Endocarditis medical therapy: Difference between revisions

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Latest revision as of 22:48, 5 March 2020

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

Antibiotic therapy for subacute hemodynamically stable disease, and in those who have received antibiotics recently can be delayed waiting for the results of blood cultures, as this delay allows an additional blood cultures without the confounding effect of empiric treatment, which is very important in determining the causing pathogens.^[1]
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). ^[2]

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

Infective endocarditis^[3]

1. Culture-negative endocarditis

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

1.2. Culture-negative, prosthetic valve endocarditis (early, ≤ 1 year)

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

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

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

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 ± 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

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

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

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

2.3.3. Endocarditis caused by enterococcal strains resistant to penicillin and susceptible to aminoglycoside and vancomycin

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

2.3.4. Endocarditis caused by enterococcal strains resistant to penicillin, gentamicin, and vancomycin

Enterococcus faecium

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

2.4. HACEK organisms

2.4.1. Endocarditis caused by Haemophilus, Aggregatibacter (Actinobacillus), Cardiobacterium, Eikenella corrodens, or Kingella

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
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

2.5. Staphylococcus

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 ± 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 ± 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

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

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

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

Anticoagulants can cause or worsen hemorrhage in patients with endocarditis but maybe carefully administered when needed.^[4]
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.

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

↑ Braunwald, Eugene; Bonow, Robert O. (2012). Braunwald's heart disease : a textbook of cardiovascular medicin. Philadelphia: Saunders. ISBN 978-1-4377-2708-1.
↑ 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)
↑ 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.
↑ 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.

[1] Braunwald, Eugene; Bonow, Robert O. (2012). Braunwald's heart disease : a textbook of cardiovascular medicin. Philadelphia: Saunders. ISBN 978-1-4377-2708-1.

[Baddour-2005-2] 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.

[Baddour-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.

[1]

[2]

[3]

[4]

