Patient Encounter Part 5 Create a Care Plan

Based on this patient's information, create a care plan for the management of his IE. Be sure to include

(a) a statement regarding treatment requirements and/or possible problems, (b) goals of therapy, (c) a patient-specific plan, including preventive plans, and (d) a follow-up plan to assess whether the goals have been met and to determine whether the patient experienced any adverse effects.

Cardiac conditions in which prophylaxis is reasonable include presence of prosthetic valves or material, prior IE, congenital cardiac disease (specific forms only), cardiac transplant patients with cardiac valvulopathy (Table 74-8). While many patients have other cardiac dysfunction, only patients with these conditions are considered to be at a high risk of developing IE. No prophylaxis is advised in other patients.

Transient bacteria may occur due to many types of dental and surgical procedures. However, the AHA has recently published new guidelines significantly limiting the types of procedures where prophylaxis is appropriate. Only dental procedures involving manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa are considered to increase the likelihood that high-risk patients will develop IE. Viridans group streptococci are the primary bacteria targeted for prophylaxis in this circumstance. On the other hand, prophylaxis for GI or genitourinary surgeries primarily targets enterococci.

Table 74-7 Dosage Considerations for Standard Antibiotics for Treatment of IEfl

H*t*atlc

Urug

Renal Adjustment:

Adjustments

Comments

PentcHllin G

Required

None

Extension □< dosing interval primarily used lor adjustment

Anfiüttn

hK|IJlKd

Niim1

St'iftjiW most coflanort Ai ifikMin<i not ¿¿JjuSlftl

NíicMfel

Ntiff

íevíWf ÍSW cunvnúnl)

Ail|ui[menti n«« *yy OM If if m pa li^nii wiih leve«1 IwpJIic AND renal ¡mmirmont

Chr^illin

£*Wf# CflrHrTTCmiJ

None

OCI tei thd^ 10m]/min 1i> lowjn mm::-1 pi normal do»

Ceíarolin

Requited

None

Dose and/» doling inicrval require adiuslment. Eased on fiiiierti'sCGI

Olifiiiíorkí

ip-ifti- (u^ «mnrirtit}

None

Do n<3l <vtfj i ^/¡lay if paik>nr has, BOTH sf^io i«ial AND bepaLc impairmttfH

VrincciTiycin

Required

None

Muralc* thertpeulk Ii "flHs to ^lkJc dn wqc *djUItiTie«H (see neinnent guidelines far ranges)

Genrtamidn

Required

None

Lised for synengjf onijf wiiligiam-pmitivHS. Theiapeutk

Ifvtii vitfy itK QiirTi- ftCQflti^ OfQflrljyra MOflMOi ! Til | M :J! I'.'VL'K to *djuftnwnif

Is-yneigy tivtut tewelscpeak i mc^mL [<iî umol/l| and

duugh Ilis Ifwn 1 nn^mL 121 urmMD

fofampn

Hone

flft^uired

Aduismnefir Lm-smI on hepatic dyifuniTion

Newer and Siluqi Drugi

Dwiiirttyiiri

Brtiuiiid

ffcfti

Adiu^nwT in itoiiiVF inte^i dti dun 30 rnL/ïrin CPK Jvuld tv mwiiraied prier ru and cUnirq therapy

Linejrfid

tone

None

MetaboMes may jccurMiol-.* in severe reml m ipjimont

Moniltx fen ht'nuroitjgk At

LP>i; in ■'•.' iyfibi k T-f>. iii n*'n( ixn 1

Ou 1 tmj pf« t i ru'i^j 1 fofjf i n 1 th

Hone

itoaJtfy

AdjtisrnneiiTS suggested based cmjihan™™*lneTir data. HcwEffll, no specific leconvnenddlons are described

AE. adveisr ewnt CPK. incarinine plwsphdHftSi^OCLinMtinlneclsSrafKe-.

Grartt-rwgai™ bjMciia. iuiKidl arypxjl UtwrenSM nut lifted ¡1 issuçjgcik'd thj: an InfeitkaJS DliWSei Consult t>; obLjiriod j rwl*;nl

Ivî IV kl (hi1 ■ rj|l(3|,',ily .irn.i ilii'n i.i'lv in rtLiivijiiH | Hw-n ■ fHI «fils.

Table 74-8 Cardiac Conditions Associated With the Highest Risk of Adverse Outcome From Endocarditis for Which Prophylaxis With Dental Procedures Is Reasonable"

AE. adveisr ewnt CPK. incarinine plwsphdHftSi^OCLinMtinlneclsSrafKe-.

Grartt-rwgai™ bjMciia. iuiKidl arypxjl UtwrenSM nut lifted ¡1 issuçjgcik'd thj: an InfeitkaJS DliWSei Consult t>; obLjiriod j rwl*;nl

Ivî IV kl (hi1 ■ rj|l(3|,',ily .irn.i ilii'n i.i'lv in rtLiivijiiH | Hw-n ■ fHI «fils.

Table 74-8 Cardiac Conditions Associated With the Highest Risk of Adverse Outcome From Endocarditis for Which Prophylaxis With Dental Procedures Is Reasonable"

Prosthetic cardiac valve or prosthetic material used for cardiac-valve repair

Previous IE

CHDb

Unrepaired cyanotic CHD, including palliative shunts and conduits

Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedurec

Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)

Cardiac transplantation recipients who develop cardiac valvulopathy

CHD, congenital heart disease.

aAll dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa is reasonable to give prophylaxis in the patient conditions listed above.

bExcept for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.

cProphylaxis is reasonable because endothelialization of prosthetic material occurs within 6 months after the procedure.

From Ref. 7. Copyright 2007, American Heart Association. All rights reserved.

Table 74-9 Prophylactic Regimens for Denta Procedure

Regimen: Single Dose 30-60 minutes Before Procedure

Situation

Agent

Adults

Children

Oral

Unable to take oral medications

Allergic to penicillins or ampicillin—oral

Allergic to penicillins or ampicillin and unable take oral medications

Amoxicillin

Ampicillin or Cefazolin or Ceftriaxone

Cephalexin11'' or Clindamycin or

Azithromycin or

Clarithromycin

Cefazolin or Ceftriaxone" or Clindamycin

600 mg 500 mg

600 mg IM or IV

50 mg/kg

50 mg/kg IM or IV

50 mg/kg IM or IV

20 mg/kg IM or IV

IM, intramuscular; IV, intravenous.

•Or other first- or second-generation oral cephalosporin in equivalent adult or pediatric dosage.

"Cephalosporins should not be used in an individual with a history cf anaphylaxis, angioedema, or urticaria with penicillins or ampicillin.

With permission from Ref. 7 Copyright 7007. Ameriran Heart Association. All rights rese ved.

The AHA guidelines include suggested antibiotic regimens for dental procedures

where prophylaxis is warranted. Recommended regimens for dental procedures are listed in Table 74-9. These guidelines recommend a single oral or intramuscular/IV dose initiated shortly before the procedure. The regimen for dental procedures consists primarily of a penicillin as first choice, with a cephalosporin for nonanaphylactic penicillin-allergic patients and clindamycin or a macrolide for penicillin-allergic patients. A second prophylactic dose is not recommended. However, if an infection develops at the procedure site, additional antibiotics (i.e., a therapeutic course) may be required.

Stop Headache Drug Free

Stop Headache Drug Free

If you are suffering from headaches, you can make the pain stop just by following some basic but little known principles. Take 15 minutes browsing through this guide and you'll find dozens of tips to gain control in the battle against headache pain.

Get My Free Audio Book


Post a comment