Sandbox ID Cardiovascular

# Aortitis, infectious
- Preferred regimen: Cefotaxime sodium 1.0 to 2.0 g IV qd
- Preferred regimen (2): Ciprofloxacin hydrochloride 400 mg IV q12h OR Ciprofloxacin hydrochloride 500 to 750 mg PO q12h OR Levofloxacin 250 to 750 mg IV/PO qd
- Preferred regimen (3): Oxacillin 1.0 to 2.0g IV or IM q4h / q6h OR Nafcillin  1.0 to 2.0 g IV or IM q4h / q6h OR Dicloxacillin  500 mg to 1.0 g IV or IM q4h /q6h
- Preferred regimen (4): Vancomycin 1.0 g (15 mg/kg, up to 3.0 to 4.0 g/d) IV q12h
- Note: Antimicrobial treatments are most effective when bactericidal, broadspectrum antibiotics are begun after obtaining blood cultures and prior to surgery. Dose of Cefotaxime sodium should be decreased by 50% in those with a creatinine clearance (CCr) of  20 mL/min. Ciprofloxacin should be used cautiously in those with a CCr  50 mL/min or when given concomitantly with drugs whose metabolism may be altered.

# Cardiovascular implantable electronic device infections
- 1.1. Early post-implantation inflammation
- Preferred regimen: Flucloxacillin 0.51 g PO tid
- 1.2. Penicillin allergy or MRSA Colonisation
- Preferred regimen: Doxycycline 100 mg PO bid OR Linezolid 600 mg PO bid OR Clindamycin 450 mg po qid
- Note: Benefit of and need for antimicrobial therapy in early post-implantation inflammation is unclear.
- 1.3. Early post-implantation inflammation in penicillin-allergic or MRSA-colonized patient
- Preferred regimen: Doxycycline 100 mg PO bid OR Linezolid 600 mg PO bid OR Clindamycin 450 mg PO qid
- 1.4. Uncomplicated generator pocket infection
- Preferred regimen: Vancomycin 1 g IV q12h OR Daptomycin 4 mg/kg IV qd OR Teicoplanin 6 mg/kg to a maximum of 1 g IV given at 0, 12 and 24 h and then qd
- 1.5. ICED-LI or ICED-IE or complicated generator pocket infection pending blood cultures, e.g. in severe sepsis
- Preferred regimen: Vancomycin 1 g IV q12h AND Meropenem 1 g IV q8h OR Daptomycin 810 mg/kg IV qd AND Meropenem 1 g IV q8h
- Note: Gentamicin or other anti-Gram-negative agents may be appropriate depending on local epidemiology.
- 1.6. ICED-LI or ICED-IE or generator pocket infection with negative blood cultures
- Preferred regimen: Vancomycin 1 g IV q12h AND Gentamicin 1 mg/kg IV q12h OR Daptomycin 810 mg/kg IV qd AND Gentamicin 1 mg/kg IV q12h
- Note: Duration of antimicrobial therapy should be at least 4 to 6 weeks for complicated infection (ie, endocarditis, septic thrombophlebitis, or osteomyelitis or if bloodstream infection persists despite device removal and appropriate initial antimicrobial therapy.

