Sandbox endocarditis

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Empirical Antibiotic Therapy

  • Antibiotic therapy for subacute 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.[1]
  • 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.
  • 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]
Native valve
Ampicillin-Sulbactam 3 g q6h IV x 4–6 weeks
PLUS
Gentamicin sulfate 1 mg per kg q8h IV/IM x 4–6 weeks
OR
Vancomycin 15 mg per kg q12h IV x 4–6 weeks
PLUS
Gentamicin sulfate 1 mg per kg q8h IV/IM x 4–6 week
PLUS
Ciprofloxacin 500 mg q12h PO or 400 mg q12h IV x 4–6 weeks
Native valve pediatric dose
Ampicillin-Sulbactam300 mg per kg per 24 h IV in 4–6 equally divided doses
Gentamicin 1 mg per kg q8h IV/IM
Vancomycin 40 mg per kg per 24 h in 2 or 3 equally divided doses
Ciprofloxacin 10-15 mg per kg q12h IV/PO
Prosthetic valve (early, ≤ 1y)
Vancomycin 15 mg per kg q12h IV x 6
PLUS
Gentamicin sulfate 1 mg per kg q8h IV/IM x 2weeks
PLUS
Cefepime 2 g q8h IV x 6 weeks
PLUS
Rifampin 300 mg q8h PO/IV x 6 weeks
Prosthetic valve pediatric dose
Vancomycin 40 mg per kg per 24 h IV in 2 or 3 equally divided doses
Gentamicin 1 mg per kg q8h IV/IM
Cefepime 50 mg q8h IV
Rifampin 20 mg per kg per 24 h PO/IV in 3 equally divided doses
Prosthetic valve (late—greater than 1 y) (same regimens as for native valve endocarditis with addition of rifampin)
Ampicillin-Sulbactam 3 g q6h IV x 4–6 weeks
PLUS
Gentamicin sulfate 1 mg per kg q8h IV/IM x 4–6 weeks
PLUS
Rifampin 300 mg q8h PO/IV x 6 weeks
OR
Vancomycin 15 mg per kg q12h IV x 4–6 weeks
PLUS
Gentamicin sulfate 1 mg per kg q8h IV/IM x 4–6 weeks
PLUS
Ciprofloxacin 500 mg q12h PO or 400 mg q12h IV x 4–6 weeks
PLUS
Rifampin 300 mg q8h PO/IV x 6 weeks
Suspected Bartonella, culture negative
Ceftriaxone sodium 2 g per 24 h IV/IM in 1 dose x 6 weeks
PLUS
Gentamicin sulfate 1 mg per kg q8h IV/IM x 2 weeks
WITH/WITHOUT
Doxycycline 100 mg per kg q12h IV/PO x 6 weeks
Documented Bartonella, culture positive
Doxycycline 100 mg q12h IV or PO x 6 weeks
PLUS
Gentamicin sulfate 1 mg per kg q8h IV/IM x 2 weeks
Documented Bartonella, culture positive pediatric dose
Ceftriaxone 100 mg per kg per 24 h IV/IM once daily
Gentamicin 1 mg per kg q8h IV/IM
Doxycycline 2–4 mg per kg per 24 h IV/PO in 2 equally divided doses
Rifampin 10 mg per kg q12h PO/IV


Regimen Dosage and Route Duration(wk)
Native valve
Ampicillin-Sulbactam 12 g per 24 h IV in 4 equally divided doses 4–6
'PLUS'
Gentamicin sulfate 3 mg per kg per 24 h IV/IM in 3 equally divided doses 4–6
OR
Vancomycin 30 mg per kg per 24 h IV in 2 equally divided doses 4–6
'PLUS'
Gentamicin sulfate 3 mg per kg per 24 h IV/IM in 3 equally divided doses 4–6
'PLUS'
Ciprofloxacin 1000 mg per 24 h PO or 800 mg per 24 h IV in 2 equally divided doses 4–6
Pediatric dose:
  • Ampicillin-Sulbactam 300 mg per kg per 24 h IV in 4–6 equally divided doses
  • Gentamicin 3 mg per kg per 24 h IV/IM in 3 equally divided doses
  • Vancomycin 40 mg per kg per 24 h in 2 or 3 equally divided doses
  • Ciprofloxacin 20–30 mg per kg per 24 h IV/PO in 2 equally divided doses
Prosthetic valve (early, ≤ 1y)
Vancomycin 30 mg per kg per 24 h IV in 2 equally divided doses 6
'PLUS'
Gentamicin sulfate 3 mg per kg per 24 h IV/IM in 3 equally divided doses 2
'PLUS'
Cefepime 6 g per 24 h IV in 3 equally divided doses 6
'PLUS'
Rifampin 900 mg per 24 h PO/IV in 3 equally divided doses 6
Pediatric dose:
  • Vancomycin 40 mg per kg per 24 h IV in 2 or 3equally divided doses
  • Gentamicin 3 mg per kg per 24 h IV/IM in 3 equally divided doses
  • Cefepime 150 mg per kg per 24 h IV in 3 equally divided doses
  • Rifampin 20 mg per kg per 24 h PO/IV in 3 equally divided doses
Prosthetic valve (late—greater than 1 y) Same regimens as listed above for native valve endocarditis
Suspected Bartonella, culture negative
Ceftriaxone sodium 2 g per 24 h IV/IM in 1 dose 6
'PLUS'
Gentamicin sulfate 3 mg per kg per 24 h IV/IM in 3 equally divided doses 2
with/without
Doxycycline 200 mg per kg per 24 h IV/PO in 2 equally divided doses 6
Documented Bartonella, culture positive
Doxycycline 200 mg per 24 h IV or PO in 2 equally divided doses 6
'PLUS'
Gentamicin sulfate 3 mg per kg per 24 h IV/IM in 3 equally divided doses 2
Pediatric dose:
  • Ceftriaxone 100 mg per kg per 24 h IV/IM once daily
  • Gentamicin 3 mg per kg per 24 h IV/IM in 3 equally divided doses
  • Doxycycline 2–4 mg per kg per 24 h IV/PO in 2 equally divided doses
  • Rifampin 20 mg per kg per 24 h PO/IV in 2 equally divided doses


==Therapy of Native Valve Endocarditis Caused by Highly Penicillin-Susceptible Viridans Group Streptococci and Streptococcus bovis==

Native Valve Endocarditis Caused by Highly Penicillin-Susceptible Viridans Group Streptococci and Streptococcus bovis
Preferred Regimen
penicillin G sodium 12–18 million U/24 h IV either continuously or in 4 or 6 equally divided doses x 4 weeks
OR
Ceftriaxone sodium 2 g/24 h IV/IM in 1 dose x 4 weeks
Pediatric dose
penicillin G sodium 200 000 U/kg q24h IV in 4–6 equally divided doses
ceftriaxone 100 mg/kg q24 h IV/IM in 1 dose
Alternative Regimen
Penicillin G sodium 12–18 million U/24 h IV either continuously or in 6 equally divided doses x 2 weeks
OR
Ceftriaxone sodium 2 g/24 h IV/IM in 1 dose x 2weeks
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 1 dose X 2 weeks
Pediatric dose
penicillin G sodium 200 000 U/kg q24h IV in 4–6 equally divided doses
ceftriaxone 100 mg/kg q24 h IV/IM in 1 dose
Alternative Regimen
Vancomycin hydrochloride 15 mg/kg q12h IV x 4 weeks,doses 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






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. 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)