@@ Line 2: / Line 2: @@
 {{Endocarditis}}
-{{CMG}}; '''Associate Editors-in-Chief:''' {{CZ}}; {{AZ}}
+{{CMG}}; '''Associate Editors-in-Chief:''' {{CZ}}
 ==Overview==
-[[Blood cultures]] should be drawn prior to instituting antibiotics to identify the etiologic agent and to determine its antimicrobial susceptibility.  Older antibiotics such as [[penicillin]] G, [[ampicillin]], [[nafcillin]], [[cefazolin]], [[gentamycin]], [[ceftriaxone]], [[rifampin]] and [[vancomycin]] are the mainstays of therapy.
+[[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.
-==Empirical Antibiotic Therapy==
+* [[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.
-*Antibiotic therapy for subacute hemodynamically stable disease, and in those who have received antibiotics recently can be delayed waiting the results of blood cultures, as this delay allows an additional blood cultures without the confounding effect of 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>
+===Duration of Antibiotic Therapy===
-*On the other hand, the rapid progression of acute cases necessitate the start of empirical treatment antibiotic therapy once the blood cultures have been collected.
+* 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.
-*Empirical therapy is needed for all likely pathogens, certain antibiotic agents, including aminoglycosides, is preferably avoided for its toxic effects.
+===Antimicrobial Regimens===
+*[[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>
-*Clinical course of infection beside the epidemiological features should be considered upon selecting empirical treatment regimen.
+:*'''1. Culture-negative endocarditis'''
+::*'''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
-*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>
+::*'''1.2. Culture-negative, prosthetic valve endocarditis (early, ≤ 1 year)'''
+:::* 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
-==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>==
+::*'''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
-===<u>Penicillin-Susceptible Strep Viridans and Other Nonenterococcal Streptococci</u>===
+::*'''1.4. Culture-negative, prosthetic valve endocarditis (early, ≤ 1 year)'''
-====Penicillin G====
+:::* 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
-*If Minimum inhibitory concentration [MIC] <0.2 µg/ml.
+:::* 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
-*Dose: 12–18 million units I.V. daily in divided doses q. 4 hour for 4 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
-====Penicillin G + Gentamicin====
+:* '''2. Pathogen-directed antimicrobial therapy'''
-*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).
+::* '''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
-====Ceftriaxone====
+:::* '''2.1.2 Documented Bartonella endocarditis'''
-*Dose: 2 g I.V. daily as a single dose for 2 weeks.
+::::* 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
-====Vancomycin====
+::*'''2.3. Enterococcus'''
-*Vancomycin can be administered to patients with a history of penicillin [[hypersensitivity]].
+:::*'''2.3.1. Endocarditis caused by enterococcal strains susceptible to penicillin, gentamicin, and vancomycin'''
-*Dose: 30 mg/kg I.V. daily in divided doses q. 12 hour for 4 weeks.
+::::* 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
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: center; width:48em" cellpadding="0" cellspacing="0";
+:::* '''2.3.2. Endocarditis caused by enterococcal strains susceptible to penicillin, streptomycin, and vancomycin and resistant to gentamicin'''
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Native Valve Endocarditis Caused by Highly Penicillin-Susceptible <br> Viridans Group Streptococci and Streptococcus bovis}}''
+::::* 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
-!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''Preferred Regimen'''''
+::::* 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
-|-
-! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
-|-
+:::* '''2.3.3. Endocarditis caused by enterococcal strains resistant to penicillin and susceptible to aminoglycoside and vancomycin'''
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[penicillin G sodium]] 12–18 million U/24 h IV either continuously or in 4-6 equally divided doses x 4 Wks'''''<BR>''OR''<BR> ▸ '''''[[Ceftriaxone|Ceftriaxone sodium]] 2 g/24 h IV/IM in 1 dose x 4 Wks'''''
+::::* 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
-! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
+:::::* 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
