Endocarditis medical therapy: Difference between revisions

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{{Endocarditis}}
{{Endocarditis}}


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==Overview==
==Overview==
Effective treatment requires identification of the etiologic agent and determination of its antimicrobial susceptibility.
[[Antimicrobial]] therapy is the mainstay of therapy for [[endocarditis]]. [[Empiric therapy|Empiric]] antimicrobial therapy depends on the nature of the [[valve]] (native vs. [[Prosthesis|prosthetic]]) and the onset of [[endocarditis]] following [[valve]] implantation (less than 1 year vs. more than 1 year). In patients with [[endocarditis]], [[Antithrombotic therapy|antithrombotic]] therapy may be administered when needed. The [[prothrombin time]] must be carefully monitored as [[anticoagulant]]s may cause or worsen [[hemorrhage]] in patients with endocarditis. [[Heparin]] administration should be avoided if possible.


==Timing of Initiation of Antibiotics==
==Medical Therapy==
Antibiotic therapy for subacute or indolent disease can be delayed until results of blood cultures are known; in fulminant infection or valvular dysfunction requiring urgent surgical intervention, begin empirical antibiotic therapy promptly after blood cultures have been obtained.
===Empirical Antibiotic Therapy===
*[[Antibiotic]] therapy for subacute [[hemodynamically]] stable disease, and in those who have received [[antibiotics]] recently can be delayed waiting for the results of [[blood culture]]s, as this delay allows an additional blood cultures without the confounding effect of [[Empirical|empiric]] treatment, which is very important in determining the causing [[pathogens]].<ref>{{Cite book  | last1 = Braunwald | first1 = Eugene | last2 = Bonow | first2 = Robert O. | title = Braunwald's heart disease : a textbook of cardiovascular medicin | date = 2012 | publisher = Saunders | location = Philadelphia | isbn = 978-1-4377-2708-1 | pages =  }}</ref>
* On the other hand, the rapid progression of acute cases necessitates the start of [[empirical]] treatment [[antibiotic]] therapy once the [[blood cultures]] have been collected.
* Clinical course of [[infection]] beside the [[epidemiological]] features should be considered upon selecting [[empirical]] treatment regimen.
* Consultation with an [[infectious]] disease specialist for the selection of one of the [[antibiotic]] regimens is recommended (see therapy for culture-negative [[endocarditis]]). <ref name="Baddour-2005">{{Cite journal  | last1 = Baddour | first1 = LM. | last2 = Wilson | first2 = WR. | last3 = Bayer | first3 = AS. | last4 = Fowler | first4 = VG. | last5 = Bolger | first5 = AF. | last6 = Levison | first6 = ME. | last7 = Ferrieri | first7 = P. | last8 = Gerber | first8 = MA. | last9 = Tani | first9 = LY. | title = Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = e394-434 | month = Jun | year = 2005 | doi = 10.1161/CIRCULATIONAHA.105.165564 | PMID = 15956145 }}</ref>


==Duration of Antibiotic Therapy==
===Timing of Initiation of Antibiotics===
The duration for native valve endocarditis is often 4 weeks. For prosthetic valve [[endocarditis]] (including the presence of a valve ring), treatment should be continued for 6 to 8 weeks. For each infective agent, the preferred antimicrobial agent, dose, and duration is listed below.


==Treatment Based Upon Infectious Agent<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F.,  Levison Matthew E.,  Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato,  Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>==
* [[Antibiotic]] therapy for the [[subacute]] or indolent disease can be delayed until results of blood cultures are known.
* In [[fulminant]] infection or [[valvular]] dysfunction requiring urgent surgical intervention, begin [[empirical]] antibiotic therapy promptly after blood cultures have been obtained.


==Penicillin-Susceptible Strep Viridans and Other Nonenterococcal Streptococci==
===Duration of Antibiotic Therapy===


===Preferred regimens===
* The duration of native valve [[endocarditis]] is often 4 weeks.
====[[Penicillin]] G====
* For [[prosthetic]] valve [[endocarditis]] (including the presence of a valve ring), treatment should be continued for 6 to 8 weeks.  
*If Minimum inhibitory concentration [MIC] <0.2 µg/ml.
* For each infective agent, the preferred [[antimicrobial]] agent, dose, and duration are listed below.
*'''Dose''': 12–18 million units I.V. daily in divided doses q. 4 hour for 4 weeks.


