• High doses of bactericidal drugs are needed because the organisms are difficult to access in avascular vegetations on valves and the protective host reaction is negligible.
• Drugs should be given parenterally at least initially and preferably by intravenous bolus injection which achieves the necessary high peak concentration to penetrate the relatively avascular vegetations.
• The infusion site should be examined daily and changed regularly to prevent opportunistic infection, which is usually with coagulase-negative staphylococci or fungi. Alternatively, use may be made of a central subclavian venous catheter sited with meticulous attention to aseptic technique.
• Prolonged therapy is needed, usually 4 weeks, and in the case of infected prosthetic valves at least 6 weeks. The patient should be reviewed one month after completing the antimicrobial treatment. Valve replacement may be needed at any time during and after antibiotic therapy if cardiovascular function deteriorates or if the infection proves impossible to control.
• Dosage must be adjusted according to the sensitivity of the infecting organism. This is established by the Minimum Inhibitory Concentration test (p. 203), rather than by testing dilutions of the patient's serum against the organism (the Serum Bactericidal Titre which was formally recommended, but which has not been proved useful).
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