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'''Endocarditis Caused by Enterococci'''
'''Endocarditis Caused by Enterococci'''

Revision as of 20:12, 5 March 2014

Streptococci

▸ Click on the following categories to expand treatment regimens.

Native Valve Endocarditis Caused by Viridans Group Streptococci and Streptococcus bovis

  ▸  Viridans Group Streptococci and Streptococcus bovis Highly Penicillin-Susceptible

  ▸  Viridans Group Streptococci and Streptococcus bovis Relatively Penicillin Resistant (MIC >0.12 μg/mL- ≤ 0.5 μg/mL)

Prosthetic Valves Endocarditis Caused by Viridans Group Streptococci and Streptococcus Bovis

  ▸  Viridans Group Streptococci and Streptococcus Bovis Penicillin-Susceptible Strain (MIC ≤ 0.12 μg/mL)

  ▸  Viridans Group Streptococci and Streptococcus Bovis Penicillin Relatively or Fully Resistant Strain (MIC >0.12 μg/mL)

  ▸  Viridans Group Streptococci and Streptococcus bovis Relatively Penicillin-Resistant Streptococci (MIC 0.2–0.5 µg/ml)

  ▸  Relatively Penicillin-Resistant Streptococci (MIC > 0.5 µg/ml)

  ▸  Unable to tolerate Penicillin or Ceftriaxone

Native Valve Endocarditis Caused by Highly Penicillin-Susceptible Viridans Group Streptococci and Streptococcus bovis
Preferred Regimen ( 4 wks )
Adult dose
Penicillin G sodium † 12–18 million U/24 h IV either continuously or in 4-6 equally divided doses x 4 Wks
OR
Ceftriaxone sodium 2 g/24 h IV/IM in 1 dose x 4 Wks
Pediatric dose ₳
Penicillin G sodium 200 000 U/kg q24h IV either continuously or in 4-6 equally divided doses x 4 Wks
OR
Ceftriaxone 100 mg/kg q24 h IV/IM in 1 dose x 4 Wks
Alternative Regimen ( 2 wks )
Adult dose
Penicillin G sodium‡ 12–18 million U/24 h IV either continuously or in 6 equally divided doses x 2 Wks
OR
Ceftriaxone sodium 2 g/24 h IV/IM in 1 dose x 2 Wks
PLUS
Gentamicin sulfate ฿ 3 mg/Kg per 24h 1 dose x 2 Wks
Pediatric dose
Penicillin G sodium 200 000 U/kg q24h IV in 4-6 equally divided doses x 2 Wks
OR
Ceftriaxone 100 mg/kg q24 h IV/IM in 1 dose x 2 Wks
PLUS
Gentamicin sulfate 3 mg/Kg per 24h 1 dose or 3 equally divided doses x 2 Wks
Alternative Regimen
Adult dose
Vancomycin hydrochloride ¶ 15 mg/kg q12h IV x 4 Wks
Doses should not to exceed 2 g/24 h unless concentrations in serum are inappropriately low
Pediatric dose
Vancomycin hydrochloride 40 mg/kg per 24 h IV in 2–3 equally divided doses
Minimum inhibitory concentration ≤ 0.12 μg/mL.
† Preferred in most patients >65 y or patients with impairment of 8th cranial nerve function or renal function.
₳ Pediatric dose should not exceed that of a normal adult.
‡ 2-wk regimen not intended for patients with known cardiac or extracardiac abscess or for those with creatinine clearance of <20 mL/min, impaired 8th cranial nerve function, or Abiotrophia, Granulicatella, or Gemella spp infection; gentamicin dosage should be adjusted to achieve peak serum concentration of 3-4 μg/mL and trough serum concentration of >1 μg/mL when 3 divided doses are used; nomogram used for single daily dosing.
¶ Vancomycin therapy recommended only for patients unable to tolerate penicillin or ceftriaxone; vancomycin 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
฿ Other potentially nephrotoxic drugs (eg, nonsteroidal antiinflammatory drugs) should be used with caution in patients receiving gentamicin therapy. Although it is preferred that gentamicin (3 mg/kg) be given as a single daily dose to adult patients with endocarditis due to viridans group streptococci, as a second option, gentamicin can be administered daily in 3 equally divided doses.
Native Valve Endocarditis Caused by Strains of Viridans Group Streptococci and Streptococcus bovis Relatively Resistant to Penicillin (MIC >0.12 μg/mL- ≤ 0.5 μg/mL))
Preferred Regimen
Adult dose