====[[Penicillin]] G + [[gentamicin]]====
===Antimicrobial Regimens===
*'''Dose''': [[Penicillin]] G, 12–18 million units I.V. daily in divided doses q. 4 hour for 4 weeks plus [[gentamicin]], 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hour for 2 weeks (peak serum concentration should be ~ 3 µg/ml and trough concentrations < 1 µg/ml).
*[[Infective endocarditis]]<ref>{{Cite journal| doi = 10.1161/CIRCULATIONAHA.105.165564| issn = 1524-4539| volume = 111| issue = 23| pages = –394-434| last1 = Baddour| first1 = Larry M.| last2 = Wilson| first2 = Walter R.| last3 = Bayer| first3 = Arnold S.| last4 = Fowler| first4 = Vance G.| last5 = Bolger| first5 = Ann F.| last6 = Levison| first6 = Matthew E.| last7 = Ferrieri| first7 = Patricia| last8 = Gerber| first8 = Michael A.| last9 = Tani| first9 = Lloyd Y.| last10 = Gewitz| first10 = Michael H.| last11 = Tong| first11 = David C.| last12 = Steckelberg| first12 = James M.| last13 = Baltimore| first13 = Robert S.| last14 = Shulman| first14 = Stanford T.| last15 = Burns| first15 = Jane C.| last16 = Falace| first16 = Donald A.| last17 = Newburger| first17 = Jane W.| last18 = Pallasch| first18 = Thomas J.| last19 = Takahashi| first19 = Masato| last20 = Taubert| first20 = Kathryn A.| last21 = Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease| last22 = Council on Cardiovascular Disease in the Young| last23 = Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia| last24 = American Heart Association| last25 = Infectious Diseases Society of America| title = Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America| journal = Circulation| date = 2005-06-14| pmid = 15956145}}</ref>


====[[Ceftriaxone]]====
:*'''1. Culture-negative endocarditis'''
*'''Dose''': 2 g I.V. daily as a single dose for 2 weeks.
::*'''1.1. Culture-negative, native valve endocarditis'''
:::* Preferred regimen: [[Ampicillin-sulbactam]] 12 g/24h IV q6h 4–6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8h for 4–6 weeks
:::* Alternative regimen: [[Vancomycin]] 30 mg/kg/24h IV q12h for 4–6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8h for 4–6 weeks {{and}} [[Ciprofloxacin]] 1000 mg/24 h PO or 800 mg/24h IV q12h for 4–6 weeks
:::* Pediatric dose: [[Ampicillin-sulbactam]] 300 mg/kg/24h IV q4–6h; [[Gentamicin]] 3 mg/kg/24h IV/IM q8h; [[Vancomycin]] 40 mg/kg/24h q8–12h; [[Ciprofloxacin]] 20–30 mg/kg/24h IV/PO q12h


====[[Vancomycin]]====
::*'''1.2. Culture-negative, prosthetic valve endocarditis (early, ≤ 1 year)'''
*[[Vancomycin]] can be administered to patients with a history of [[penicillin]] [[hypersensitivity]].
:::* Preferred regimen : [[Vancomycin]] 30 mg/kg/24h IV q12h for 6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8h for 2 weeks {{and}} [[Cefepime]] 6 g/24h IV q8h for 6 weeks {{and}} [[Rifampin]] 900 mg/24 h PO/IV q8h for 6 weeks
:::* Pediatric dose: [[Vancomycin]] 40 mg/kg/24h IV q8–12h; [[Gentamicin]] 3 mg/kg/24h IV/IM q8h; [[Cefepime]] 150 mg/kg/24h IV q8h; [[Rifampin]] 20 mg/kg/24 h PO/IV q8h


*'''Dose''': 30 mg/kg I.V. daily in divided doses q. 12 hour for 4 weeks.
::*'''1.3. Culture-negative, prosthetic valve endocarditis (late, > 1 year)'''
:::* Preferred regimen: [[Ampicillin-sulbactam]] 12 g/24h IV q6h 6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8h for 6 weeks
:::* Alternative regimen: [[Vancomycin]] 30 mg/kg/24h IV q12h for 4–6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8h for 6 weeks {{and}} [[Ciprofloxacin]] 1000 mg/24 h PO or 800 mg/24h IV q12h for 6 weeks
:::* Pediatric dose: [[Ampicillin-sulbactam]] 300 mg/kg/24h IV q4h; [[Gentamicin]] 3 mg/kg/24h IV/IM q8h; [[Vancomycin]] 40 mg/kg/24h q8–12h; [[Ciprofloxacin]] 20–30 mg/kg/24h IV/PO q12h


==Relatively Penicillin-Resistant Streptococci==
::*'''1.4. Culture-negative, prosthetic valve endocarditis (early, ≤ 1 year)'''
:::* Preferred regimen: [[Ampicillin-sulbactam]] 12 g/24h IV q6h 4–6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8h for 4–6 weeks {{and}} [[Rifampin]] 900 mg/24 h PO/IV q8h for 6 weeks
:::* Alternative regimen: [[Vancomycin]] 30 mg/kg/24h IV q12h for 4–6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8h for 4–6 weeks {{and}} [[Ciprofloxacin]] 1000 mg/24 h PO or 800 mg/24h IV q12h for 4–6 weeks {{and}} [[Rifampin]] 900 mg/24 h PO/IV q8h for 6 weeks
:::* Pediatric dose: [[Ampicillin-sulbactam]] 300 mg/kg/24h IV q4–6h; [[Gentamicin]] 3 mg/kg/24h IV/IM q8h; [[Vancomycin]] 40 mg/kg/24h IV q8–12h; [[Cefepime]] 150 mg/kg/24h IV q8h; [[Rifampin]] 20 mg/kg/24 h PO/IV q8h