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[penicillin G sodium]] 200 000 U/kg q24h IV either continuously or in 4-6 equally divided doses x 4 Wks'''''<BR>''OR''<BR> ▸'''''[[Ceftriaxone]] 100 mg/kg q24 h IV/IM in 1 dose x 4 Wks'''''
+::::* 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
-!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''Alternative Regimen'''''
+:::::* Pediatric dose: [[Vancomycin]] 40 mg/kg/24h IV q8–12h; [[Gentamicin]] 3 mg/kg/24h IV/IM q8h
-|-
-! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
-|-
-|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''[[Vancomycin|Vancomycin hydrochloride]] 15 mg/kg q12h IV x 4 Wks''''' <br> Doses should not to exceed 2 g/24 h unless concentrations in serum are inappropriately low
-|-
-! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
-|-
-|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left |▸'''''[[Vancomycin|Vancomycin hydrochloride]] 40 mg/kg per 24 h IV in 2–3 equally divided doses'''''
-|-
-|}
+:::* '''2.3.4. Endocarditis caused by enterococcal strains resistant to penicillin, gentamicin, and vancomycin'''
+::::* Enterococcus faecium
+:::::* 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
-===Endocarditis of Prosthetic Valves or Other Prosthetic Material Caused by Viridans Group Streptococci and Streptococcus bovis===
+::* '''2.4. HACEK organisms'''
+:::* '''2.4.1. Endocarditis caused by Haemophilus, Aggregatibacter (Actinobacillus), Cardiobacterium, Eikenella corrodens, or Kingella'''
+::::* 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
+::::* 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
+::* '''2.5. Staphylococcus'''
+:::* '''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
+:::* '''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'''
-|-
+::::* 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
-| valign=top |
+::::* 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
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:48em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Penicillin-susceptible strain (minimum inhibitory concentration ≤ 0.12 g/mL)}}''
-|-
-!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''Preferred Regimen'''''
-|-
-! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
-|-
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[penicillin G sodium]] 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 6 wks'''''<BR>''OR''<BR> ▸ '''''[[Ceftriaxone]] 2 g/24 h IV/IM in 1 dose x 6 wks'''''
-|-
-|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''WITH OR WITHOUT''
-|-
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin|Gentamicin sulfate]] 3 mg/kg per 24 h IV/IM in 1 dose x 2 wks'''''
-|-
-! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
-|-
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium]] 300 000 U/kg per 24 h IV in 4–6 equally divided doses'''''<BR>''OR''<BR> ▸ '''''[[Ceftriaxone]] 100 mg/kg IV/IM once daily'''''
-|-
-|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''WITH OR WITHOUT''
-|-
+:::* '''2.5.4 Prosthetic valve endocarditis caused by oxacillin-resistant staphylococci'''
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 3 mg/kg per
+::::* 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
-h IV/IM, in 1 dose or 3 equally divided doses'''''
+::::* 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
-|-
-!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''Alternative Regimen'''''
-|-
-! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
-|-
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin|Vancomycin
-hydrochloride]] 30 mg/kg per 24 h IV in 2 equally divided doses x 6 wks'''''
-|-
-! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
-|-
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''40 mg/kg per 24 h IV or in 2 or 3 equally divided doses'''''
-|-
-|}
-|}
+::* '''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
-| valign=top |
+::::* Preferred regimen (2): [[Vancomycin]] 30 mg/kg/24h IV q12h not to exceed 2 g/24h for 4 weeks
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:48em" cellpadding="0" cellspacing="0";
+::::* 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
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Penicillin relatively or fully resistant strain (minimum inhibitory concentration >0.12 >μg/mL))}}''
-|-
-!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[penicillin G sodium]] 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 6 wks'''''<BR>''OR''<BR> ▸ '''''[[Ceftriaxone]] 2 g/24 h IV/IM in 1 dose x 6 wks'''''
-|-
-|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''PLUS''
-|-
