the procedure to coincide with the bacteraemia and avoid emergence of resistant organisms. There follow general recommendations4-5'6 on antimicrobial prophylaxis; not every contingency is covered because prophylaxis may be needed for patients with cardiac defects whenever surgery or instrumentation is undertaken on tissue that is heavily colonised or infected, e.g. in surgery or instrumentation of the upper respiratory or genitourinary tracts, or obstetric, gynaecological or gastrointestinal procedures. Different national Working Parties have recommended differing prophylactic measures,4,5'6 and the physician should consult special sources and exercise a clinical judgement that relates to individual circumstances. All oral drugs should be taken under supervision.
• Adults who are not allergic to penicillins and who have not taken penicillin more than once in the previous month (including those with a prosthetic valve, but not if they have had endocarditis in the past) should receive amoxicillin 3 g by mouth 1 h before the procedure.
• Patients allergic to penicillins or who have taken penicillin more than once in the previous month should receive clindamycin 600 mg by mouth 1 h before the procedure.
Under general anaesthesia
• Patients who are not allergic to penicillins and who have not taken penicillin more than once in the previous month should receive amoxicillin
1 g i.m. or i.v. at induction then 0.5 g by mouth 6 h later. Alternatively amoxicillin 3 g may be taken by mouth together with probenecid 1 g by
4 Simmons N A1993 Recommendations for endocarditis prophylaxis. Journal of Antimicrobial Chemotherapy 31: 437.
5 Littler W A, McGowan D A, Shanson D C 1997 Changes in recommendations about amoxycillin prophylaxis for prevention of endocarditis. Lancet 350:1100.
6 Dajani A S, Taubert K A, Wilson W et al 1997 Prevention of bacterial endocarditis. Recommendations by the American Heart Association. Journal of the American Medical Association 277:1794.
mouth 4 h before the procedure (probenecid delays renal excretion and thus maintains a high blood concentration of amoxicillin), or amoxicillin 3 g may be followed by another 3 g dose as soon as possible after the procedure. • Special risk patients, i.e. with prosthetic valves or with previous endocarditis, should receive amoxicillin 1 g i.m. or i.v. and gentamicin 120 mg at induction, then amoxicillin 0.5 g by mouth 6 h later. Patients who are penicillin-allergic or have received penicillin more that once in the previous month should receive vancomycin 1 g i.v. over 100 min then gentamicin 120 mg i.v. at induction or 15 min before the procedure; or teicoplanin 400 mg i.v. plus gentamicin 120 mg i.v. at induction or 15 min before the procedure; or clindamycin 300 mg over at least 10 min at induction or 15 min before the procedure then clindamycin 150 mg i.v. or by mouth 6 h later.
Special sources should be consulted for prophylactic regimens recommended for children and for other procedures, such as instrumentation of the urogenital or gastrointestinal tracts.
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