===Preferred regimens===
:* '''2. Pathogen-directed antimicrobial therapy'''
::* '''2.1. Bartonella'''
:::* '''2.1.1. Suspected Bartonella endocarditis'''
::::* Preferred regimen : [[Ceftriaxone sodium]] 2 g/24h IV/IM in 1 dose for 6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8h for 2 weeks {{withorwithout}} [[Doxycycline]] 200 mg/kg/24h IV/PO q12h for 6 weeks
::::* Pediatric dose: [[Ceftriaxone]] 100 mg/kg/24h IV/IM once daily; [[Gentamicin]] 3 mg/kg/24h IV/IM q8h; [[Doxycycline]] 2–4 mg/kg/24h IV/PO q12h; [[Rifampin]] 20 mg/kg/24h PO/IV q12h


====If MIC 0.2–0.5 µg/ml====
:::* '''2.1.2 Documented Bartonella endocarditis'''
::::* Preferred regimen: [[Doxycycline]] 200 mg/24h IV or PO q12h for 6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8h for 2 weeks
::::* Pediatric dose: [[Ceftriaxone]] 100 mg/kg/24h IV/IM once daily; [[Gentamicin]] 3 mg/kg/24h IV/IM q8h; [[Doxycycline]] 2–4 mg/kg/24h IV/PO q12h; [[Rifampin]] 20 mg/kg/24h PO/IV q12h


=====[[Penicillin]] G + [[gentamicin]]=====
::*'''2.3. Enterococcus'''
*'''Dose''': [[Penicillin]] G, 20–30 million units I.V. daily in divided doses q. 4 hour for 4 weeks; [[gentamicin]], 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr for 2 wk (peak serum concentration should be ~ 3 µg/ml and trough concentrations < 1 µg/ml).
:::*'''2.3.1. Endocarditis caused by enterococcal strains susceptible to penicillin, gentamicin, and vancomycin'''
::::* Preferred regimen : [[Ampicillin]] 12 g/24h IV q4h for 4–6 weeks {{or}} [[Penicillin G]] 18–30 million U/24h IV either continuously or q4h for 4–6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8h for 4–6 weeks
::::* Alternative regimen : [[Vancomycin]] 30 mg/kg/24h IV q12h for 6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8h for 6 weeks
::::* Pediatric dose: [[Vancomycin]] 40 mg/kg/24h IV q8–12h; [[Gentamicin]] 3 mg/kg/24h IV/IM q8h


====If MIC > 0.5 µg/ml====
:::* '''2.3.2. Endocarditis caused by enterococcal strains susceptible to penicillin, streptomycin, and vancomycin and resistant to gentamicin'''
::::* Preferred regimen : [[Ampicillin]] 12 g/24h IV q4h for 4–6 weeks {{or}} [[Penicillin G]] 24 million U/24h IV continuously or q4h for 4–6 weeks {{and}} [[Streptomycin]] 15 mg/kg/24h IV/IM q12h for 4–6 weeks
::::* Alternative regimen : [[Vancomycin]] 30 mg/kg/24h IV q12h for 6 weeks {{and}} [[Streptomycin]] 15 mg/kg/24h IV/IM q12h for 6 weeks
::::* Pediatric dose: [[Ampicillin]] 300 mg/kg/24h IV q4–6h; [[Penicillin]] 300 000 U/kg/24h IV q4–6h; [[Streptomycin]] 20–30 mg/kg/24h IV/IM q12h; [[Vancomycin]] 40 mg/kg/24h IV q8–12h; [[Streptomycin]] 20–30 mg/kg/24h IV/IM q12h


=====[[Penicillin]] G + [[gentamicin]]=====
:::* '''2.3.3. Endocarditis caused by enterococcal strains resistant to penicillin and susceptible to aminoglycoside and vancomycin'''
*'''Dose''' is [[penicillin]] G, 20–30 million units I.V. daily in divided doses q. 4 hour for 4 week; [[gentamicin]], 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hour for 4 week (peak serum concentration should be ~ 3 µg/ml and trough concentrations < 1 µg/ml).
::::* β-Lactamase–producing strain
:::::* Preferred regimen: [[Ampicillin-sulbactam]] 12 g/24h IV q6h for 6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8h for 6 weeks
:::::* Alternative regimen : [[Vancomycin]] 30 mg/kg/24h IV q12h for 6 weeks
:::::* Pediatric dose: [[Ampicillin-sulbactam]] 300 mg/kg/24h IV q6h; [[Gentamicin]] 3 mg/kg/24h IV/IM q8h
::::* Intrinsic penicillin resistance
:::::* Preferred regimen: [[Vancomycin]] 30 mg/kg/24h IV q12h for 6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8h for 6 weeks
:::::* Pediatric dose: [[Vancomycin]] 40 mg/kg/24h IV q8–12h; [[Gentamicin]] 3 mg/kg/24h IV/IM q8h


