Endocarditis medical therapy
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Associate Editors-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]
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Overview
Effective treatment requires identification of the etiologic agent and determination of its antimicrobial susceptibility.
Timing of Initiation of Antibiotics
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.
Duration of Antibiotic Therapy
For prosthetic valve endocarditis, treatment should be continued for 6 to 8 weeks.
Treatment Based Upon Infectious Agent
Penicillin-Susceptible Strep Viridans and Other Nonenterococcal Streptococci[1]
Preferred regimens
- Penicillin G: If Minimum inhibitory concentration [MIC]: <0.2 µg/ml: Dose: 12–18 million units I.V. daily in divided doses q. 4 hour for 4 weeks
- Penicillin G + gentamicin or ceftriaxone: Dose: penicillin G, 12–18 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 hour for 2 weeks (peak serum concentration should be ~ 3 µg/ml and trough concentrations < 1 µg/ml); ceftriaxone, 2 g I.V. daily as a single dose for 2 weeks
- Vancomycin: for patients with history of penicillin hypersensitivityDose: 30 mg/kg I.V. daily in divided doses q. 12 hour for 4 weeks
Relatively Penicillin-Resistant Streptococci[1]
Preferred regimens
- If MIC 0.2–0.5 µg/ml
- Penicillin G + gentamicin: 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)
- If MIC > 0.5 µg/ml
- Penicillin G + gentamicin: Dose: 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)
- Vancomycin: regimen for patients with history of penicillin hypersensitivity. Dose: 30 mg/kg I.V. daily in divided doses q. 12 hour for 4 weeks
Enterococci[1]
Preferred regimens
- Penicillin G + gentamicin:Dose: 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:Dose: ampicillin, 12 g I.V. daily in divided doses q. 4 hour for 4–6 weeks; gentamicin, dose as above
- Vancomycin + gentamicin: regimen for patients with history of penicillin hypersensitivity. Dose: vancomycin, 30 mg/kg I.V. daily in divided doses q. 12 hour for 4–6 weeks; gentamicin, dose as above
Staphylococci (Methicillin Susceptible) in the Absence of Prosthetic Material[1]
Preferred regimens
- Nafcillin or oxacillin + gentamicin (optional): 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)
- Cefazolin + gentamicin (optional): alternative regimen for patients with history of penicillin hypersensitivity. Dose: cefazolin, 12 g I.V. daily in divided doses q. 4 hour for 4–6 weeks; gentamicin, dose as above
- Vancomycin: alternative regimen for patients with history of penicillin hypersensitivity. Dose: 30 mg/kg I.V. daily in divided doses q. 12 hr for 4–6 weeks
Staphylococci (Methicillin Resistant) in the Absence of Prosthetic Material[1]
Preferred regimens
- Vancomycin: Dose: 30 mg/kg I.V. daily in divided doses q. 12 hour for 4–6 weeks
Staphylococci (Methicillin Susceptible) in the Presence of Prosthetic Material[1]
Preferred regimens
- Nafcillin or oxacillin + rifampin + gentamicin. Dose: 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
Staphylococci (Methicillin Resistant) in the Presence of Prosthetic Material[1]
Preferred regimens
- Vancomycin + rifampin + gentamicin. Dose: 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
HACEK Organisms[1]
- Ceftriaxone or another third-generation cephalosporin. Dose: 2 g I.V. daily as a single dose for 4 weeks
Chronic Pharmacotherapies [1]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 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.