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin|Gentamicin sulfate]] 3 mg/kg per 24 h IV/IM in 1 dose x 6 wks'''''
-|-
-! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
-|-
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G sodium]] 300 000 U/kg per 24 h IV in 4–6 equally divided doses'''''
-|-
-!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''Alternative Regimen'''''
-|-
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin|Vancomycin
-hydrochloride]] 30 mg/kg per 24 h IV in 2 equally divided doses x 6 wks'''''
-|-
-! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
-|-
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''40 mg/kg per 24 h IV or in 2 or 3 equally divided doses'''''
-|-
-|}
-|}
-===<u>Relatively Penicillin-Resistant Streptococci</u>===
+:::* '''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
+:::* '''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==
-|-
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:48em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Relatively Penicillin-Resistant Streptococci, MIC 0.2–0.5 µg/ml}}''
-|-
-!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''Adult''':'''''[[Penicillin G potassium|Aqueous crystalline penicillin G sodium]] 24 million U/24 h IV either continuously or in 4–6 equally divided doses X 4 Wks '''''<BR> ▸ '''Pediatrics''':'''''[[Penicillin G potassium|Aqueous crystalline penicillin G sodium]] 300 000 U/24 h IV in 4–6 equally divided doses X 4 Wks '''''<BR>''OR'' <BR>▸'''Adult''':'''''[[Ceftriaxone]] 2 g/24 h IV/IM in 1 dose''''' <BR> ▸'''Pediatrics''':'''''[[Ceftriaxone]] 100 mg/kg per 24 h IV/IM in 1 dose'''''
-|-
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | AND
-|-
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''Adult''':'''''[[Gentamicin]] 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr X 2 Wks  '''''<BR> ▸ '''Pediatrics''': '''''[[Gentamicin]] 3 mg/kg per 24 h IV/IM in 1 dose or 3 equally divided doses X 2 Wks'''''
-|-
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Relatively Penicillin-Resistant Streptococci, MIC > 0.5 µg/ml, consider Enterococcal regimen}}''
-|-
-!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''Adult''':'''''[[Penicillin G potassium|Aqueous crystalline penicillin G sodium]] 24 million U/24 h IV either continuously or in 4–6 equally divided doses X 4 Wks '''''
-|-
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | AND
-|-
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''Adult''':'''''[[Gentamicin]] 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr X 2 Wks  '''''
-|-
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Unable to tolerate [[Penicillin G potassium|Aqueous crystalline penicillin G sodium]] or [[Ceftriaxone]] }}''
-|-
-!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''Preferred Regimen'''''
-|-
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''Adult''': '''''[[Vancomycin]] 30 mg/kg per 24 h IV in 2 equally divided doses not to exceed 2 g/24 h, unless serum concentrations are inappropriately low  '''''
-|-
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''Pediatrics''': '''''[[Vancomycin]] 40 mg/kg 24 h in 2 or 3 equally divided doses X 4 Wks '''''
-|-
-|}
-|}
-===<u>Enterococci</u>===
-In general, treatment of [[enterococcal]] endocarditis requires combination therapy with two antibiotics:
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: center; width:48em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Native Valve Endocarditis Caused by Highly Penicillin-Susceptible Viridans Group Streptococci and Streptococcus bovis}}''
-|-
-!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''Preferred Regimen'''''
-|-
-! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
-|-
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[penicillin G sodium]] 20–30 million units I.V. daily in 4-6 equally divided doses q. 4 hr X 4–6 Wks'''''<br> ''AND'' <br> ▸'''''[[Gentamicin|Gentamicin sulfate]] 3 mg/kg per 24 h 3 equally divided doses IV/IM in 1 dose X 4-6 Wks'''''
-|-
-|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''OR''
-|-
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 12 g I.V. daily in divided doses q. 4 hour X 4–6 Wks'''''<br> ''AND'' <br> ▸'''''[[Gentamicin|Gentamicin sulfate]] 3 mg/kg per 24 h 3 equally divided doses IV/IM in 1 dose X 4-6 Wks'''''
-|-
-|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''OR (in penicillin hypersensitivity)''
-|-
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 30 mg/kg I.V. daily in divided doses q. 12 hour X 4–6 Wks'''''<br> ''AND'' <br> ▸'''''[[Gentamicin|Gentamicin sulfate]] 3 mg/kg per 24 h 3 equally divided doses IV/IM in 1 dose X 4-6 Wks'''''|-
