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==Culture-Negative Endocarditis <SMALL><SMALL><SMALL><SMALL><SMALL>Adapted from ''Circulation 2005;111(23):e394-434.''<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> and ''Circulation 2008;118(15):e523-661.''<ref name="Bonow-2008">{{Cite journal  | last1 = Bonow | first1 = RO. | last2 = Carabello | first2 = BA. | last3 = Chatterjee | first3 = K. | last4 = de Leon | first4 = AC. | last5 = Faxon | first5 = DP. | last6 = Freed | first6 = MD. | last7 = Gaasch | first7 = WH. | last8 = Lytle | first8 = BW. | last9 = Nishimura | first9 = RA. | title = 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal = J Am Coll Cardiol | volume = 52 | issue = 13 | pages = e1-142 | month = Sep | year = 2008 | doi = 10.1016/j.jacc.2008.05.007 | PMID = 18848134 }}</ref></SMALL></SMALL></SMALL></SMALL></SMALL>==
==Culture-Negative Endocarditis <SMALL><SMALL><SMALL><SMALL><SMALL>Adapted from ''Circulation 2005;111(23):e394-434.''<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> and ''Circulation 2008;118(15):e523-661.''<ref name="Bonow-2008">{{Cite journal  | last1 = Bonow | first1 = RO. | last2 = Carabello | first2 = BA. | last3 = Chatterjee | first3 = K. | last4 = de Leon | first4 = AC. | last5 = Faxon | first5 = DP. | last6 = Freed | first6 = MD. | last7 = Gaasch | first7 = WH. | last8 = Lytle | first8 = BW. | last9 = Nishimura | first9 = RA. | title = 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal = J Am Coll Cardiol | volume = 52 | issue = 13 | pages = e1-142 | month = Sep | year = 2008 | doi = 10.1016/j.jacc.2008.05.007 | PMID = 18848134 }}</ref></SMALL></SMALL></SMALL></SMALL></SMALL>==

Revision as of 20:18, 26 June 2015

Endocarditis Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Ahmed Zaghw, M.D. [3]; Mohamed Moubarak, M.D. [4]

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.

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 (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 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.
  • Empirical therapy is needed for all likely pathogens, certain antibiotic agents, including aminoglycosides, is preferably avoided for its toxic effects.
  • 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]

Pathogen-Based Therapy Adapted from Circulation 2005;111(23):e394-434.[2] and Circulation 2008;118(15):e523-661.[3]

Viridans Streptococci or Streptococcus bovis

▸ Click on the following categories to expand treatment regimens.

