Infectious endocarditis (IE) occurs when nonbacterial thrombotic endocarditis (NBTE) becomes infected after an episode of transient bacteremia. NBTE results from platelet/fibrin deposition at areas of abnormal and turbulent blood flow. Any event that can cause transient bacteremia (eg. violation of the GI tract) can transform NBTE to IE.
The AHA recommendations for endocarditis prophylaxis were modified in 2007 [Circulation (2007);116:1736-54) in light of the understanding that most IE results from random episodes of bacteremia not related to specific procedures and the concern for the potential harmful effects of unwarranted antibiotic administration
Only patients with specific cardiac IE risk factors [table] should be considered for prophylactic antibiotic administration.
Recommendations for respiratory tract procedures:
Single pre-procedure antibiotic dose (Cefazolin/clindamycin/ceftriaxone or Vanco if MRSA suspected) for any procedure expected to violate (incision/biopsy) the mucosa or for procedures intended to treat an existing infection (drainage of empyema/abscess).
Recommendations for GI or GU tract procedures:
Single pre-procedure antibiotic dose effective against enterococci should be used, when indicated, since these are the only organisms likely to cause IE.
Prophylaxis is NOT indicated for diagnostic GI/GU procedures (endoscopy, cycstoscopy etc..).
When patients are receiving antibiotics for a GI/GU infection or to prevent wound infection, it is suggested that the antibiotics used include an agent effective against enterococci (PCN, ampicillin, piperacillin, or Vanco).
Recommendations for infected skin/skin structure/musculoskeletal tissue
Only staph and B-hemolytic strep are likely causes of IE in this situation. Prudent to use antistaphylococcal agents.
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