# Intravascular catheter-related infections
- 1. Pathogen based treatment
- 1.1. Gram positive bacilli
- 1.1.1 Staphylococcus aureus
- 1.1.1.1. Methicillin susceptible
- Preferred regimen: Naficillin  2 g IV q6h OR Oxacillin 2 g IV q6h
- Alternative regimen: Cefazolin, 2 g IV q8h OR Vancomycin 15 mg/kg IV q12h
- Pediatric doses:
- Nafcillin
- Neonates
- 04 weeks of age and 1200 g- 50 mg/kg/day in divided doses every 12 h
- <=7 days and 12002000 g- 50 mg/kg/day in divided doses every 12 h
- >7 days of age and <2000g- 75 mg/kg/day in divided doses every 8 h
- >7 days of age and >1200 g - 100 mg/kg/day in divided doses every 6 h
- Oxacillin
- Neonates
- 04 weeks of age and 1200 g- 50 mg/kg/day in divided doses every 12 h
- Postnatal age < 7 days and 12002000 g- 50100 mg/kg/day in divided doses every 12 h
- Postnatal age 2000 g, 75150 mg/kg/day in divided doses every 8 h
- Postnatal age >=7 days and 12002000 g- 75150 mg/kg/day in divided doses every 8 h
- Postnatal age >=7 days and >2000 g, 100200 mg/kg/day in divided doses every 6 h
- Infants and children Nafcillin 100200 mg/kg/day in divided doses every 46 h
- Cefazolin
- Neonates
- Postnatal age <=7 days: 40 mg/kg/day divided every 12 h
- Postnatal age >7 days and 2000 g: 40 mg/kg/day divided every 12 h
- Postnatal age >7 days and 12000 g: 60 mg/kg/day divided every 8 h
- Infants and children: 50 mg/kg/day divided every 8 h
- Vancomycin
- Neonates
- Postnatal age <=7 days and <1200 g, 15 mg/kg/day given every 24 h
- Postnatal age <=7 days and 12002000 g, 1015 mg/kg given every 1218 h
- Postnatal age 2000 g, 1015 mg/kg given every 812 h
- Postnatal age >7 days and <1200 g, 15 mg/kg/day given every 24 h
- Postnatal age >7 days and 12002000 g, 1015 mg/kg given every 812 h
- Postnatal age >7 days and >2000 g, 1520 mg/kg given every 8 h
- Infants and children: 40 mg/kg/day in divided doses every 68 h
- 1.1.1.2. Methicillin resistant Staphylococcus aureus
- Preferred regimen: (Vancomycin 15 mg/kg IV q12h OR Daptomycin 68 mg/kg per day IV, or Linezolid IV; OR Vancomycin IV) AND (Rifampicin IV OR Gentamycin IV OR TMP-SMZ IV alone) (if susceptible).
- Pediatric dose
- Linezolid
- Neonates
- 04 weeks of age and birthweight <1200 g: 10 mg/kg every 812 h (note: use every 12 h in patients <34 weeks gestation and <1 week of age)
- 1200 g, 10 mg/kg every 812 h (note: use every 12 h in patients <34 weeks gestation and <1 week of age)
- 7 days and birthweight >1200 g, 10 mg/kg every 8 h
- Infants and children <12 years of age: 10 mg/kg every 8 h Children 12 years of age and adolescents: 10 mg/kg every 12 h
- Gentamycin
- Neonates
- Premature neonates and <1000 g, 3.5 mg/kg every 24 h; 04 weeks and <1200 g, 2.5 mg/kg every 1824 h
- Postnatal age 7 days: 2.5 mg/kg every 12 h
- Postnatal age 17 days and 12002000 g, 2.5 mg/kg every 812 h
- Postnatal age 17 days and 12000 g, 2.5 mg/kg every 8 h
- Once daily dosing for premature neonates with normal renal function, 3.54 mg/kg every 24 h
- Once daily dosing for term neonates with normal renal function, 3.55 mg/kg every 24 h
- Infants and children <5 years of age: 2.5 mg/kg every 8 h; once daily dosing in patients with normal renal function, 57.5 mg/kg every 24 h
- Children >5 years of age: 22.5 mg/kg every 8 h; once daily dosing in patients with normal renal function, 57.5 mg/kg every 24 h
- TMP-SMZ
- Infants 12 months of age and children: mild-to-moderate infections, 612 mg TMP/kg/day in divided doses every 12 h; serious infection, 1520 mg TMP/kg/day in divided doses every 68 h
- 1.2. Coagulase-negative staphylococci
- Methicillin susceptible