Native Valve Endocarditis

  ▸  Highly PCN Susceptible, Adult

  ▸  Highly PCN Susceptible, Pediatric

  ▸  Relatively PCN Resistant, Adult

  ▸  Relatively PCN Resistant, Pediatric

  ▸  Highly PCN Resistant

Prosthetic Valve Endocarditis

  ▸  PCN Susceptible, Adult

  ▸  PCN Susceptible, Pediatric

  ▸  PCN Resistant, Adult

  ▸  PCN Resistant, Pediatric

Viridans Streptococci or S. bovis NVE, Penicillin MIC ≤0.12 μg/mL, Adult
Preferred Regimen
Penicillin G 12—18 MU/day IV continuously or q4—6h x 4 weeks
OR
Ceftriaxone 2 g IV/IM q24h x 4 weeks
Alternative Regimen 1
Penicillin G 12—18 MU/day IV continuously or q4—6h x 2 weeks
OR
Ceftriaxone 2 g IV/IM q24h x 2 weeks
PLUS
Gentamicin 3 mg/kg IV/IM q24h (or 1 mg/kg IV/IM q8h) x 2 weeks
Alternative Regimen 2
Vancomycin 15 mg/kg IV q12h x 4 weeksǁ
Preferred in most patients greater than 65 y of age or patients with impairment of 8th cranial nerve function or renal function.
Two-week regimen not intended for patients with known cardiac or extracardiac abscess or for those with creatinine clearance of less than 20 ml per min, impaired 8th cranial nerve function, or Abiotrophia, Granulicatella, or Gemella infection.
Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
ǁ Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
Viridans Streptococci or S. bovis NVE, Penicillin MIC ≤0.12 μg/mL, Pediatric
Preferred Regimen
Penicillin G 0.2 MU/kg/day IV q4—6h x 4 weeks
OR
Ceftriaxone 100 mg/kg IV/IM q24h x 4 weeks
Alternative Regimen 1
Penicillin G 0.2 MU/kg/day IV q4—6h x 2 weeks
OR
Ceftriaxone 100 mg/kg IV/IM q24h x 2 weeks
PLUS
Gentamicin 3 mg/kg IV/IM q24h (or 1 mg/kg IV/IM q8h) x 2 weeks
Alternative Regimen 2
Vancomycin 40 mg/kg/day IV q8—12h x 4 weeksǁ
Preferred in most patients greater than 65 y of age or patients with impairment of 8th cranial nerve function or renal function.
Two-week regimen not intended for patients with known cardiac or extracardiac abscess or for those with creatinine clearance of less than 20 ml per min, impaired 8th cranial nerve function, or Abiotrophia, Granulicatella, or Gemella infection.
Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
ǁ Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
Viridans Streptococci or S. bovis NVE, Penicillin MIC >0.12 to ≤0.5 μg/ml, Adult
Preferred Regimen
Penicillin G 24 MU/day IV continuously or q4—6h x 4 weeks
OR
Ceftriaxone 2 g IV/IM q24h x 4 weeks
PLUS
Gentamicin 3 mg/kg IV/IM q24h (1 mg/kg IV/IM q8h) x 2 weeks
Alternative Regimen
Vancomycin 15 mg/kg IV q12h x 4 weeksǁ
Patients with endocarditis caused by Penicillin Resistant (MIC greater than 0.5 μg/ml) strains should be treated with regimen recommended for enterococcal endocarditis.
Recommended for enterococcal endocarditis.
Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
