Cardiovascular System

ALL suspected/ confirmed cases of endocarditis MUST be discussed with Microbiologists and Cardiologists and entered to the IE Care Pathway form.

Discuss with Microbiologist at first opportunity in working hours and daytime during the weekend (within 24 hours of suspected diagnosis)

Microbiological specimens
Three sets of blood cultures need to be taken before initiating antibiotics.  If antibiotics already started, blood culture must
be collected before next dose of antibiotic. Must LABEL BC AS ENDOCARDITIS for prolonged incubation and endocarditis specific sensitivity testing and MIC determinations.
Serology for Coxiella and Bartonella if blood culture negative endocarditis.

• Valve tissue at operation in sterile container without saline and inform the laboratory prior to delivery and deliver by hand to member of the senior laboratory staff  for 16s rRNA PCR and other specialist molecular tests.
• The below recommendations are for empiric therapy only.  Targeted regimes will be provided by Consultant Microbiologist and Cardiologist.  
• The choice of agent should take into account the patient's risk for C. difficile infection.
• Vancomycin plus Gentamicin may accentuate renal impairment.  Discuss with Microbiologist at first opportunity.

Antibiotic - 1st line
Vancomycin IV (dosed as per trust vancomycin guideline)

2nd Line
Discuss with Microbiology.

1st  Line
Vancomycin IV (dosed as per trust vancomycin guideline) 
plus

2nd Line
Penicillin Allergy or history/risk of MRSA
Vancomycin IV (dosed as per trust vancomycin guideline) 
plus
Gentamicin1mg/kg q12h IV (modified according to renal function)

Antibiotic - 1st line
Vancomycin (dosed as per trust vancomycin guideline) 
plus
Rifampicin 600mg q12h PO
plus
Gentamicin1mg/kg IV 12 hourly (modified according to renal function). Adjusted body weight if obese - i.e. if 20% over ideal body weight.
Discuss continuation of Gentamicin beyond 48 hours with Microbiology.

ALL suspected/ confirmed cases of infected inplantable cardiac electronic devices MUST be discussed with Microbiologists and Cardiologists

Microbiology specimens

• For early (<30 days) post implantation inflammation / uncomplicated superficial wound infection without fluctuance, discharge or dehiscence AND without systemic symptoms or signs of infection – address any obvious cause and take blood cultures. Wound should be reviewed by appropriate personnel (ideally implanting physician, if unavailable on-call cardiology registrar)
• For generator pocket infection – If evidence of severe sepsis take 3 sets of blood cultures within 1h, then give antibiotics. If no evidence of sepsis withhold antibiotics and take three sets of blood cultures at different times >6h apart, organise echocardiography and urgent cardiology review with a view to prompt removal of entire system and temporary pacing if needed. Theatre samples during extraction – lead fragments (proximal and distal), lead vegetation, generator pocket tissue (-2sq.cm) and pus aspirated from generator pocket wound (swabs are least preferred samples)
• The below recommendations are for empiric therapy only.  Targeted regimes will be provided by Consultant Microbiologist and Cardiologist.  

Antibiotic - 1st line

Vancomycin IV as per vancomycin dosing guide

Oral option- Clindamycin 600mg PO q6h (discuss with microbiologist if Erythromycin or clindamycin resistant staphylococci isolated)

Antibiotic - 1st line
Vancomycin IV as per vancomycin dosing guide
 
Change to targeted treatment once culture results are available

2nd Line
Discuss with microbiologist

Antibiotic - 1st line
Discuss with microbiologist and cardiologist