=====[[Vancomycin]]=====
:::* '''2.3.4. Endocarditis caused by enterococcal strains resistant to penicillin, gentamicin, and vancomycin'''
*Regimen for patients with history of [[penicillin]] [[hypersensitivity]].
::::* Enterococcus faecium
*'''Dose''': 30 mg/kg I.V. daily in divided doses q. 12 hour for 4 weeks.
:::::* Preferred regimen : [[Linezolid]] 1200 mg/24h IV/PO q12h for ≥ 8 weeks {{or}} [[Quinupristin-Dalfopristin]] 22.5 mg/kg/24h IV q8h for 8 weeks
::::* Enterococcus faecalis
:::::* Preferred regimen : [[Imipenem/cilastatin]] 2 g/24h IV q6h for ≥ 8 weeks {{and}} [[Ampicillin]] 12 g/24h IV q4h for ≥ 8 weeks  {{or}} [[Ceftriaxone sodium]] 4 g/24h IV/IM q12h for ≥ 8 weeks {{and}} [[Ampicillin]] 12 g/24h IV q4h for ≥ 8 weeks
:::::* Pediatric dose: [[Linezolid]] 30 mg/kg/24h IV/PO q8h; [[Quinupristin-Dalfopristin]] 22.5 mg/kg/24h IV q8h; [[Imipenem/cilastatin]] 60–100 mg/kg/24h IV q6h; [[Ampicillin]] 300 mg/kg/24h IV q4–6h; [[Ceftriaxone]] 100 mg/kg/24h IV/IM q12h


==Enterococci==
::* '''2.4. HACEK organisms'''
In general, treatment of [[enterococcal]] endocarditis requires combination therapy with two antibiotics:
:::* '''2.4.1. Endocarditis caused by Haemophilus, Aggregatibacter (Actinobacillus), Cardiobacterium, Eikenella corrodens, or Kingella'''
===Preferred regimens===
::::* Preferred regimen : [[Ceftriaxone sodium]] 2 g/24h IV/IM in 1 dose for 4 weeks {{or}} [[Ampicillin]] 12 g/24h IV q6h for 4 weeks {{or}} [[Ciprofloxacin]] 1000 mg/24h PO or 800 mg/24h IV q12h for 4 weeks
====[[Penicillin]] G + [[gentamicin]]====
::::* Pediatric dose: [[Ceftriaxone]] 100 mg/kg/24h IV/IM once daily; [[Ampicillin-sulbactam]] 300 mg/kg/24h IV divided into 4 or 6 equally divided doses; [[Ciprofloxacin]] 20–30 mg/kg/24h IV/PO q12h
*'''Dose''' is [[penicillin]] G, 20–30 million units I.V. daily in divided doses q. 4 hr for 4–6 weeks; [[gentamicin]], 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hour for 4–6 weeks (peak serum concentration should be ~ 3 µg/ml and trough concentrations < 1 µg/ml).


====[[Ampicillin]] + [[gentamicin]]====
::* '''2.5. Staphylococcus'''
*'''Dose''' is [[ampicillin]], 12 g I.V. daily in divided doses q. 4 hour for 4–6 weeks; [[gentamicin]], dose as above.
:::* '''2.5.1. Native valve endocarditis caused by oxacillin-susceptible staphylococci'''
::::* Preferred regimen (1): [[Nafcillin]] or [[Oxacillin]] 12 g/24h IV q4–6h for 6 weeks {{withorwithout}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8–12h for 3–5 days
::::* Preferred regimen (2): [[Cefazolin]] 6 g/24h IV q8h for 6 weeks {{withorwithout}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8–12h for 3–5 days
::::* Pediatric dose: [[Nafcillin]] or [[Oxacillin]] 200 mg/kg/24h IV q4–6h; [[Gentamicin]] 3 mg/kg/24h IV/IM q8h; [[Cefazolin]] 100 mg/kg/24h IV q8h; [[Gentamicin]] 3 mg/kg/24h IV/IM q8h


====[[Vancomycin]] + [[gentamicin]]====
:::* '''2.5.2. Native valve endocarditis caused by oxacillin-resistant staphylococci'''
*This regimen is for patients with history of [[penicillin]] [[hypersensitivity]].
::::* Preferred regimen: [[Vancomycin]] 30 mg/kg/24h IV q12h for 6 weeks
*'''Dose''': [[Vancomycin]], 30 mg/kg I.V. daily in divided doses q. 12 hour for 4–6 weeks; [[gentamicin]], dose as above.
::::* Pediatric dose: [[Vancomycin]] 40 mg/kg/24h IV q8–12h