Penicillin G sodium 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 4 wks
OR
Ceftriaxone 2 g/24 h IV/IM in 1 dose x 4 wks
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 1 dose x 2 wks
Pediatric dose
Penicillin G sodium 300 000 U/kg per 24 h IV in 4–6 equally divided doses
OR
Ceftriaxone 100 mg/kg per 24 h IV/IM in 1 dose
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 1 dose or equally divided doses
Alternative Regimen
Adult dose
Vancomycin hydrochloride 30 mg/kg per 24 h IV in 2 equally divided doses x 4 wks
Pediatric dose
Vancomycin hydrochloride 40 mg/kg per 24 h IV or in 2 or 3 equally divided doses
Penicillin-susceptible strain (MIC ≤ 0.12 g/mL)
Preferred Regimen
Adult dose
Penicillin G sodium † 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 6 wks
OR
Ceftriaxone 2 g/24 h IV/IM in 1 dose x 6 wks
WITH OR WITHOUT
Gentamicin sulfate ‡ 3 mg/kg per 24 h IV/IM in 1 dose x 2 wks
Pediatric dose
Penicillin G sodium 300 000 U/kg per 24 h IV in 4–6 equally divided doses
OR
Ceftriaxone 100 mg/kg IV/IM once daily
WITH OR WITHOUT
Gentamicin 3 mg/kg per 24 h IV/IM, in 1 dose or 3 equally divided doses
Alternative Regimen
Adult dose
Vancomycin hydrochloride 30 mg/kg per 24 h IV in 2 equally divided doses x 6 wks
Pediatric dose
40 mg/kg per 24 h IV or in 2 or 3 equally divided doses
*Dosages recommended are for patients with normal renal function.
† Penicillin or ceftriaxone together with gentamicin has not demonstrated superior cure rates compared with monotherapy with penicillin or ceftriaxone for patients with highly susceptible strain; gentamicin therapy should not be administered to patients with creatinine clearance of <30 mL/min.
‡ Although it is preferred that gentamicin (3 mg/kg) be given as a single daily dose to adult patients with endocarditis due to viridans group streptococci, as a second option, gentamicin can be administered daily in 3 equally divided doses.
Penicillin relatively or fully resistant strain (MIC >0.12 >μg/mL))
Preferred Regimen
Adult dose
Penicillin G sodium 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 6 wks
OR
Ceftriaxone 2 g/24 h IV/IM in 1 dose x 6 wks
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 1 dose x 6 wks
Pediatric dose
Penicillin G sodium 300 000 U/kg per 24 h IV in 4–6 equally divided doses
Alternative Regimen
Adult dose
Vancomycin hydrochloride 30 mg/kg per 24 h IV in 2 equally divided doses x 6 wks
Pediatric dose
Vancomycin hydrochloride 40 mg/kg per 24 h IV or in 2 or 3 equally divided doses
Relatively Penicillin-Resistant Streptococci (MIC 0.2–0.5 µg/ml
Preferred Regimen
Adult dose
Penicillin G potassium 24 million U/24 h IV either continuously or in 4–6 equally divided doses X 4 Wks
OR
Ceftriaxone 2 g/24 h IV/IM in 1 dose
AND
Gentamicin 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr X 2 Wks
Pediatric dose
Penicillin G potassium 300 000 U/24 h IV in 4–6 equally divided doses X 4 Wks
OR
Ceftriaxone 100 mg/kg per 24 h IV/IM in 1 dose
AND
Gentamicin 3 mg/kg per 24 h IV/IM in 1 dose or 3 equally divided doses X 2 Wks
Relatively Penicillin-Resistant Streptococci(MIC > 0.5 µg/ml, consider Enterococcal regimen
Preferred Regimen
Adult dose
Penicillin G potassium 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 4 Wks
PLUS
Gentamicin 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr x 2 Wks
Pediatric dose
Penicillin G potassium 24 million U/24 h IV either continuously or in 4–6 equally divided doses x 4 Wks
PLUS
Gentamicin 3 mg/kg I.M. or I.V. daily in divided doses q. 8 hr x 2 Wks
Unable to Tolerate Aqueous crystalline penicillin G sodium or Ceftriaxone
Preferred Regimen
Adult dose
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
Pediatric dose
Vancomycin 40 mg/kg 24 h in 2 or 3 equally divided doses X 4 Wks