- Preferred regimen: Naficillin 2 g IV q4h OR Oxacillin 2 g IV q4h
- Alternative regimen: First-generation Cephalosporin OR Vancomycin OR TMP-SMZ
- Methicillin resistant
- Preferred regimen: Vancomycin 15 mg/kg IV q12h
- Alternative regimen:  Daptomycin 6 mg/kg per day IV OR linezolid IV
- 1.3. Enterococcus faecalis/Enterococcus faecium
- Ampicillin susceptible
- Preferred regimen: Ampicillin, 2 g IV q4h/ q6h;OR Ampicillin 1 mg/kg IV q8h OR Gentamycin 1 mg/kg IV q8h.
- Alternative regimen: Vancomycin
- Pediatric dose:
- Ampicillin
- Neonates
- Postnatal age <=7 days and <=2000 g: 50 mg/kg/day divided every 12 h.
- Postnatal age 2000 g, 75 mg/kg/day divided every 8 h.
- Postnatal age >7 days and <1200 g, 50 mg/kg/day divided every 12 h.
- Postnatal age >7 days and 12002000 g, 75 mg/kg/day divided every 8 h.
- Postnatal age >7 days and >2000 g, 100 mg/kg/day divided every 6 h.
- Infants and children: 100200 mg/kg/day divided every 6 h 1
- Ampicillin resistant, Vancomycin susceptible
- Preferred regimen: Vancomycin, 15 mg/kg IV q12h  Gentamycin, 1 mg/kg IV q8h.
- Alternative regimen: Linezolid 6 mg/kg per day IV  or Daptomycin 6 mg/kg per day IV.
- Ampicillin resistant, Vancomycin resistant
- Preferred regimen: Linezolid IV 600 mg q12h OR Daptomycin 6 mg/kg per day IV.
- Alternative regimen: Quinupristin/Dalfopristin 7.5 mg/kg IV q8h.
- 1.4. Gram-negative bacilli
- 1.4.1. Escherichia coli and Klebsiella species
- 1.4.1.1. ESBL negative
- Preferred regimen: Ceftriaxone  12 g per day IV.
- Alternative regimen:  Ciprofloxacin IV OR Aztreonam IV.
- Pediatric dose:
- Ceftriaxone
- Neonates
- Postnatal age <=7 days, 50 mg/kg/day given every 24 h.
- Postnatal age >7 days and <=2000 g, 50 mg/kg/day given every 24 h.
- Postnatal age >7 days and >2000 g, 5075 mg/kg/day given every 24 h.
- Infants and children: 5075 mg/kg/day divided every 1224 h.
- Ciprofloxacin
- Neonates: 740 mg/kg/day divided every 12 h.
- Infants and children: 2030 mg/kg/day divided every 12 h.
- 1.4.1.2. ESBL positive
- Preferred regimen: Ertapenem 1 g per day IV OR Imipenem 500 mg IV q6h OR Meropenem 1 g IV q8h OR Doripenem 500 mg IV q8h.
- Alternative regimen:  Ciprofloxacin IV OR Aztreonam IV.
- Pediatric dose:
- Meropenem
- Neonates
- Postnatal age 07 days, 20 mg/kg every 12 h.
- Postnatal age >7 days and 12002000 g, 20 mg/kg every 12 h.
- Postnatal age >7 days and >2000 g, 20 mg/kg every 8 h.
- Infants 3 months of age and children: 20 mg/kg every 8 h.
- 1.4.2. Enterobacter species and Serratia marcescens
- Preferred regimen: Ertapenem 1 g per day IV OR Imipenem 500 mg IV q6h OR Meropenem 1 g IV q8h.
- Alternative regimen:  Cefepime IV OR Ciprofloxacin IV.
- Pediatric dose:
- Cefepime
- Neonates 14 days of age: 30 mg/kg every 12 h.
- Infants >14 days of age and Children 40 kg in weight: 50 mg/kg every 12 h.
- 1.4.3. Acinetobacter
- Preferred regimen: Ampicillin/Sulbactam 3 g IV q6h OR Imipenem 500 mg IV q6h OR Meropenem 1 g IV q8h.
- 1.4.4. Stenotrophomonas maltophilia
- Preferred regimen: Trimethoprim-sulfamethoxazole 35 mg/kg IV q8h.
- Alternative regimen: Ticarcillin IV AND Clavulanate IV.
- Pediatric dose:
- Ticarcillin
- Neonates
- Postnatal age <=7 days and 2000 g, 150 mg/kg/day in divided doses every 12 h.
- Postnatal age 2000 g, 225 mg/kg/day in divided doses every 8 h.
- Postnatal age >7 days and <1200 g, 150 mg/kg/day in divided doses every 12 h.
- Postnatal age >7 days and 12002000 g, 225 mg/kg/day in divided doses every 8h.
- Postnatal age >7 days and >2000 g, 300 mg/kg/day in divided doses every 68 h.
- Infants and children: 200300 mg/kg/day in divided doses every 46 2.
- 1.4.5. Pseudomonas aeruginosa