ǁ Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
Viridans Streptococci or S. bovis NVE, Penicillin MIC >0.12 to ≤0.5 μg/ml, Pediatric
Preferred Regimen
Penicillin G 0.3 MU/kg/day IV q4—6h x 4 weeks
OR
Ceftriaxone 100 mg/kg IV/IM q24h x 4 weeks
PLUS
Gentamicin 3 mg/kg IV/IM q24h (or 1 mg/kg IV/IM q8h) x 2 weeks
Alternative Regimen
Vancomycin 40 mg/kg IV q8—12h x 4 weeksǁ
Patients with endocarditis caused by Penicillin Resistant (MIC greater than 0.5 μg/ml) strains should be treated with regimen recommended for enterococcal endocarditis.
Recommended for enterococcal endocarditis.
Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
ǁ Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
Viridans Streptococci or S. bovis NVE, Penicillin MIC >0.5 μg/ml
▸ Endocarditis caused by highly penicillin resistant (MIC >0.5 μg/ml) strains of viridans streptococci, Abiotrophia defectiva, Granulicatella species, and Gemella species should be treated with a regimen that is recommended for enterococcal endocarditis.
Viridans Streptococci or S. bovis PVE, Penicillin MIC ≤0.12 μg/ml, Adult
Preferred Regimen
Penicillin G 24 MU/day IV continuously or q4—6h x 6 weeks
OR
Ceftriaxone 2 g IV/IM q24h x 6 weeks
WITH OR WITHOUT
Gentamicin 3 mg/kg IV/IM q24h (or 1 mg/kg IV/IM q8h) x 2 weeks
Alternative Regimen
Vancomycin 15 mg/kg IV q12h x 6 weeksǁ
Gentamicin therapy should not be administered to patients with creatinine clearance of <30 mL/min
ǁ Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
Viridans Streptococci or S. bovis PVE, Penicillin MIC ≤0.12 μg/ml, Pediatric
Preferred Regimen
Penicillin G 0.3 MU/kg/day IV q4—6h x 6 weeks
OR
Ceftriaxone 100 mg/kg IV/IM q24h x 6 weeks
WITH OR WITHOUT
Gentamicin 3 mg/kg IV/IM q24h (or 1 mg/kg IV/IM q8h) x 2 weeks
Alternative Regimen
Vancomycin 40 mg/kg/day IV q8—12h x 6 weeksǁ
Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
ǁ Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
Viridans Streptococci or S. bovis PVE, Penicillin MIC >0.12 μg/ml, Adult
Preferred Regimen
Penicillin G 24 MU/day IV continuously or q4—6h x 6 weeks
OR
Ceftriaxone 2 g IV/IM q24h x 6 weeks
PLUS
Gentamicin 3 mg/kg IV/IM q24h (or 1 mg/kg IV/IM q8h) x 6 weeks
Alternative Regimen
Vancomycin 15 mg/kg IV q12h x 6 weeksǁ
Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
ǁ Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
Viridans Streptococci or S. bovis PVE, Penicillin MIC >0.12 μg/ml, Pediatric
Preferred Regimen
Penicillin G 0.3 MU/kg/day IV q4—6h x 6 weeks
OR
Ceftriaxone 100 mg/kg IV/IM q24h x 6 weeks
PLUS
Gentamicin 3 mg/kg IV/IM q24h (or 1 mg/kg IV/IM q8h) x 6 weeks
Alternative Regimen
Vancomycin 40 mg/kg/day IV q8—12h x 6 weeksǁ
Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
ǁ Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.