Enterococci

Endocarditis Caused by Enterococci

  ▸  Enterococci Strains Susceptible to Penicillin, Gentamicin, and Vancomycin

  ▸  Enterococci Strains Susceptible to Penicillin, Streptomycin, and Vancomycin and Resistant to Gentamicin

  ▸  Enterococci Strains Resistant to Penicillin and Susceptible to Aminoglycoside and Vancomycin

  ▸  Enterococci Strains Resistant to Penicillin, Aminoglycoside, and Vancomycin

Enterococci Strains Susceptible to Penicillin, Gentamicin, and Vancomycin
Preferred Regimen
Adult dose
Ampicillin 12 g/24 h I.V.in 6 equally divided doses x 4–6 Wks
OR
Penicillin G sodium 18–30 million U. I.V. daily in 6 equally divided doses x 4–6 Wks
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 3 equally divided doses x 4-6 Wks
Pediatric dose
Ampicillin 300 mg/kg per 24 h IV in 4–6 equally divided doses; X 4–6 Wks
OR
Penicillin G sodium 300 000 U/kg per 24 h IV in 4–6 equally divided doses X 4–6 Wks
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 3 equally divided doses X 4-6 Wks
Alternative Regimen
Vancomycin 30 mg/kg I.V. daily in 2 equally divided doses x 6 Wks
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 3 equally divided doses x 6 Wks
Pediatric dose
Vancomycin 30 mg/kg I.V. daily in divided doses q. 12 hour X 4–6 Wks
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 3 equally divided doses X 4-6 Wks
*Native valve: 4-wk therapy recommended for patients with symptoms of illness < 3 months.
  • 6-wk therapy recommended for patients with symptoms >3 months.
  • Prosthetic valve or other prosthetic cardiac material: minimum of 6 wk of therapy recommended.
  • Vancomycin therapy recommended only for patients unable to tolerate penicillin or ampicillin.
  • 6 wk of vancomycin therapy recommended because of decreased activity against enterococci.
Enterococci Strains Susceptible to Penicillin, Streptomycin, and Vancomycin and Resistant to Gentamicin
Preferred Regimen
Adult dose
Ampicillin 12 g/24 h I.V.in 6 equally divided doses x 4–6 Wks
OR
Penicillin G sodium 24 million U. I.V. continuously or in 6 equally divided doses x 4–6 Wks
PLUS
Streptomycin sulfate 15 mg/kg per 24 h IV/IM in 2 equally divided doses x 4-6 Wks
Pediatric dose
Ampicillin 300 mg/kg per 24 h IV in 4–6 equally divided doses; x 4–6 Wks
OR
Penicillin G sodium 300 000 U/kg per 24 h IV in 4–6 equally divided doses x 4–6 Wks
PLUS
Streptomycin sulfate 20–30 mg/kg per 24 h IV/IM in 2 equally divided doses
Alternative Regimen
Adult dose
Vancomycin 30 mg/kg I.V. daily in 2 equally divided doses x 6 Wks
PLUS
Streptomycin sulfate 15 mg/kg per 24 h IV/IM in 2 equally divided doses x 4-6 Wks
Pediatric dose
Vancomycin 40 mg/kg per 24 h IV in 2 or 3 equally divided doses X 4–6 Wks
PLUS
Streptomycin sulfate 20–30 mg/kg per 24 h IV/IM in 2 equally divided doses
  • Native valve: 4-wk therapy recommended for patients with symptoms of illness < 3 months.
  • 6-wk therapy recommended for patients with symptoms >3 months.