- Preferred regimen: Cefepime, 2 g IV q8h OR Imipenem 500 mg IV q6h OR Meropenem 1 g IV q8h OR Piperacillin IV  and Tazobactum 4.5 g IV q6h OR Amikacin 15 mg/kg once a day IV OR Tobramycin 57 mg/kg once a day IV.
- Pediatric dose:
- Amikacin
- Neonates
- 04 weeks of age and <1200 g, 7.5 mg/kg every 1824 h.
- Postnatal age <=7 days and 12002000 g, 7.5 mg/ kg every 12 h.
- Postnatal age 2000 g, 7.510 mg/kg every 12 h.
- Postnatal age >7 days and 12002000 g, 7.510 mg/kg every 812 h.
- Postnatal age >7 days and >2000 g, 10 mg/kg every 8 h.
- Infants and children: 1522.5 mg/kg/day divided every 8 h.
- 1.4.6. Burkholderia cepacia
- Preferred regimen: Trimethoprim-sulfamethoxazole 35 mg/kg IV q8h OR Imipenem 500 mg IV q6h OR Meropenem 1g IV q8h.
- 1.2. Fungi
- 1.2.1. Candida albicans or other Candida species
- Preferred regimen: Caspofungin 70-mg loading dose, then 50 mg per day OR Micafungin, 100 mg per day OR  Anidulafungin, 200 mg loading dose followed by 100 mg per day OR fluconazole, 400600 mg per day.
- Alternative regimen: Lipid  amphotericin B preparations.
- Pediatric dose:
- Caspofungin
- Intravenous dosing: infants and children aged 3 months17 years: loading dose of 70 mg/m2/day on day 1 followed by 50 mg/m2/day thereafter.
- Micafungin
- Children 12 years of age: 14 mg/kg/day
- Anidulafungin
- Children 2 17 years of agea: 1.5 mg/kg/day
- 1.3. Uncommon pathogens
- 1.3.1. Corynebacterium jeikeium (group JK)
- Preferred regimen: Vancomycin 15 mg/kg IV q12h.
- Alternative regimen: Linezolid IV.
- 1.3.2. Chryseobacterium (Flavobacterium)
- Preferred regimen: Levofloxacin 750 mg IV qd.
- Alternative regimen: Trimethoprim-sulfamethoxazole IV OR Imipenem IV OR Meropenem IV.
- 1.3.3. Ochrobacterium anthropi
- Preferred regimen: Trimethoprim-sulfamethoxazole 35 mg/kg IV q8h OR ciprofloxacin 400 mg IV q12h.
- 1.3.4. Malassezia furfur
- Preferred regimen: Amphotericin B IV.
- Alternative regimen:  Voriconazole IV.
- Pediatric dose:
- Voriconazole
- Children 12 years of age: 6 mg/kg every 12 h for 2 doses on day 1 (loading dose) followed by 4 mg/kg every 12 h (note: doses as high as 8 mg/kg every 12 h have been reported.
- Note (1):  Scheduled replacement of intravascular catheters has been proposed as a method to prevent phlebitis and catheter related infections. No specific recommendation can be made regarding routine replacement of catheters that need to be in place for >7 days
- Note (2): Peripheral Venous Catheters: Short peripheral catheter sites commonly are rotated at 7296-hour intervals. There is no need to replace peripheral catheters more frequently than every 72-96 hours to reduce risk of infection and phlebitis in adults. Replace peripheral catheters in children only when clinically indicated. Replace midline catheters only when there is a specific indication.
- Note (3): Midline Catheters: Midline catheters were in place a median of 7 days, but for as long as 49 days.
- Note (4): Hemodialysis Catheters: Hemodialysis catheters should be avoided in favor of arteriovenous fistulas and grafts. If temporary access is needed for dialysis, a cuffed catheter is preferable to a noncuffed catheter, even in the ICU setting, if the catheter is expected to stay in place for >3 weeks.
- Note (5): Pulmonary Artery Catheters: Pulmonary Artery Catheters typically remain in place an average of 3 days.
- Note (6): An umbilical catheter may be replaced if it is malfunctioning, and there is no other indication for catheter removal, and the total duration of catheterization has not exceeded 5 days for an umbilical artery catheter or 14 days for an umbilical vein catheter.