==Staphylococci (Methicillin Susceptible) in the Absence of Prosthetic Material==
:::* '''2.5.3. Prosthetic valve endocarditis caused by oxacillin-susceptible staphylococci'''
::::* Preferred regimen: [[Nafcillin]] or [[Oxacillin]] 12 g/24h IV q4h for ≥ 6 weeks {{and}} [[Rifampin]] 900 mg/24h IV/PO q8h for ≥ 6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8–12h for 2 weeks
::::* Pediatric dose: [[Nafcillin]] or [[Oxacillin]] 200 mg/kg/24h IV q4–6h; [[Rifampin]] 20 mg/kg/24h IV/PO q8h; [[Gentamicin]] 3 mg/kg/24h IV/IM q8h


===Preferred regimens===
:::* '''2.5.4 Prosthetic valve endocarditis caused by oxacillin-resistant staphylococci'''
====[[Nafcillin]] or [[oxacillin]] + [[gentamicin]] (optional)====
::::* Preferred regimen: [[Vancomycin]] 30 mg/kg 24 h q12h for ≥ 6 weeks {{and}} [[Rifampin]] 900 mg/24h IV/PO q8h for ≥ 6 weeks {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM q8–12h for 2 weeks
*'''Dose''': [[Nafcillin]] or [[oxacillin]], 12 g I.V. daily in divided doses q. 4 hour for 4–6 weeks; [[gentamicin]], 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr for 3–5 days (peak serum concentration should be ~ 3 µg/ml and trough concentrations <1 µg/ml).
::::* Pediatric dose: [[Vancomycin]] 40 mg/kg/24h IV q8–12h; [[Rifampin]] 20 mg/kg/24h IV/PO q8h (up to adult dose); [[Gentamicin]] 3 mg/kg/24h IV or IM q8h


====[[Cefazolin]] + [[gentamicin]] (optional)====
::* '''2.6 Viridans group streptococci and Streptococcus bovis'''
*Alternative regimen for patients with history of [[penicillin]] [[hypersensitivity]].
:::* '''2.6.1. Native valve endocarditis caused by highly penicillin-susceptible viridans group streptococci and Streptococcus bovis (MIC ≤ 0.12 μg/mL)'''
*'''Dose''': [[Cefazolin]], 12 g I.V. daily in divided doses q. 4 hour for 4–6 weeks; [[gentamicin]], dose as above.
::::* Preferred regimen: [[Penicillin G]] 12–18 million U/24h IV either continuously or q4–6h for 4 weeks {{or}} [[Ceftriaxone]] 2 g/24h IV/IM in 1 dose for 4 weeks
::::* Alternative regimen (1): ([[Penicillin G]] 12–18 million U/24h IV either continuously or q4h for 2 weeks {{or}} [[Ceftriaxone]] 2 g/24h IV/IM in 1 dose for 2 weeks) {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM in 1 dose for 2 weeks
::::* Alternative regimen (2): [[Vancomycin]] 30 mg/kg/24h IV q12h not to exceed 2 g/24h for 4 weeks
::::* Pediatric dose: [[Penicillin G]] 200,000 U/kg/24h IV q4–6h; [[Ceftriaxone]] 100 mg/kg/24h IV/IM in 1 dose; [[Gentamicin]] 3 mg/kg/24h IV/IM in 1 dose or q8h; [[Vancomycin]] 40 mg/kg/24h IV q8–12h


====[[Vancomycin]]====
:::* '''2.6.2. Native valve endocarditis caused by relatively penicillin-resistant viridans group streptococci and Streptococcus bovis (MIC > 0.12 to ≤ 0.5 μg/mL)'''
*Alternative regimen for patients with history of [[penicillin]] [[hypersensitivity]].
::::* Preferred regimen (1): ([[Penicillin G]] 24 million U/24h IV either continuously or q4–6h for 4 weeks {{or}} [[Ceftriaxone]] 2 g/24h IV/IM in 1 dose for 4 weeks) {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM in 1 dose for 2 weeks
'''Dose''': 30 mg/kg I.V. daily in divided doses q. 12 hr for 4–6 weeks.
::::* Preferred regimen (2): [[Vancomycin]] 30 mg/kg/24h IV q12h not to exceed 2 g/24h for 4 weeks
::::* Pediatric dose: [[Penicillin G]] 200,000 U/kg/24h IV q4–6h; [[Ceftriaxone]] 100 mg/kg/24h IV/IM in 1 dose; [[Gentamicin]] 3 mg/kg/24h IV/IM in 1 dose or q8h; [[Vancomycin]] 40 mg/kg/24h IV q8–12h