-|-
-! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
-|-
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[penicillin G sodium]] 300 000 U/kg per 24 h IV in 4–6 equally divided doses X 4–6 Wks''''' <br> ''AND'' <br> ▸'''''[[Gentamicin|Gentamicin sulfate]] 3 mg/kg per 24 h IV/IM in 3 equally divided doses X 4-6 Wks'''''
-|-
-|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''OR''
-|-
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin]] 300 mg/kg per 24 h IV in 4–6 equally divided doses; X 4–6 Wks'''''<br> ''AND'' <br> ▸'''''[[Gentamicin|Gentamicin sulfate]] 3 mg/kg per 24 h IV/IM in 3 equally divided doses X 4-6 Wks'''''
-|-
-|style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ''OR (in penicillin hypersensitivity)''
-|-
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 30 mg/kg I.V. daily in divided doses q. 12 hour X 4–6 Wks'''''<br> ''AND'' <br> ▸'''''[[Gentamicin|Gentamicin sulfate]] 3 mg/kg per 24 h IV/IM in 3 equally divided doses X 4-6 Wks'''''
-|-
-|-
-|}
+*[[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>
+* 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.
-===<u>Staphylococci (Methicillin Susceptible) in the Absence of Prosthetic Material</u>===
-{|
+{| class="wikitable"
 |-
-| valign=top |
+| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:48em" cellpadding="0" cellspacing="0";
+| bgcolor="LightGreen" |
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Staphylococci (Methicillin Susceptible) in the Absence of Prosthetic Material}}''
 |-
-!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''Preferred Regimen'''''
+| bgcolor="LightGreen" |"'''1.'''  Penicillin G or Amoxicilline or Ceftriaxonef''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  A]])''"
+| bgcolor="LightGreen" |
 |-
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''Adult''':'''''[[Nafcillin]] or [[Oxacillin]] 12 g I.V. daily in divided doses q. 4 hour X 4–6 Wks '''''<BR> ▸ '''Pediatrics''':'''''[[Nafcillin]] or [[oxacillin]] 200 mg/kg per 24 h IV in 4–6 equally divided doses X 4-6 Wks''''' <BR>''OR ( in non anaphylactoid [[Penicillin]] hypersensitivity)''<BR> ▸ '''Adult''':'''''[[Cefazolin]] 12 g I.V. daily in divided doses q. 4 hour X 4–6 Wks '''''<BR> ▸ '''Pediatrics''':'''''[[Cefazolin]] 100 mg/kg per 24 h IV in 3 equally divided doses X 4-6 Wks'''''
+| bgcolor="LightGreen" |”'''2.'''  (Paste guideline here) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  C]])''"
-|-
+| bgcolor="LightGreen" |
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | AND (optional)
-|-
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''Adult''':'''''[[Gentamicin]] 3 mg/kg per 24 h IV/IM in 2 or 3 equally divided doses X 3-5 days '''''<BR> ▸ '''Pediatrics''': '''''[[Gentamicin]] 3 mg/kg per 24 h IV/IM in 3 equally divided doses'''''
 |-
-|}
+| bgcolor="LightGreen" |”'''3.'''  (Paste guideline here) ''([[ACC AHA guidelines classification  scheme#Level of Evidence|Level of Evidence:  B]])''"
+| bgcolor="LightGreen" |
 |}
-===<u>Staphylococci (Methicillin Resistant) in the Absence of Prosthetic Material</u>===
+==References==
-{|
+{{reflist|2}}
-|-
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:48em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Staphylococci (Methicillin-resistant) in the Absence of Prosthetic Material <br> {in anaphylactoid [[Penicillin G potassium adverse reactions|Penicillin hypersensitivity]]}}}''
-|-
-!style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | '''''Preferred Regimen'''''
-|-
-! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Adult dose}}''
-|-
-! style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 30 mg/kg per 24 h IV in 2 equally divided doses x 6 wks''''' <br> Adjust vancomycin dosage to achieve 1-h serum concentration of 30–45 > g/mL and trough concentration of 10–15 >g/mL
-|-
-! style="padding: 0 5px; font-size: 95%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatrics dose}}''
-|-
-| style="font-size: 95%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''Pediatrics''': '''''[[Vancomycin]] 40 mg/kg per 24 h IV in 2 or 3 equally divided doses x 6 wks '''''
-|-
-|}
-|}
-===<u>Staphylococci (Methicillin Susceptible) in the Presence of Prosthetic Material</u>===
-====Nafcillin or Oxacillin + Rifampin + Gentamicin====
-{|
-|-