Streptococcus pneumoniae, Streptococcus pyogenes, and Groups B, C, and G Streptococci

▸ Click on the following categories to expand treatment regimens.

Streptococcus pneumoniae

  ▸  PCN Susceptible

  ▸  PCN Resistant, Without Meningitis

  ▸  PCN Resistant, With Meningitis

Streptococcus pyogenes

  ▸  S. pyogenes Endocarditis

Group B, C, and G Streptococcus

  ▸  Group B, C, and G Streptococcus Endocarditis

S. pneumoniae Endocarditis, PCN Susceptible (MIC ≤0.1 μg/mL)
Preferred Regimen
Penicillin G 12—18 MU/day IV continuously or q4—6h x 4 weeks
OR
Cefazolin 1—1.5 g IV q6h x 4 weeks
OR
Ceftriaxone 2 g IV q24h x 4 weeks
Alternative Regimen
Vancomycin 15 mg/kg IV q12h x 4 weeksǁ
ǁ Recommended only for patients unable to tolerate β-lactams. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
S. pneumoniae Endocarditis, PCN Resistant (MIC >0.1 μg/mL), Without Meningitis
Preferred Regimen
Penicillin G 24 MU/day IV continuously or q4—6h x 4 weeks
OR
Cefotaxime 2 g IV q6—8h x 4 weeks
OR
Ceftriaxone 2 g IV q24h x 4 weeks
Alternative Regimen
Vancomycin 15 mg/kg IV q12h x 4 weeksǁ
ǁ Recommended only for patients unable to tolerate β-lactams. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
S. pneumoniae Endocarditis, PCN Resistant (MIC >0.1 μg/mL), With Meningitis
Preferred Regimen
Cefotaxime 2 g IV q4—6h x 4 weeks
OR
Ceftriaxone 2 g IV q12h x 4 weeks
PLUS
Vancomycin 15 mg/kg IV q6h x 4 weeks
PLUS
Rifampin 600 mg IV q24h x 4 weeks
S. pyogenes Endocarditis
Preferred Regimen
Penicillin G 12—18 MU/day IV continuously or q4—6h x 4 weeks
OR
Cefazolin 1—1.5 g IV q6h x 4 weeks
OR
Ceftriaxone 2 g IV q24h x 4 weeks
Alternative Regimen
Vancomycin 15 mg/kg IV q12h x 4 weeksǁ
ǁ Recommended only for patients unable to tolerate β-lactams. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
Group B, C, or G Streptococcus Endocarditis
Preferred Regimen
Penicillin G 24 MU/day IV continuously or q4—6h x 4—6 weeks
OR
Ceftriaxone 2 g IV/IM q24h x 4—6 weeks
PLUS
Gentamicin 3 mg/kg IV/IM q24h (1 mg/kg IV/IM q8h) x 2 weeks
Alternative Regimen
Vancomycin 15 mg/kg IV q12h x 4—6 weeksǁ
Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
ǁ Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.


Staphylococcus

▸ Click on the following categories to expand treatment regimens.