==Staphylococci (Methicillin Resistant) in the Absence of Prosthetic Material==
:::* '''2.6.3. Prosthetic valve endocarditis caused by highly penicillin-susceptible viridans group streptococci and Streptococcus bovis (MIC ≤ 0.12 μg/mL)'''
::::* Preferred regimen (1): ([[Penicillin G]] 24 million U/24h IV either continuously or q4–6h for 6 weeks {{or}} [[Ceftriaxone]] 2 g/24h IV/IM in 1 dose for 6 weeks) {{withorwithout}} [[Gentamicin]] 3 mg/kg/24h IV/IM in 1 dose for 2 weeks
::::* Preferred regimen (2): [[Vancomycin]] 30 mg/kg/24h IV q12h not to exceed 2 g/24h for 6 weeks
::::* Pediatric dose: [[Penicillin G]] 200,000 U/kg/24h IV q4–6h; [[Ceftriaxone]] 100 mg/kg/24h IV/IM in 1 dose; [[Gentamicin]] 3 mg/kg/24h IV/IM in 1 dose or q8h; [[Vancomycin]] 40 mg/kg/24h IV q8–12h


===Preferred regimens===
:::* '''2.6.4. Prosthetic valve endocarditis caused by relatively penicillin-resistant viridans group streptococci and Streptococcus bovis (MIC > 0.12 μg/mL)'''
*[[Vancomycin]]: '''Dose'''is 30 mg/kg I.V. daily in divided doses q. 12 hour for 4–6 weeks.
::::* Preferred regimen (1): ([[Penicillin G]] 24 million U/24h IV either continuously or q4–6h for 6 weeks {{or}} [[Ceftriaxone]] 2 g/24h IV/IM in 1 dose for 6 weeks) {{and}} [[Gentamicin]] 3 mg/kg/24h IV/IM in 1 dose for 2 weeks
::::* Preferred regimen (2): [[Vancomycin]] 30 mg/kg/24h IV q12h not to exceed 2 g/24h for 6 weeks
::::* Pediatric dose: [[Penicillin G]] 200,000 U/kg/24h IV q4–6h; [[Ceftriaxone]] 100 mg/kg/24h IV/IM in 1 dose; [[Gentamicin]] 3 mg/kg/24h IV/IM in 1 dose or q8h; [[Vancomycin]] 40 mg/kg/24h IV q8–12h


==Staphylococci (Methicillin Susceptible) in the Presence of Prosthetic Material==
==Antithrombotic Therapy==


===Preferred regimens===
*[[Anticoagulant]]s can cause or worsen [[hemorrhage]] in patients with [[endocarditis]] but maybe carefully administered when needed.<ref name="Baddour">{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F.,  Levison Matthew E.,  Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato,  Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>
*[[Nafcillin]] or [[oxacillin]] + [[rifampin]] + [[gentamicin]]. '''Dose''' is [[nafcillin]] or [[oxacillin]], 12 g I.V. daily in divided doses q. 4 hour for 6–8 weeks; rifampin, 300 mg p.o., q. 8 hour for 6–8 weeks; [[gentamicin]] (administer during the initial 2 weeks), 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hour for 2 weeks.
* The [[prothrombin time]] should be carefully maintained at an [[INR]] of 2.0–3.0.
*[[Anticoagulation]] should be reversed immediately in the event of [[CNS]] [[complications]] and interrupted for 1–2 weeks after an acute [[embolic]] [[stroke]].
* Avoid [[heparin]] administration during active [[endocarditis]] if possible.


==Staphylococci (Methicillin Resistant) in the Presence of Prosthetic Material==


===Preferred regimens===
{| class="wikitable"
*[[Vancomycin]] + [[rifampin]] + [[gentamicin]]. '''Dose''' is [[vancomycin]], 30 mg/kg I.V. daily in divided doses q. 12 hour for 6–8 weeks; [[rifampin]], 300 mg p.o., q. 8 hour for 6–8 weeks; [[gentamicin]] (administer during the initial 2 weeks), 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hour for 2 weeks.
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| bgcolor="LightGreen" |
|-
| bgcolor="LightGreen" |"'''1.''' Penicillin G or Amoxicilline or Ceftriaxonef''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  A]])''"
| bgcolor="LightGreen" |
|-
| bgcolor="LightGreen" |”'''2.'''  (Paste guideline here) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
| bgcolor="LightGreen" |
|-
| bgcolor="LightGreen" |”'''3.'''  (Paste guideline here) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
| bgcolor="LightGreen" |
|}


==[[HACEK organism|HACEK Organisms]]==
==References==


*[[Ceftriaxone]] or another [[cephalosporin|third-generation cephalosporin]]. '''Dose''' is 2 g I.V. daily as a single dose for 4 weeks.
{{reflist|2}}
 
==References==
{{Reflist|2}}


[[Category:Emergency medicine]]
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Latest revision as of 22:48, 5 March 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

Antimicrobial therapy is the mainstay of therapy for endocarditis. Empiric antimicrobial therapy depends on the nature of the valve (native vs. prosthetic) and the onset of endocarditis following valve implantation (less than 1 year vs. more than 1 year). In patients with endocarditis, antithrombotic therapy may be administered when needed. The prothrombin time must be carefully monitored as anticoagulants may cause or worsen hemorrhage in patients with endocarditis. Heparin administration should be avoided if possible.