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:48em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Oxacillin-susceptible strains}}''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Nafcillin]] or [[oxacillin]] 2 g q4h IV x  ≥6 weeks'''''<BR>''PLUS''<BR> ▸ '''''[[Rifampin]] 300 mg q8h IV/PO x ≥6 weeks''''' <BR>''PLUS''<BR> ▸ '''''[[Gentamicin]] 3 mg/kg per 24 h IV/IM in 2 or 3 equally divided doses x 2 weeks'''''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Nafcillin]] or [[oxacillin]] 200 mg/kg per 24 h IV in 4–6 equally divided doses'''''
-|-
-|style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Rifampin]] 20 mg/kg per 24 h IV/PO in 3 equally divided doses'''''
-|-
-|style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left |▸'''''[[Gentamicin]] 1 mg/kg q8h IV/IM'''''
-|-
-|}
-|}
-===<u>Staphylococci (Methicillin Resistant) in the Presence of Prosthetic Material</u>===
-{|
-|-
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:48em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Oxacillin-resistant strains}}''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg/kg q12h x  ≥6 weeks'''''<BR>''PLUS''<BR> ▸ '''''[[Rifampin]] 300 mg q8h IV/PO x ≥6 weeks''''' <BR>''PLUS''<BR> ▸ '''''[[Gentamicin]] 3 mg/kg per 24 h IV/IM in 2 or 3 equally divided doses x 2 weeks'''''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[vancomycin]] 40 mg/kg per 24 h
-IV in 2 or 3 equally divided doses'''''
-|-
-|style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Rifampin]] 20 mg/kg per 24 h IV/PO in 3 equally divided doses'''''
-|-
-|style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''[[Gentamicin]] 1 mg/kg q8h
-IV/IM '''''
-|-
-|}
-|}
-===<u>HACEK Organisms</u>===
-[[HACEK organism]]s are more indolent and the infection is less complicated.
-{|
-|-
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:48em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Therapy for Both Native and Prosthetic Valve Endocarditis Caused by HACEK Microorganisms}}''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone|Ceftriaxone sodium]] 2 g/24 h IV/IM in 1 dose x 4 weeks'''''<BR>''OR''<BR> ▸ '''''[[Ampicillin sulbactam|Ampicillin- sulbactam]] 12 g/24 h IV in 4 equally divided doses x 4 weeks'''''<BR>''OR''<BR>▸ '''''[[Ciprofloxacin]] 500 mg q12h PO or 400 mg q12h IV x 4 weeks'''''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Pediatric dose}}''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone]] 100 mg/kg per 24 h IV/IM once daily'''''
-|-
-|style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Ampicillin sulbactam|Ampicillin- sulbactam]] 300 mg/kg per 24 h IV divided into 4 or 6 equally divided doses'''''
-|-
-|style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Ciprofloxacin]] 10-15 mg/kg q12h IV/PO '''''
-|-
-|}
-|}
-===<u>Culture Negative Endocarditis</u>===
-Patients should be divided into 2 groups:
-=====Patients who Received Antibiotic Therapy before the Blood Culture being Drawn=====
-*Patients with acute clinical presentations with native valve infection: coverage of S. aureus should be followed as detailed in proven staphylococcal disease.
-*Patients with subacute presentation: antibiotic coverage for S. aureus, viridians group streptococci, and enterococci should be considered.
-*Antibiotics for HACEK group of organism also should be considered.
-*Symptomatic patients with prosthetic valve and culture negative infection within 1 year of valve replacement should receive vancomycin to cover the oxacillin-resistant staphylococci.
-*Symptomatic patients with prosthetic valve and culture negative infection within 2 months of valve replacement should also receive cefepime for gram negative bacilli coverage.
-*Symptomatic patients with prosthetic valve more than 1 year, the most likely causing organisms are oxacillin-susceptible staphylococci, viridians group streptococci, and enterococci.   Antibiotic coverage for those organisms should be continued for at least 6 weeks.
-=====Patients with Culture-Negative Endocarditis and Suspected Infection with Uncommon Endocarditis Pathogens=====
-*Examples of these pathogens include Bartonella species, Chlamydia species, Coxiella burnetii, Brucella species, Legionella species, Tropheryma whippleii, and non-Candida fungi.
-*The most common pathogens that have been reported with culture-negative endocarditis are [[Bartonella|Bartonella species]], [[Coxiella burnetii]], and [[Brucella|Brucella species]].
-*Antibiotic therapy for these pathogens should include aminoglycosides for at least 2 weeks.
-*Therapeutic regimens for Bartonella endocarditis are mentioned below.<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>
-{|
-|-