Native Valve Endocarditis

  ▸  Oxacillin Susceptible, Adult

  ▸  Oxacillin Susceptible, Pediatric

  ▸  Oxacillin Resistant, Adult

  ▸  Oxacillin Resistant, Pediatric

Prosthetic Valve Endocarditis

  ▸  Oxacillin Susceptible, Adult

  ▸  Oxacillin Susceptible, Pediatric

  ▸  Oxacillin Resistant, Adult

  ▸  Oxacillin Resistant, Pediatric

Staphylococcal NVE, Oxacillin Susceptible, Adult
Preferred Regimen
Nafcillin 12 g/day IV q4—6h x 6 weeks
OR
Oxacillin 12 g/day IV q4—6h x 6 weeks
WITH OR WITHOUT
Gentamicin 3 mg/kg/day IV/IM q8—12h x 3—5 days
Alternative Regimen
Cefazolin 2 g IV q8h x 6 weeks§
WITH OR WITHOUT
Gentamicin 3 mg/kg/day IV/IM q8—12h x 3—5 days
For complicated right-sided IE and for left-sided IE; for uncomplicated right-sided IE, 2 weeks.
Gentamicin should be administered in close proximity to vancomycin, nafcillin, or oxacillin dosing. Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
For penicillin-allergic (nonanaphylactoid type) patients; consider skin testing for oxacillin-susceptible staphylococci and questionable history of immediate-type hypersensitivity to penicillin.
§ Cephalosporins should be avoided in patients with anaphylactoid-type hypersensitivity to β-lactams; vancomycin should be used in these cases.
Staphylococcal NVE, Oxacillin Susceptible, Pediatric
Preferred Regimen
Nafcillin 200 mg/kg/day IV q4—6h x 6 weeks
OR
Oxacillin 200 mg/kg/day IV q4—6h x 6 weeks
WITH OR WITHOUT
Gentamicin 1 mg/kg IV/IM q8h x 3—5 days
Alternative Regimen
Cefazolin 100 mg/kg/day IV q8h x 6 weeks§
WITH OR WITHOUT
Gentamicin 1 mg/kg IV/IM q8h x 3—5 days
For complicated right-sided IE and for left-sided IE; for uncomplicated right-sided IE, 2 weeks.
Gentamicin should be administered in close proximity to vancomycin, nafcillin, or oxacillin dosing. Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
For penicillin-allergic (nonanaphylactoid type) patients; consider skin testing for oxacillin-susceptible staphylococci and questionable history of immediate-type hypersensitivity to penicillin.
§ Cephalosporins should be avoided in patients with anaphylactoid-type hypersensitivity to β-lactams; vancomycin should be used in these cases.
Staphylococcal NVE, Oxacillin Resistant, Adult
Preferred Regimen
Vancomycin 15 mg/kg IV q12h x 6 weeksǁ
Alternative Regimen
Linezolid 600 mg IV/PO q12h x 8 weeks
OR
Daptomycin 6 mg/kg IV q24h x 2—6 weeks
ǁ Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
Staphylococcal NVE, Oxacillin Resistant, Pediatric
Preferred Regimen
Vancomycin 40 mg/kg/day IV q8—12h x 6 weeksǁ
Alternative Regimen
Linezolid 10 mg/kg IV/PO q8h x 8 weeks
ǁ Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
Staphylococcal PVE, Oxacillin Susceptible, Adult
Preferred Regimen
Nafcillin 2 g IV q4h x ≥6 weeks
OR
Oxacillin 2 g IV q4h x ≥6 weeks
PLUS
Rifampin 300 mg IV/PO q8h x ≥6 weeks
PLUS
Gentamicin 3 mg/kg/day IV/IM q8—12h x 2 weeks
Penicillin G 24 million U/24 h IV in 4 to 6 equally divided doses may be used in place of nafcillin or oxacillin if strain is penicillin susceptible (minimum inhibitory concentration ≤0.1 μg/mL) and does not produce β-lactamase; vancomycin should be used in patients with immediate-type hypersensitivity reactions to β-lactam antibiotics; cefazolin may be substituted for nafcillin or oxacillin in patients with non–immediate-type hypersensitivity reactions to penicillins.
Gentamicin should be administered in close proximity to vancomycin, nafcillin, or oxacillin dosing. Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
Staphylococcal PVE, Oxacillin Susceptible, Pediatric
Preferred Regimen
Nafcillin 200 mg/kg/day IV q4—6h x ≥6 weeks
OR
Oxacillin 2 g IV q4h x ≥6 weeks
PLUS
Rifampin 20 mg/kg/day IV/PO q8h x ≥6 weeks
PLUS
Gentamicin 1 mg/kg IV/IM q8h x 2 weeks
Penicillin G 24 million U/24 h IV in 4 to 6 equally divided doses may be used in place of nafcillin or oxacillin if strain is penicillin susceptible (minimum inhibitory concentration ≤0.1 μg/mL) and does not produce β-lactamase; vancomycin should be used in patients with immediate-type hypersensitivity reactions to β-lactam antibiotics; cefazolin may be substituted for nafcillin or oxacillin in patients with non–immediate-type hypersensitivity reactions to penicillins.
Gentamicin should be administered in close proximity to vancomycin, nafcillin, or oxacillin dosing. Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
Staphylococcal PVE, Oxacillin Resistant, Adult
Preferred Regimen
Vancomycin 15 mg/kg IV q12h x ≥6 weeksǁ
PLUS
Rifampin 300 mg IV/PO q8h x ≥6 weeks
PLUS
Gentamicin 3 mg/kg/day IV/IM q8—12h x 2 weeks
ǁ Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
Gentamicin should be administered in close proximity to vancomycin, nafcillin, or oxacillin dosing. Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
Staphylococcal PVE, Oxacillin Resistant, Pediatric
Preferred Regimen
Vancomycin 40 mg/kg/day IV q8—12h x ≥6 weeksǁ
PLUS
Rifampin 20 mg/kg/day IV/PO q8h x ≥6 weeks
PLUS
Gentamicin 1 mg/kg IV/IM q8h x 2 weeks
ǁ Recommended only for patients unable to tolerate penicillin or ceftriaxone. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
Gentamicin should be administered in close proximity to vancomycin, nafcillin, or oxacillin dosing. Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.


