INDICES> MDD versus ODA in infective endocarditis (2)

["Janet McNeece" <Jmcneece@mail.rah.sa.gov.au>]

INDICES> MDD versus ODA in infective endocarditis (2)
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Dear Chee Lan

In Australia  The recommendations for Endocarditis are

1.  For the empirical treatment of endocarditis, once-daily dosing
of gentamicin is recommended to cover the possibility of gram-
negative sepsis and is only an interim regimen pending blood
culture results.

Empiracle Treatment Recommendations are

benzylpenicillin (child 30mg/kg up to) 1.8g intravenously 4 hourly

PLUS

Di(flu)cloxacillin (child 50mg/kg up to) 2g intravenously 4 hourly

PLUS

Gentamicin 4-6mg/kg (child <<10years 7.5mg/kg; > or = 10years:
6mg/kg) intravenously daily (tailor dose to age and renal function of
the patient)

2. Conversely, in proven penicillin-susceptible streptococcal
endocarditis, only limited clinical data are available on the once
daily dosing of aminoglycoside, therefore, thrice daily
administration is recommended until adequate data are reported.
The recomended starting dose of gentamicin in endocarditis is
1mg/kg 8 hourly. Then the gentamicin should be monitored,
however the optimum method of monitoring levels in endocarditis is
unknown.  As doses are lower, dosing more frequent and synergy
is the objective, the methods of monitoring used for gentamicin in
other circumstances are inappropriate.  Instead troughs should be
measured only and values between 0.5 and 1mg/ml will likely
maximise synergy and minimise toxicity with 8hour dosing.
Patients should be clinically monitored for vestibular and auditory
ototoxicity.  Baseline audiometry should be recordede close to the
time of initiation of therapy and repeated periodically if the course
of aminoglycoside extends beyond 14 days.

Treatment reccomendations Differ for Streptococcal endocarditis/
Enterococcal endocarditis/ Staphlococcal endocarditis and
endocarditis caused by the HACEK group as well as weather the
bacteria is penicillin sensitive or resistant or if the patient has a
hypersensitivity to penicillin.  These reccomendations are taken
from  The Therapeutic Guidelines: Antibiotic Version 11 2000
published by the Therapeutic Guidelines Ltd Level2, 55 Flemington
Road, North Melbourne, Victoria 3051 Australia Website
www.tg.com.au, Email sales@tg.co,.au

A good review of endocarditis treatment is also available from The
New England Medical Journal

Mylonakis E, Calderwood S B. Infective Endocarditis in Adults N
Eng J Med 2001; 18: 1318-1130 this may also be available on their
web site www.nejm.org.  There are also some USA guigelines at
http://www.americanheart.org.Scientific/statements/1997/079701.ht
ml which are refered to in the NEJM review.

Hope this is useful

Janet McNeece
Senior Pharmacist, Medicines Information centre,
Royal Adelaide Hospital
South Australia, SA5063
email jmcneece@mail.rah.sa.gov.au
Telephone (61)88225546
Fax  (61) 882225891

[thanks, Janet! Useful information.  But please do not send HTML messages
to INDICES. We prefer to receive plain ASCII (text) messages. WB]



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