeks OR Vancomycin 1 gm IV q12h for 4-6 weeks. Staphylococcus aureus (methicillin sensitive, native valve): -Nafcillin or Oxacillin 2 gm IV q4h for 4-6 weeks OR Vancomycin 1 gm IV q12h for 4-6 weeks AND Gentamicin 1 mg/kg IV q8h for first 3-5 days.

Methicillin resistant Staphylococcus aureus (native valve):

-Vancomycin 1 gm IV q12h (1 gm in 250 mL D5W over 1h) for 4-6 weeks AND

Gentamicin 1 mg/kg IV q8h for 3-5 days.

Methicillin resistant Staph aureus or epidermidis (prosthetic valve): -Vancomycin 1 gm IV q12h for 6 weeks AND Rifampin 600 mg PO q8h for 6 weeks AND Gentamicin 1 mg/kg IV q8h for 2 weeks. Culture Negative Endocarditis:

-Penicillin G 3-5 million U IV q4h for 4-6 weeks OR Ampicillin 2 gm IV q4h for 4-6 weeks AND

Gentamicin 1.5 mg/kg q8h for 2 weeks (or nafcillin, 2 gm IV q4h, and gen-tamicin if Staph aureus suspected in drug abuser or prosthetic valve). Fungal Endocarditis:

-Amphotericin B 0.5 mg/kg/d IV plus flucytosine (5-FC) 150 mg/kg/d PO.

9. Extras: CXR PA and LAT, echocardiogram, ECG.

11. Labs: CBC with differential, SMA 7&12. Blood C&S x 3-4 over 24h, serum cidal titers, minimum inhibitory concentration, minimum bactericidal concentration. Repeat C&S in 48h, then once a week. Antibiotic levels peak and trough at 3rd dose. UA, urine C&S.

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