# Mediastinitis, acute
- Treatment secondary to cardiac infection and surgery
- Preferred regimen: Clindamycin 450 mg IV q6h AND Ceftriaxone 2 g IV q24h, for at least 2 weeks
- Prophylaxis
- Methicillin susceptible staphylococcus aureus infection
- Preferred regimen: Second generation cephalosporin.
- Methicillin resistant staphylococcus aureus infection
- Preferred regimen: Vancomycin
- Note (1): Preoperative antibiotics should be administered to all patients to reduce the risk of mediastinitis in cardiac surgery.
- Note (2): A deep sternal wound infection should be treated with aggressive surgical debridement in the absence of complicating circumstances.
- Note (3): Primary or secondary closure with muscle or omental flap is recommended. Vacuum therapy in conjunction with early and aggressive debridement is an effective adjunctive therapy.
- Note (4): Use of a continuous intravenous insulin protocol to achieve and maintain an early postoperative blood glucose concentration less than or equal to 180 mg/dL while avoiding hypoglycemia is indicated to reduce the risk of deep sternal wound infection.
- Note (5): The use of intranasal mupirocin is reasonable in nasal carriers of S. aureus.

# Myocarditis, viral

# Treatment
- Note (1): Mainstay of therapy for myocarditis is supportive care and standard management of CHF. Ribavarin and interferon alpha improved survival in mice with acute myocarditis.
- Note (2): Temporary pacemaker insertion is indicated in patients with symptomatic bradycardia and/or heart block during the acute phase of myocarditis.
- Note (3): ICD implantation is not indicated during the acute phase of myocarditis.
- Note (4): ICD implantation can be beneficial in patients with life-threatening ventricular arrhythmias who are not in the acute phase of myocarditis, as indicated in the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices.
- Note (5): Antiarrhythmic therapy can be useful in patients with symptomatic NSVT or sustained VT during the acute phase of myocarditis.

# Pericarditis, fungal
- Fungal Pericarditis
- Empiric therapy : Fluconazole, Ketoconazole, Itraconazole, Amphotericin B, Liposomal amphotericin B or Amphotericin B lipid complex is indicated.
- Histoplasmosis
- Preferred regimen: Nonsteroidal anti-inflammatory drugs given during 212 weeks.
- Nocardiosis
- Preferred regimen: Sulfonamides are the drugs of choice.
- Actinomycosis
- Preferred regimen: Combination of three antibiotics including Penicillin.

# Pericarditis, tuberculous
- Preferred regimen: Isoniazid 5 mg/kg (300 mg) OD  AND Rifampicin  10 mg/kg (600 mg) OD AND Pyrazanamide  1,500 mg OD AND Ethambutol 1,200 OD for 2 months followed by Rifampicin 10 mg/kg (600 mg) OD AND Pyrazanamide 1,500 mg OD for 4 months. Prednisolone 12 mg/kg per day for 57 days is also given and is progressively reduced to discontinuation in 68 weeks.
- Pediatric dose: Isoniazid  1015 mg/kg (300 mg); Rifampin 1020 mg/kg (600 mg); Pyrazinamide 1530 mg/kg (2.0 g); Ethambutol 1520 mg/kg daily (1.0 g).