Medical Therapy

Empirical Antibiotic Therapy

Timing of Initiation of Antibiotics

  • Antibiotic therapy for the subacute or indolent disease can be delayed until results of blood cultures are known.
  • In fulminant infection or valvular dysfunction requiring urgent surgical intervention, begin empirical antibiotic therapy promptly after blood cultures have been obtained.

Duration of Antibiotic Therapy

  • The duration of native valve endocarditis is often 4 weeks.
  • For prosthetic valve endocarditis (including the presence of a valve ring), treatment should be continued for 6 to 8 weeks.
  • For each infective agent, the preferred antimicrobial agent, dose, and duration are listed below.

Antimicrobial Regimens

  • 1. Culture-negative endocarditis
  • 1.1. Culture-negative, native valve endocarditis
  • 1.2. Culture-negative, prosthetic valve endocarditis (early, ≤ 1 year)
  • 1.3. Culture-negative, prosthetic valve endocarditis (late, > 1 year)
  • 1.4. Culture-negative, prosthetic valve endocarditis (early, ≤ 1 year)
  • 2. Pathogen-directed antimicrobial therapy
  • 2.1. Bartonella
  • 2.1.1. Suspected Bartonella endocarditis
  • 2.1.2 Documented Bartonella endocarditis
  • 2.3. Enterococcus
  • 2.3.1. Endocarditis caused by enterococcal strains susceptible to penicillin, gentamicin, and vancomycin
  • Preferred regimen : Ampicillin 12 g/24h IV q4h for 4–6 weeks OR Penicillin G 18–30 million U/24h IV either continuously or q4h for 4–6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 4–6 weeks
  • Alternative regimen : Vancomycin 30 mg/kg/24h IV q12h for 6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 6 weeks
  • Pediatric dose: Vancomycin 40 mg/kg/24h IV q8–12h; Gentamicin 3 mg/kg/24h IV/IM q8h
  • 2.3.2. Endocarditis caused by enterococcal strains susceptible to penicillin, streptomycin, and vancomycin and resistant to gentamicin
  • 2.3.3. Endocarditis caused by enterococcal strains resistant to penicillin and susceptible to aminoglycoside and vancomycin
  • β-Lactamase–producing strain
  • Intrinsic penicillin resistance
  • 2.3.4. Endocarditis caused by enterococcal strains resistant to penicillin, gentamicin, and vancomycin
  • Enterococcus faecium
  • Enterococcus faecalis
  • 2.4. HACEK organisms
  • 2.4.1. Endocarditis caused by Haemophilus, Aggregatibacter (Actinobacillus), Cardiobacterium, Eikenella corrodens, or Kingella
  • 2.5. Staphylococcus
  • 2.5.1. Native valve endocarditis caused by oxacillin-susceptible staphylococci
  • 2.5.2. Native valve endocarditis caused by oxacillin-resistant staphylococci
  • Preferred regimen: Vancomycin 30 mg/kg/24h IV q12h for 6 weeks
  • Pediatric dose: Vancomycin 40 mg/kg/24h IV q8–12h
  • 2.5.3. Prosthetic valve endocarditis caused by oxacillin-susceptible staphylococci
  • 2.5.4 Prosthetic valve endocarditis caused by oxacillin-resistant staphylococci
  • Preferred regimen: Vancomycin 30 mg/kg 24 h q12h for ≥ 6 weeks AND Rifampin 900 mg/24h IV/PO q8h for ≥ 6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8–12h for 2 weeks
  • Pediatric dose: Vancomycin 40 mg/kg/24h IV q8–12h; Rifampin 20 mg/kg/24h IV/PO q8h (up to adult dose); Gentamicin 3 mg/kg/24h IV or IM q8h
  • 2.6 Viridans group streptococci and Streptococcus bovis
  • 2.6.1. Native valve endocarditis caused by highly penicillin-susceptible viridans group streptococci and Streptococcus bovis (MIC ≤ 0.12 μg/mL)
  • Preferred regimen: Penicillin G 12–18 million U/24h IV either continuously or q4–6h for 4 weeks OR Ceftriaxone 2 g/24h IV/IM in 1 dose for 4 weeks
  • Alternative regimen (1): (Penicillin G 12–18 million U/24h IV either continuously or q4h for 2 weeks OR Ceftriaxone 2 g/24h IV/IM in 1 dose for 2 weeks) AND Gentamicin 3 mg/kg/24h IV/IM in 1 dose for 2 weeks
  • Alternative regimen (2): Vancomycin 30 mg/kg/24h IV q12h not to exceed 2 g/24h for 4 weeks
  • Pediatric dose: Penicillin G 200,000 U/kg/24h IV q4–6h; Ceftriaxone 100 mg/kg/24h IV/IM in 1 dose; Gentamicin 3 mg/kg/24h IV/IM in 1 dose or q8h; Vancomycin 40 mg/kg/24h IV q8–12h
  • 2.6.2. Native valve endocarditis caused by relatively penicillin-resistant viridans group streptococci and Streptococcus bovis (MIC > 0.12 to ≤ 0.5 μg/mL)
  • Preferred regimen (1): (Penicillin G 24 million U/24h IV either continuously or q4–6h for 4 weeks OR Ceftriaxone 2 g/24h IV/IM in 1 dose for 4 weeks) AND Gentamicin 3 mg/kg/24h IV/IM in 1 dose for 2 weeks
  • Preferred regimen (2): Vancomycin 30 mg/kg/24h IV q12h not to exceed 2 g/24h for 4 weeks
  • Pediatric dose: Penicillin G 200,000 U/kg/24h IV q4–6h; Ceftriaxone 100 mg/kg/24h IV/IM in 1 dose; Gentamicin 3 mg/kg/24h IV/IM in 1 dose or q8h; Vancomycin 40 mg/kg/24h IV q8–12h
  • 2.6.3. Prosthetic valve endocarditis caused by highly penicillin-susceptible viridans group streptococci and Streptococcus bovis (MIC ≤ 0.12 μg/mL)
  • Preferred regimen (1): (Penicillin G 24 million U/24h IV either continuously or q4–6h for 6 weeks OR Ceftriaxone 2 g/24h IV/IM in 1 dose for 6 weeks) ± Gentamicin 3 mg/kg/24h IV/IM in 1 dose for 2 weeks
  • Preferred regimen (2): Vancomycin 30 mg/kg/24h IV q12h not to exceed 2 g/24h for 6 weeks
  • Pediatric dose: Penicillin G 200,000 U/kg/24h IV q4–6h; Ceftriaxone 100 mg/kg/24h IV/IM in 1 dose; Gentamicin 3 mg/kg/24h IV/IM in 1 dose or q8h; Vancomycin 40 mg/kg/24h IV q8–12h
  • 2.6.4. Prosthetic valve endocarditis caused by relatively penicillin-resistant viridans group streptococci and Streptococcus bovis (MIC > 0.12 μg/mL)
  • Preferred regimen (1): (Penicillin G 24 million U/24h IV either continuously or q4–6h for 6 weeks OR Ceftriaxone 2 g/24h IV/IM in 1 dose for 6 weeks) AND Gentamicin 3 mg/kg/24h IV/IM in 1 dose for 2 weeks
  • Preferred regimen (2): Vancomycin 30 mg/kg/24h IV q12h not to exceed 2 g/24h for 6 weeks
  • Pediatric dose: Penicillin G 200,000 U/kg/24h IV q4–6h; Ceftriaxone 100 mg/kg/24h IV/IM in 1 dose; Gentamicin 3 mg/kg/24h IV/IM in 1 dose or q8h; Vancomycin 40 mg/kg/24h IV q8–12h