  • Prosthetic valve or other prosthetic cardiac material: minimum of 6 wk of therapy recommended.
  • Vancomycin therapy recommended only for patients unable to tolerate penicillin or ampicillin.
β-Lactamase–producing strain
Preferred Regimen
Adult dose
Ampicillin-sulbactam 12 g/24 h IV in 4 equally divided doses x 6 Wks
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 3 equally divided doses x 6 Wks
Pediatric dose
Ampicillin-sulbactam 300 mg/kg per 24 h IV in 4 equally divided doses x 6 Wks
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 3 equally divided doses x 6 Wks
Alternative Regimen
Vancomycin hydrochloride 30 mg/kg per 24 h IV in 2 equally divided doses x 6 Wks
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 3 equally divided doses x 6 Wks
Pediatric dose
Vancomycin hydrochloride 40 mg/kg per 24 h in 2 or 3 equally divided doses
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 3 equally divided doses x 6 Wks
Intrinsic penicillin resistance
Adult dose
Vancomycin hydrochloride 30 mg/kg per 24 h IV in 2 equally divided doses x 6 Wks
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 3 equally divided doses x 6 Wks
Pediatric dose
Vancomycin hydrochloride 40 mg/kg per 24 h in 2 or 3 equally divided doses
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 3 equally divided doses x 6 Wks
E faecium
Adult dose
Linezolid 1200 mg/24 h IV/PO in 2 equally divided doses x ≥8 Wks
OR
Quinupristin-dalfopristin 22.5 mg/kg per 24 h IV in 3 equally divided doses x ≥ 8 Wks
Pediatric dose
Linezolid 30 mg/kg per 24 h IV/PO in 3 equally divided doses ≥8 Wks
OR
Quinupristin-dalfopristin 22.5 mg/kg per 24 h IV in 3 equally divided doses ≥8 Wks
E faecalis
Adult dose
Preferred Regimen
Imipenem/cilastatin 2 g/24 h IV in 4 equally divided doses x ≥8 Wks
PLUS
Ampicillin sodium 12 g/24 h IV in 6 equally divided doses x ≥ 8 Wks
Pediatric dose
Imipenem/cilastatin 60–100 mg/kg per 24 h IV in 4 equally divided doses x ≥8 Wks
PLUS
Ampicillin sodium 300 mg/kg per 24

h IV in 4–6 equally divided doses x ≥ 8 Wks

Alternative Regimen
Adult dose
Ceftriaxone sodium 4 g/24 h IV/IM in 2 equally divided doses x ≥8 Wks
PLUS
Ampicillin sodium 12 g/24 h IV in 6 equally divided doses x ≥ 8 Wks
Pediatric dose
Ceftriaxone sodium 100 mg/kg per 24 h IV/IM in 2 equally divided doses x ≥8 Wks
PLUS
Ampicillin sodium 300 mg/kg per 24 h IV in 4–6 equally divided doses x ≥ 8 Wks
  • Patients with endocarditis caused by these strains should be treated in consultation with an infectious diseases specialist.
  • Cardiac valve replacement may be necessary for bacteriologic cure.
  • Cure with antimicrobial therapy alone may be < 50%
  • Severe, usually reversible thrombocytopenia may occur with use of linezolid, especially after 2 wk of therapy.
  • Quinupristin-dalfopristin only effective against E faecium and can cause severe myalgias, which may require discontinuation of therapy
  • Only small no. of patients have reportedly been treated with imipenem/cilastatin-ampicillin or ceftriaxone + ampicillin.