# Pericarditis, viral
- Viral pericarditis
- CMV pericarditis
- Preferred regimen: immunoglobulin 1 time per day 4 ml/kg on day 0, 4, and 8; 2 ml/kg on day 12 and 16.
- Coxsackie B pericarditis
- Preferred regimen: Interferon alpha or beta 2,5 Mio. IU/m2 surface area s.c. 3 times per week
- Adenovirus and parvovirus B19 perimyocarditis
- Preferred regimen: Immunoglobulin 10 g IV at day 1 and 3 for 68 hours

# Rheumatic fever, primary  prophylaxis
- Preferred regimen: Penicillin V (Phenoxymethyl penicillin) 500 mg PO 2 to 3 times daily for 10 days OR Amoxicillin 50 mg/kg PO qd (maximum 1 g) oral for 10 days OR Benzathine penicillin G IM 600 000 U for patients 27 kg (60 lb); 1 200 000 U for patients >27 kg (60 lb) once.
- Alternative regimen: Narrow-spectrum Cephalosporin(Cephalexin, Cefadroxil) PO for 10 days OR Clindamycin 20 mg/kg per day divided in 3 doses (maximum 1.8 g/d) PO for 10 days OR Azithromycin 12 mg/kg PO qd (maximum 500 mg)  for 5 days OR Clarithromycin 15 mg/kg per day PO bid (maximum 250 mg bid) for 10 days.

# Rheumatic fever, secondary  prophylaxis
- Preferred regimen (1): Penicillin G benzathine 1.2 million units IM every 4 wk
- Preferred regimen (2): Penicillin V potassium 250 mg PO bid
- Preferred regimen (3): Sulfadiazine 1 g PO qd
- Preferred regimen (4): Macrolide or Azalide antibiotic (for patients allergic to Penicillin and Sulfadiazine) varied dose.
- Note: Duration of secondary prophylaxis for rheumatic fever differs for different scenarios. For Rheumatic fever with carditis and residual heart disease (persistent VHD) 10 y or until patient is 40 y of age (whichever is longer). For Rheumatic fever with carditis but no residual heart disease (no valvular disease) 10 y or until patient is 21 y of age (whichever is longer). For Rheumatic fever without carditis 5 y or until patient is 21 y of age (whichever is longer).

# Septic pelvic vein thrombophlebitis
- Based on the CT and MRI findings septic pelvic vein thrombophlebitis is classified into following categories for management..
- 1. Right ovarian vein thrombosis
- Preferred regimen (1): Ertapenem 1 g PO qd for 7 days AND Enoxaparin (1 mg/Kg) initially AND  36 months of Warfarin (INR 2.5)
- Preferred regimen (2): Gentamicin 4 mg/kg AND Ampicillin 2 g  AND Clindamycin 1200 mg for 7 days AND Enoxaparin (1 mg/Kg) initially AND  36 months Warfarin (INR 2.5).
- Note: Repeat CT scan after 3 months. If negative, stop anticoagulation. If still positive for thrombi, anticoagulate for 3 additional months.
- 2. Pelvic branch vein thrombosis
- Preferred regimen (1): Ertapenem  1 g PO qd for 7 days AND Enoxaparin (1 mg/Kg) PO for 2 weeks
- Preferred regimen (2): Gentamicin (4 mg/kg) PO AND Ampicillin 2 g PO AND Clindamycin 1200 mg PO for 7 days AND Enoxaparin (1 mg/Kg) for 2 weeks.
- 3. Negative for pelvic thrombi
- Preferred regimen (1): Ertapenem 1 g PO qd for 7 days AND Enoxaparin (1 mg/Kg) for 1 week
- Preferred regimen (2): Gentamicin  (4 mg/kg) PO qd AND Ampicillin 2 g PO qd AND Clindamycin 1200 mg PO qd for 7 days AND Enoxaparin (1 mg/Kg) PO qd for 1 weeks