Enterococcus

▸ Click on the following categories to expand treatment regimens.

PCN/GM/VM Susceptible

  ▸  PCN/GM/VM Susceptible, Adult

  ▸  PCN/GM/VM Susceptible, Pediatric

PCN/VM Susceptible, GM Resistant

  ▸  PCN/VM Susceptible, GM Resistant, Adult

  ▸  PCN/VM Susceptible, GM Resistant, Pediatric

VM/AG Susceptible, PCN Resistant

  ▸  VM/AG Susceptible, PCN Resistant, Adult

  ▸  VM/AG Susceptible, PCN Resistant, Pediatric

PCN/VM/AG Resistant

  ▸  PCN/VM/AG Resistant, Adult

  ▸  PCN/VM/AG Resistant, Pediatric

Enterococcal Endocarditis, PCN/GM/VM Susceptible, Adult
Preferred Regimen
Ampicillin 2 g IV q4h x 4—6 weeks
OR
Penicillin G 18—30 MU/day IV continuously or q4h x 4—6 weeks
PLUS
Gentamicin 1 mg/kg IV/IM q8h x 4—6 weeks
Alternative Regimen
Vancomycin 15 mg/kg IV q12h x 6 weeksǁ
PLUS
Gentamicin 1 mg/kg IV/IM q8h x 6 weeks
Native valve: 4-wk therapy recommended for patients with symptoms of illness ≤3 mo; 6-wk therapy recommended for patients with symptoms >3 mo. Prosthetic valve or other prosthetic cardiac material: minimum of 6 wk of therapy recommended.
Gentamicin should be administered in close proximity to vancomycin dosing. Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
ǁ Vancomycin therapy recommended only for patients unable to tolerate penicillin or ampicillin. Six wk of vancomycin therapy recommended because of decreased activity against enterococci. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
Enterococcal Endocarditis, PCN/GM/VM Susceptible, Pediatric
Preferred Regimen
Ampicillin 300 mg/kg/day IV q4—6h x 4—6 weeks
OR
Penicillin G 0.3 MU/kg/day IV q4—6h x 4—6 weeks
PLUS
Gentamicin 1 mg/kg IV/IM q8h x 4—6 weeks
Alternative Regimen
Vancomycin 40 mg/kg/day IV q8—12h x 6 weeksǁ
PLUS
Gentamicin 1 mg/kg IV/IM q8h x 6 weeks
Native valve: 4-wk therapy recommended for patients with symptoms of illness ≤3 mo; 6-wk therapy recommended for patients with symptoms >3 mo. Prosthetic valve or other prosthetic cardiac material: minimum of 6 wk of therapy recommended.
Gentamicin should be administered in close proximity to vancomycin dosing. Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
ǁ Vancomycin therapy recommended only for patients unable to tolerate penicillin or ampicillin. Six wk of vancomycin therapy recommended because of decreased activity against enterococci. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
Enterococcal Endocarditis, PCN/VM Susceptible, GM Resistant, Adult
Preferred Regimen
Ampicillin 2 g IV q4h x 4—6 weeks
OR
Penicillin G 24 MU/day IV continuously or q4h x 4—6 weeks
PLUS
Streptomycin 7.5 mg/kg IV/IM q12h x 4—6 weeks
Alternative Regimen
Vancomycin 15 mg/kg IV q12h x 6 weeksǁ
PLUS
Streptomycin 7.5 mg/kg IV/IM q12h x 6 weeks
Native valve: 4-wk therapy recommended for patients with symptoms of illness ≤3 mo; 6-wk therapy recommended for patients with symptoms >3 mo. Prosthetic valve or other prosthetic cardiac material: minimum of 6 wk of therapy recommended.
Streptomycin dosage adjusted to achieve a 1-hour serum concentration of 20 to 35 μg/mL and a trough concentration of <10 μg/mL Patients with a creatinine clearance of <50 mL/min should be treated in consultation with an infectious diseases specialist.
ǁ Vancomycin therapy recommended only for patients unable to tolerate penicillin or ampicillin. Six wk of vancomycin therapy recommended because of decreased activity against enterococci. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
Enterococcal Endocarditis, PCN/VM Susceptible, GM Resistant, Pediatric
Preferred Regimen
Ampicillin 300 mg/kg/day IV q4—6h x 4—6 weeks
OR
Penicillin G 0.3 MU/kg/day IV q4—6h x 4—6 weeks
PLUS
Streptomycin 40 mg/kg/day IV q8—12h x 6 weeks
Alternative Regimen
Vancomycin 15 mg/kg IV q12h x 6 weeksǁ
PLUS
Streptomycin 10—15 mg/kg IV/IM q12h x 6 weeks
Native valve: 4-wk therapy recommended for patients with symptoms of illness ≤3 mo; 6-wk therapy recommended for patients with symptoms >3 mo. Prosthetic valve or other prosthetic cardiac material: minimum of 6 wk of therapy recommended.
Streptomycin dosage adjusted to achieve a 1-hour serum concentration of 20 to 35 μg/mL and a trough concentration of <10 μg/mL Patients with a creatinine clearance of <50 mL/min should be treated in consultation with an infectious diseases specialist.
ǁ Vancomycin therapy recommended only for patients unable to tolerate penicillin or ampicillin. Six wk of vancomycin therapy recommended because of decreased activity against enterococci. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.

Gram-Negative Bacteria

▸ Click on the following categories to expand treatment regimens.

Gram-Negative Bacteria

  ▸  Bartonella spp.

  ▸  Escherichia coli

  ▸  HACEK Microorganisms

  ▸  Klebsiella spp.

  ▸  Neisseria spp.

