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
The duration for native valve endocarditis is often 4 weeks. For prosthetic valve endocarditis, 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[1]
Penicillin-Susceptible Strep Viridans and Other Nonenterococcal Streptococci
Preferred regimens
- Penicillin G: If Minimum inhibitory concentration [MIC] <0.2 µg/ml. Dose is 12–18 million units I.V. daily in divided doses q. 4 hour for 4 weeks.
- Penicillin G + gentamicin or ceftriaxone: Dose is 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 hypersensitivity.Doseis 30 mg/kg I.V. daily in divided doses q. 12 hour for 4 weeks.
Relatively Penicillin-Resistant Streptococci
Preferred regimens
- If MIC 0.2–0.5 µg/ml
- Penicillin G + gentamicin: Dose is 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 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).
- Vancomycin: regimen for patients with history of penicillin hypersensitivity. Dose is 30 mg/kg I.V. daily in divided doses q. 12 hour for 4 weeks.
Enterococci
Preferred regimens
- Penicillin G + gentamicin: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:Dose is 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 is 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
Preferred regimens
- Nafcillin or oxacillin + gentamicin (optional): Dose is 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 is 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 is 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
Preferred regimens
- Vancomycin: Doseis 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
Preferred regimens
- 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.
Staphylococci (Methicillin Resistant) in the Presence of Prosthetic Material
Preferred regimens
- 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.
HACEK Organisms
- Ceftriaxone or another third-generation cephalosporin. Dose is 2 g I.V. daily as a single dose for 4 weeks
References
- ↑ 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.