1. When do you give prophylactic treatment in MVP?

2. Clinical approach to determination of the need for prophylaxis in patients with suspected MVP Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association

3. A reasonable approach for endocarditis prophylaxis should consider the following: – the degree to which the patient’s underlying condition creates a risk of endocarditis – the apparent risk of bacteremia with the procedure – the potential adverse reactions of the prophylactic antimicrobial agent to be used; and the cost-benefit aspects of the recommended prophylactic regimen Failure to consider all of these factors may lead to overuse of antimicrobial agents, excessive cost, and risk of adverse drug reactions Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association

4. Prophylaxis is recommended in individuals who have a higher risk for developing endocarditis than the general population and is particularly important for individuals in whom endocardial infection is associated with high morbidity and mortality Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association

5. Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association

6. Endocarditis prophylaxis recommended High-risk category Prosthetic cardiac valves Previous bacterial endocarditis Complex cyanotic congenital heart disease Eg. Single ventricle states, Transposition of the great arteries, Tetralogy of Fallot Surgically constructed systemic pulmonary shunts or conduits Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association

7. Moderate-risk category Acquired valvular dysfunction (eg, rheumatic heart disease) Hypertrophic cardiomyopathy Mitral valve prolapse with valvular regurgitation and/or thickened leaflets Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association

8. Endocarditis prophylaxis NOT recommended Negligible-risk category Isolated secundum atrial septal defect Surgical repair of ASD, VSD or PDA Previous coronary artery bypass graft surgery Mitral valve prolapse without valvular regurgitation Physiologic, functional, or innocent heart murmurs Previous Kawasaki disease without valvular dysfunction Previous rheumatic fever without valvular dysfunction Cardiac pacemakers and implanted defibrillators Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association

9. Prophylaxis at the time of cardiac surgery should be directed primarily against staphylococci and should be of short duration First-generation cephalosporins are most often used Prophylaxis is most effective when given perioperatively in doses that are sufficient to assure adequate antibiotic concentrations during and after the procedure Antibiotics should be used only during the perioperative period - initiated shortly before a procedure and should not be continued no more than 6 to 8 hours In the case of delayed healing, or of a procedure that involves infected tissue, it may be necessary to provide additional doses of antibiotics Prophylaxis

10. Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association Antimicrobial prophylaxis administered within 2 hours following the procedure will provide effective prophylaxis

11. Streptococcus viridans is the most common cause of endocarditis following: – dental or oral procedures – certain upper respiratory tract procedures – bronchoscopy with a rigid bronchoscope – surgical procedures that involve the respiratory mucosa – esophageal procedures

12. Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association

13. The recommended standard prophylactic regimen for all these procedures is a single dose of oral amoxicillin to be administered 1 hour before the anticipated procedure – Adult dose is 2.0 g – Pediatric dose is 50 mg/kg (not to exceed adult dose) For individuals who are unable to take or unable to absorb oral medications, parenteral Ampicillin sodium is recommended Durack DT. Prevention of infective endocarditis. N Engl J Med. 1995

14. Individuals who are allergic to penicillin – Clindamycin hydrochloride – Azithromycin or clarithromycin When parenteral administration is needed in an individual who is allergic to penicillin, clindamycin phosphate is recommended Durack DT. Prevention of infective endocarditis. N Engl J Med. 1995

15. Prophylaxis Enterococcus faecalis is the most common cause of bacterial endocarditis that occurs following genitourinary and gastrointestinal tract surgery or instrumentation Antibiotic prophylaxis should be directed primarily against Enterococci

16. Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association

17. Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association

18. Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association

19. High-risk patients – Ampicillin plus gentamicin High-risk patients allergic to ampicillin/amoxicillin – Vancomycin plus gentamicin Moderate-risk patients – Amoxicillin or ampicillin Moderate-risk patients allergic to ampicillin/amoxicillin – Vancomycin Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association

21. Endocarditis Endocarditis is a life-threatening disease, although it is relatively uncommon. Substantial morbidity and mortality result from this infection, despite antimicrobial therapy and enhanced ability to diagnose and treat complications. – Primary prevention of endocarditis whenever possible is therefore very important. Endocarditis usually develops in individuals with underlying structural cardiac defects who develop bacteremia with organisms likely to cause endocarditis.

22. Bacteremia Bacteremia commonly occurs during activities of daily living such as routine tooth brushing or chewing. With respect to endocarditis prophylaxis, significant bacteremia is only those caused by organisms commonly associated with endocarditis and attributable to identifiable procedures. The procedures for which prophylaxis is recommended are those known to induce bacteremia Invasive procedures performed through surgically scrubbed skin are NOT likely to produce bacteremia.