University of Pennsylvania Medical Center Guidelines for Antibiotic Use

 

Antimicrobial Prophylaxis for the Prevention of Bacterial Endocarditis in Patients with Underlying Cardiac Conditions1,2

Full text of the 2007 American Heart Association Guidelines

Endocarditis Prophylaxis is Recommended for People Only with the Following Conditions

Prosthetic cardiac valves (including bioprosthetic and homograft valves)

Previous bacterial endocarditis

Unrepaired cyanotic congenital heart disease (CHD), including palliative shunts and conduits

Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter, but only during the 1st six months after the procedure

Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device

Cardiac transplantation recipients who develop cardiac valvulopathy

 

 

Procedures for Which Prophylaxis is Recommended for People with the Above Conditions
Dental Procedures

All dental procedures that involve the manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa.

Excluded are: routine anesthetic injections through uninfected tissue, taking radiographs, placement of removable prosthodontic or orthodontic appliances, adjustment of orthodontic appliances, placement of orthodontic brackets, shedding of deciduous teeth, and bleeding from trauma to the lips or oral mucosa.
Respiratory Tract

Invasive procedure of the respiratory tract that involves incision and biopsy of the respiratory mucosa, such as tonsillectomy or adenoidectomy.

Excluded is: bronchoscopy unless it involves incision of the respiratory tract mucosa

Skin, skin structure or musculoskeletal tissue Surgery on infected soft tissues - prophylaxis is directed against hemolytic streptococci and staphylococci
Cytoscopy without knowledge of urine culture results Cytoscopy of patients with urinary tract infections should, if possible, be conducted after successful treatment of the infection, in which case endocarditis prophylaxis is not indicated. If cystoscopy is required without knowledge of urine culture results, then prophylaxis against enterococcus may be indicated.
Other excluded procedures

All other GI and GU procedures, tatooing, piercing of ears or other body areas, vaginal delivery, hysterectomy.

 

For patients with established GU or other intraabdominal infections, the guidelines suggest that anti-enterococcal therapy may be indicated, if the patients meet the criteria for requiring prophylaxis - call an infectious diseases consultant for questions on this point.

1Recommendations of the American Heart Association (Circulation 2007;115 - May 8th issue); refer to article for a complete discussion about the topic

2This table is not meant to be all-inclusive. Please read the complete text of the guidelines for details.

 

Antimicrobial Prophylaxis for the Prevention of Bacterial Endocarditis1

Situation Drug Dosage Regimen- all single dose only, within 30 to 60 minutes prior to procedure
Oral therapy amoxicillin 2gm PO
Unable to take oral medications ampicillin 2gm IM or IV
OR cefazolin 1 gm IM or IV
Allergic to penicillins or ampicillin- oral dosing cephalexin2 OR 2gm PO
clindamycin OR 600mg PO
azithromycin or clarithromycin 500mg PO
Allergic to penicillin or ampicillin and unable to take oral medications cefazolin2 OR 1gm IM or IV
clindamycin 600mg IV
Surgery on infected soft tissues cefazolin OR vancomycin, depending on antimicrobial susceptibility

see above for dosage

Cystoscopy when UTI eradication not possible anti-enterococcal therapy (amoxicillin or vancomycin), depending on antimicrobial susceptibility, if available. If not available, consult with infectious diseases. see above for dosage
Recent prior or concurrent antimicrobial therapy consult with infectious diseases, see full text of AHA guidelines  

1Modified from recommendations of the American Heart Association (Circulation 2007;115 - May 8th issue); refer to article for a complete discussion about the topic. Ceftriaxone usage omitted from UPHS recommendations.

2Cephalosporins should not be used in individuals with immediate-type hypersensitivity reactions (urticaria, angioedema or anaphylaxis to penicillins or ampicillin)

Written by P. Edelstein, 5/23/07

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