Antithrombotic Therapy


Class I
"1. Penicillin G or Amoxicilline or Ceftriaxonef(Level of Evidence: A)"
”2. (Paste guideline here) (Level of Evidence: C)"
”3. (Paste guideline here) (Level of Evidence: B)"

References

  1. ↑ Braunwald, Eugene; Bonow, Robert O. (2012). Braunwald's heart disease : a textbook of cardiovascular medicin. Philadelphia: Saunders. ISBN 978-1-4377-2708-1.
  2. ↑ Baddour, LM.; Wilson, WR.; Bayer, AS.; Fowler, VG.; Bolger, AF.; Levison, ME.; Ferrieri, P.; Gerber, MA.; Tani, LY. (2005). "Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America". Circulation. 111 (23): e394–434. doi:10.1161/CIRCULATIONAHA.105.165564. PMID 15956145. Unknown parameter |month= ignored (help)
  3. ↑ Baddour, Larry M.; Wilson, Walter R.; Bayer, Arnold S.; Fowler, Vance G.; Bolger, Ann F.; Levison, Matthew E.; Ferrieri, Patricia; Gerber, Michael A.; Tani, Lloyd Y.; Gewitz, Michael H.; Tong, David C.; Steckelberg, James M.; Baltimore, Robert S.; Shulman, Stanford T.; Burns, Jane C.; Falace, Donald A.; Newburger, Jane W.; Pallasch, Thomas J.; Takahashi, Masato; Taubert, Kathryn A.; Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease; Council on Cardiovascular Disease in the Young; Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia; American Heart Association; Infectious Diseases Society of America (2005-06-14). "Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America". Circulation. 111 (23): –394-434. doi:10.1161/CIRCULATIONAHA.105.165564. ISSN 1524-4539. PMID 15956145.
  4. ↑ Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A. (2005). "Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America". Circulation. 111 (23): 3167–84. PMID 15956145.
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