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:32em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Native valve}}''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin sulbactam|Ampicillin-Sulbactam]] 3 g q6h IV x 4–6 weeks'''''<BR>''PLUS''<BR> ▸ '''''[[Gentamicin|Gentamicin sulfate]] 1 mg per kg q8h IV/IM x 4–6 weeks'''''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ''OR''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''[[Vancomycin]] 15 mg per kg q12h IV x 4–6 weeks''''' <BR>''PLUS''<BR>▸ '''''[[Gentamicin|Gentamicin sulfate]] 1 mg per kg q8h IV/IM x 4–6 week''''' <BR>''PLUS''<BR>'''''[[Ciprofloxacin]] 500 mg q12h PO or 320 mg q12h IV x 4–6 weeks'''''
-|-
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Native valve pediatric dose}}''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Ampicillin sulbactam|Ampicillin-Sulbactam]]300 mg per kg per 24 h IV in 4–6 equally divided doses'''''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Gentamicin]] 1 mg per kg q8h IV/IM'''''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Vancomycin]] 32 mg per kg per 24 h in 2 or 3 equally divided doses '''''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Ciprofloxacin]] 10-15 mg per kg q12h IV/PO'''''
-|-
-|}
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float:left; width:32em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Prosthetic valve (early, ≤ 1y)}}''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg per kg q12h IV x 6'''''<BR>''PLUS''<BR>▸ '''''[[Gentamicin|Gentamicin sulfate]] 1 mg per kg q8h IV/IM x 2weeks'''''<BR>''PLUS''<BR>▸'''''[[Cefepime]] 2 g q8h IV x 6 weeks''''' <BR>''PLUS''<BR>▸ '''''[[Rifampin]] 300 mg q8h PO/IV x 6 weeks'''''
-|-
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Prosthetic valve pediatric dose}}''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Vancomycin]] 32 mg per kg per 24 h IV in 2 or 3 equally divided doses'''''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Gentamicin]] 1 mg per kg q8h IV/IM '''''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Cefepime]] 50 mg q8h IV '''''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Rifampin]] 20 mg per kg per 24 h PO/IV in 3 equally divided doses'''''
-|-
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Prosthetic valve (late—greater than 1 y) (same regimens as for native valve endocarditis with addition of [[rifampin]])}}''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ampicillin sulbactam|Ampicillin-Sulbactam]] 3 g q6h IV x 4–6 weeks'''''<BR>''PLUS''<BR>▸ '''''[[Gentamicin|Gentamicin sulfate]] 1 mg per kg q8h IV/IM x 4–6 weeks'''''<BR>''PLUS''<BR>▸ '''''[[Rifampin]] 300 mg q8h PO/IV x 6 weeks'''''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ''OR''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15 mg per kg q12h IV x 4–6 weeks'''''<BR>''PLUS''<BR>▸ '''''[[Gentamicin|Gentamicin sulfate]] 1 mg per kg q8h IV/IM x 4–6 weeks'''''<BR>''PLUS''<BR>▸ '''''[[Ciprofloxacin]] 500 mg q12h PO or 320 mg q12h IV x 4–6 weeks'''''<BR>''PLUS''<BR>▸ '''''[[Rifampin]] 300 mg q8h PO/IV x 6 weeks'''''
-|-
-|}
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float:left; width:32em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Suspected Bartonella, culture negative}}''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone sodium]] 2 g per 24 h IV/IM in 1 dose x 6 weeks'''''<BR>''PLUS''<BR>▸ '''''[[Gentamicin|Gentamicin sulfate]] 1 mg per kg q8h IV/IM x 2 weeks'''''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left |''WITH/WITHOUT''
-|-
-|style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Doxycycline]] 100 mg per kg q12h IV/PO x 6 weeks'''''
-|-
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Documented Bartonella, culture positive}}''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Doxycycline]] 100 mg q12h IV or PO x 6 weeks'''''<BR>''PLUS''<BR>▸ '''''[[Gentamicin|Gentamicin sulfate]] 1 mg per kg q8h IV/IM x 2 weeks'''''
-|-
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B|Documented Bartonella, culture positive pediatric dose}}''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Ceftriaxone]] 100 mg per kg per 24 h IV/IM once daily'''''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Gentamicin]] 1 mg per kg q8h IV/IM'''''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Doxycycline]] 2–4 mg per kg per 24 h IV/PO in 2 equally divided doses'''''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸'''''[[Rifampin]] 10 mg per kg q12h PO/IV'''''
-|-
-|}
-|}
-==References==
-{{Reflist|2}}
 [[Category:Emergency medicine]]
 [[Category:Cardiology]]
-[[Category:Infectious disease]]
 [[Category:Intensive care medicine]]
 [[Category:Up-To-Date]]
+[[Category: Infectious Disease Project]]
-{{WH}}
-{{WS}}