  ▸  Proteus mirabilis

  ▸  Pseudomonas aeruginosa

Suspected Bartonella Endocarditis, Culture Negative
Preferred Regimen
Ceftriaxone 2 g IV/IM q24h x 6 weeks
PLUS
Gentamicin 1 mg/kg IV/IM q8h x 2 weeks
WITH OR WITHOUT
Doxycycline 100 mg IV/PO q12h x 6 weeks
Documented Bartonella Endocarditis, Culture Positive
Preferred Regimen
Doxycycline 100 mg IV/PO q12h x 6 weeks
PLUS
Gentamicin 1 mg/kg IV/IM q8h x 2 weeks
Alternative Regimen
Doxycycline 100 mg IV/PO q12h x 6 weeks
PLUS
Rifampin 300 mg PO/IV q12h x 6 weeks
Patients with Bartonella endocarditis should be treated in consultation with an infectious diseases specialist.
Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
Escherichia coli Endocarditis
Preferred Regimen
Ampicillin 2 g IV q4h x 4—6 weeks
OR
Penicillin G 20 MU/day IV continuously x 4—6 weeks
OR
Ceftriaxone 2 g IV/IM q24h x 4—6 weeks
PLUS
Gentamicin 1.7 mg/kg IV/IM q8h x 2 weeks
Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
HACEK Endocarditis, Adult
Preferred Regimen
Ceftriaxone 2 g IV/IM q24h x 4 weeks
Alternative Regimen
Ampicillin-Sulbactam 1.5 g IV q6h x 4 weeks
OR
Ciprofloxacin 500 mg PO q12h (or 400 mg IV q12h) x 4 weeks§
HACEK Endocarditis, Pediatric
Preferred Regimen
Ceftriaxone 100 mg/kg IV/IM q24h x 4 weeks
Alternative Regimen
Ampicillin-Sulbactam 300 mg/kg/day IV q4—6h x 4 weeks
OR
Ciprofloxacin 10—15 mg/kg IV/PO q12h x 4 weeks§
Prosthetic valve: patients with endocarditis involving prosthetic cardiac valve or other prosthetic cardiac material should be treated for 6 wk.
Cefotaxime or another third- or fourth-generation cephalosporin may be substituted.
§ Fluoroquinolone therapy recommended only for patients unable to tolerate cephalosporin and ampicillin therapy; levofloxacin, gatifloxacin, or moxifloxacin may be substituted; fluoroquinolones generally not recommended for patients <18 y old.
Klebsiella Endocarditis
Preferred Regimen
Ceftriaxone 2 g IV/IM q24h x 4 weeks
PLUS
Gentamicin 1 mg/kg IV/IM q8h x 2 weeks
OR
Amikacin 15 mg/kg/day IV q8—12h x 2 weeks§
Alternative Regimen
Piperacillin/Tazobactam 3.375 g IV q6h x 4 weeks
Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
§ Peak concentrations (30 to 90 minutes after injection) above 35 μg/mL and trough concentrations (just prior to the next dose) above 10 μg/mL should be avoided. Dosage should be adjusted as indicated.
Neisseria Endocarditis
Preferred Regimen
Penicillin G 12—18 MU/day IV continuously or q4—6h x 4 weeks
OR
Cefazolin 1—1.5 g IV q6h x 4 weeks
OR
Ceftriaxone 2 g IV q24h x 4 weeks
Infectious disease consultation should be obtained in cases in which Neisseria are resistant to penicillin.
Proteus mirabilis Endocarditis
Preferred Regimen
Ampicillin 2 g IV q4h x 4—6 weeks
OR
Penicillin G 20 MU/day IV continuously x 4—6 weeks
OR
Ceftriaxone 2 g IV/IM q24h x 4—6 weeks
PLUS
Gentamicin 1.7 mg/kg IV/IM q8h x 2 weeks
Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
Pseudomonas aeruginosa Endocarditis
Preferred Regimen
Ticarcillin 3 g IV q4h (or 4 g IV q6h) x ≥6 weeks
OR
Piperacillin/Tazobactam 3.375 gm IV q4h (or 4.5 g IV q6h) x ≥6 weeks
OR
Ceftazidime 2 g IV q8h x ≥6 weeks
OR
Cefepime 2 g IV q8h x ≥6 weeks
PLUS
Tobramycin 8 mg/kg IV/IM q24h x ≥6 weeks
Maintenance of peak and trough concentrations of 15—20 μg/mL and ≤2 μg/mL, respectively.

Culture-Negative Endocarditis Adapted from Circulation 2005;111(23):e394-434.[2] and Circulation 2008;118(15):e523-661.[3]

▸ Click on the following categories to expand treatment regimens.

Native Valve Endocarditis

  ▸  Culture-Negative NVE, Adult

  ▸  Culture-Negative NVE, Pediatric

Prosthetic Valve Endocarditis

  ▸  Culture-Negative PVE, Adult (Early, ≤1 year)

  ▸  Culture-Negative PVE, Pediatric (Early, ≤1 year)

  ▸  Culture-Negative PVE, Adult (Late, >1 year)

  ▸  Culture-Negative PVE, Adult (Late, >1 year)

