Prophylactic treatment is recommended for patients with congenital heart malformations and rheumatic fever with valvular disease who are undergoing surgical or dental procedures and instrumentation involving mucosal surfaces. The administration of the medication should be timed such that an effective serum level will be present during the 15 min after the mucosal manipulation, when the transient bacteremia occurs. Amoxicillin 50 mg/kg (maximum, 2 g) is given 1 h before the procedure and 25 mg/kg (maximum, 1.5 g) 6 h later. For patients with valvular disease, 2 mg/kg gentamicin is given intravenously or intramuscularly 30 min before the procedure and 8 h later, in addition to the amoxicillin. Erythromycin 20 mg/kg orally (maximum, 800 mg erythromycin ethylsuccinate or 1 g stearate) can be given 2 h before the procedure, with half the dose given 6 h later.
The indications for prophylaxis and treatment options are well outlined in the American Heart Association guidelines for prophylaxis of endocarditis. Cases of endocarditis can occur despite appropriate prophylaxis. Vigilance in performing appropriate blood cultures is warranted in any children with symptoms suggestive of endocarditis.35
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