General Medical Officer (GMO) Manual: Clinical Section: 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.

Dental procedures not likely to induce gingival bleeding such as adjustment of orthodontic appliances.
Injection of local intraoral anesthetic (except intraligament injections).
Endotracheal intubation

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

This web version of The General Medical Officer Manual, NAVMEDPUB 5134 is provided by The Brookside Associates Medical Education Division. It contains original contents from the official US Navy version, but has been reformatted for web access and includes advertising and links that were not present in the original version. This web version has not been approved by the Department of the Navy or the Department of Defense. The presence of any advertising on these pages does not constitute an endorsement of that product or service by either the Department of Defense or the Brookside Associates. The Brookside Associates is a private organization, not affiliated with the United States Department of Defense. All material in this version is unclassified. This formatting © 2006 Medical Education Division, Brookside Associates, Ltd. All rights reserved.

Home · Textbooks and Manuals · Videos · Lectures · Distance Learning · Training · Operational Safety · Search

This website is dedicated to the development and dissemination of medical information that may be useful to those who practice Operational Medicine. This website is privately-held and not connected to any governmental agency. The views expressed here are those of the authors, and unless otherwise noted, do not necessarily reflect the views of the Brookside Associates, Ltd., any governmental or private organizations. All writings, discussions, and publications on this website are unclassified.

Contact Us