Culture-Negative Native Valve Endocarditis, Adult
Preferred Regimen
Ampicillin-Sulbactam 3 g IV q6h x 4—6 weeks
PLUS
Gentamicin 1 mg/kg IV/IM q8h x 4—6 weeks
Alternative Regimen
Vancomycin 15 mg/kg IV q12h x 4—6 weeksǁ
PLUS
Gentamicin 1 mg/kg IV/IM q8h x 4—6 weeks
PLUS
Ciprofloxacin 500 mg PO q12h (or 400 mg IV q12h) x 4—6 weeks
Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
ǁ Recommended only for patients unable to tolerate penicillins. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
Culture-Negative Native Valve Endocarditis, Pediatric
Preferred Regimen
Ampicillin-Sulbactam 300 mg/kg/day IV q4—6h x 4—6 weeks
PLUS
Gentamicin 1 mg/kg IV/IM q8h x 4—6 weeks
Alternative Regimen
Vancomycin 40 mg/kg/day IV q8—12h x 4—6 weeksǁ
PLUS
Gentamicin 1 mg/kg IV/IM q8h x 4—6 weeks
PLUS
Ciprofloxacin 10—15 mg/kg IV/PO q12h x 4—6 weeks
Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
ǁ Recommended only for patients unable to tolerate penicillins. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
Culture-Negative Prosthetic Valve Endocarditis, Adult (Early, ≤1 year)
Preferred Regimen
Vancomycin 15 mg/kg IV q12h x 6 weeksǁ
PLUS
Gentamicin 1 mg/kg IV/IM q8h x 2 weeks
PLUS
Cefepime 2 g IV q8h x 6 weeks
PLUS
Rifampin 300 mg PO/IV q8h x 6 weeks
ǁ Recommended only for patients unable to tolerate penicillins. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
Culture-Negative Prosthetic Valve Endocarditis, Pediatric (Early, ≤1 year)
Preferred Regimen
Vancomycin 40 mg/kg/day IV q8—12h x 6 weeksǁ
PLUS
Gentamicin 1 mg/kg IV/IM q8h x 2 weeks
PLUS
Cefepime 50 mg/kg IV q8h x 6 weeks
PLUS
Rifampin 20 mg/kg/day PO/IV q8h x 6 weeks
ǁ Recommended only for patients unable to tolerate penicillins. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
Culture-Negative Prosthetic Valve Endocarditis, Adult (Late, >1 year)
Preferred Regimen
Ampicillin-Sulbactam 3 g IV q6h x 6 weeks
PLUS
Gentamicin 1 mg/kg IV/IM q8h x 6 weeks
PLUS
Rifampin 300 mg PO/IV q8h x 6 weeks
Alternative Regimen
Vancomycin 15 mg/kg IV q12h x 6 weeksǁ
PLUS
Gentamicin 1 mg/kg IV/IM q8h x 6 weeks
PLUS
Ciprofloxacin 500 mg PO q12h (or 400 mg IV q12h) x 6 weeks
PLUS
Rifampin 300 mg PO/IV q8h x 6 weeks
Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
ǁ Recommended only for patients unable to tolerate penicillins. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.
Culture-Negative Prosthetic Valve Endocarditis, Pediatric (Late, >1 year)
Preferred Regimen
Ampicillin-Sulbactam 300 mg/kg/day IV q4—6h x 6 weeks
PLUS
Gentamicin 1 mg/kg IV/IM q8h x 6 weeks
PLUS
Rifampin 20 mg/kg/day PO/IV q8h x 6 weeks
Alternative Regimen
Vancomycin 40 mg/kg/day IV q8—12h x 6 weeksǁ
PLUS
Gentamicin 1 mg/kg IV/IM q8h x 6 weeks
PLUS
Ciprofloxacin 10—15 mg/kg IV/PO q12h x 6 weeks
PLUS
Rifampin 20 mg/kg/day PO/IV q8h x 6 weeks
Gentamicin dosage should be adjusted to achieve peak serum concentration of 3—4 μg/ml and trough serum concentration of less than 1 μg/ml when 3 divided doses are used; nomogram used for single daily dosing; other potentially nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) should be used with caution in patients receiving gentamicin therapy.
ǁ Recommended only for patients unable to tolerate penicillins. Vancomycin doses should not exceed 2 g per 24 h, unless serum concentrations are inappropriately low. Dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30–45 μg/ml and a trough concentration range of 10–15 μg/ml. Vancomycin should be infused during course of at least 1 h to reduce risk of histamine-release red man syndrome.


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. 2.0 2.1 2.2 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. 3.0 3.1 Bonow, RO.; Carabello, BA.; Chatterjee, K.; de Leon, AC.; Faxon, DP.; Freed, MD.; Gaasch, WH.; Lytle, BW.; Nishimura, RA. (2008). "2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". J Am Coll Cardiol. 52 (13): e1–142. doi:10.1016/j.jacc.2008.05.007. PMID 18848134. Unknown parameter |month= ignored (help)